AIDS Behav (2006) 10:575–578
Correlates of Unprotected Anal Sex with Casual Partners:
A Study of Gay Men Living in the Southern United States
David R. Holtgrave · Richard Crosby · R. Luke Shouse
Published online: 20 May 2006
C ?Springer Science+Business Media, Inc. 2006
correlates of engaging in unprotected anal sex (UAS) with
non-main partners among men having sex with men (MSM).
Just over 1,000 men completed anonymous surveys with
25% of the men reporting their most recent sexual act with
a non-main male partner was UAS. These men tended to be
white, older, HIV seropositive, and high (or drunk) when
D. R. Holtgrave
Department of Behavioral Sciences and Health Education, Rollins
School of Public Health,
Atlanta, GA, USA
D. R. Holtgrave (?)
Department of Health, Behavior & Society, Bloomberg School of
Public Health, Johns Hopkins University,
624 N Broadway, Room 280, Baltimore, MD 21212, USA
D. R. Holtgrave
Emory Center for AIDS Research,
Atlanta, GA, USA
College of Public Health, University of Kentucky,
Lexington, KY, USA
Rural Center for AIDS/STD Prevention at Indiana University,
Bloomington, IN, USA
The Kinsey Institute for Research in Sex, Gender, and
Bloomington, IN, USA
R. L. Shouse
Georgia Department of Human Resources, Division of Public
Atlanta, GA, USA
having sex. In multivariate analysis being seropositive, and
being high or drunk retained significance. Subsequent re-
search may build upon these findings to determine the causal
pathway to UAS among MSM having sex with non-main
partners. Findings may be useful in constructing prevention
interventions for MSM frequenting gay venues.
Keywords HIV prevention.Risk behavior.Behavioral
surveillance.Men who have sex with men.Homosexual
MSM experience a substantial risk of infection with HIV
(Centers for Disease Control & Prevention, 2000, 2001a,
2001b; Sullivan, Chu, Fleming, & Ward, 1997). Moreover,
MSM are disproportionately at-risk of acquiring and trans-
mitting bacterial STDs (Centers for Disease Control and
Prevention, 1997, 1999, 2001c, 2001d; Fox et al., 2001;
Rietmeijer, Patanaik, Judson, & Douglas, 2003). Engaging
in UAS is the primary risk factor for HIV acquisition and
transmission among MSM. Unfortunately, empirical inves-
tigations have not always distinguished between men having
UAS in the context of a committed relationship and those
having sex with non-main partners. In studies where this
distinction has been made, UAS is far less common with
non-main sex partners (Misovich, Fisher, & Fisher, 1997).
This observation is important because it implies that MSM
who do not practice safer sex with non-main partners may
be particularly at-risk of infection.
Studies of MSM in Sydney, Australia have identified
knowingly being seropositive for HIV as an important cor-
relate of engaging in UAS with a casual partner (Van De
Ven et al., 1997, 1998). Further, data from Sydney and from
576 AIDS Behav (2006) 10:575–578
British Columbia suggest that recreational drug use may be
an important correlate of having UAS with casual partners
(Strathdee et al., 1998; Van De Ven et al., 1998). Data from
Sydney also suggest that knowledge of the sex partner’s
serostatus and disclosure of serostatus may be important
determinants of UAS with casual partners (Prestage et al.,
2001). Level of education may also be a factor (Strathdee
et al., 1998). Unfortunately, recent studies have not inves-
tigated correlates of UAS with non-main partners among
MSM in the United States. Accordingly, this study identified
demographic and behavioral correlates of recently engaging
in UAS with non-main partners among MSM residing in a
large metropolitan area.
Participants and procedures
From October 2003 until October 2004 men residing in
Atlanta, Georgia were recruited to participate in an anony-
mous, cross-sectional, venue-based survey. Project staff re-
cruited men in gay identified venues. The large majority
(about 75%) of these venues were bars or nightclubs. The
remainder were community based organizations, parks, food
asked to complete a brief anonymous survey, 1145 of those
to participate and provided a complete interview (87.9%).
Of these men, 391 reported having had sex with a non-main,
male partner in the past year and provided data about UAS
with the most recent non-main partner.
Men were eligible for study participation if they were
18 years of age or older and they had not previously partici-
pated in the same study. Volunteers were asked if they would
like to complete the interview in a semi-private area (e.g., a
place in or nearby the venue that may be a bit more quiet).
For men selecting this option, interviewers typically located
areas of the venue that were less crowded or conducted the
interview on a nearby sidewalk that was not busy at the time.
Trained interviewers used personal digital assistants (PDAs)
to record answers provided by men.
“not main” male sex partners. Men were asked if they had
used a condom for the entire duration of the last anal sex
act (as compared to part or none of the duration). Separate
questions assessed this for receptive and insertive acts of
likely correlates of UAS: being seropositive for HIV, being
high or drunk during last sex, discussing HIV serostatus
with partner before sex, knowing partner’s HIV serostatus,
and whether men had talked with a counselor or other pro-
fessional about HIV prevention.
Fifty-eight men indicated being both in a receptive and in-
sertive position during their most recent act of anal sex with
a non-main partner. These men classified as having UAS if
either event was not protected by a condom. Bivariate as-
sociations between dichotomous correlates and UAS were
assessed by contingency table analyses. Variables testing
significant (p ≤ .05) at the bivariate level were entered into
a forward stepwise multiple logistic regression model.
One-quarter (25.3%) of the men were classified as having
participated in UAS. Table 1 displays the percent of men
reporting UAS stratified by their responses (i.e., yes vs. no)
to the dichotomous measures. The table also provides preva-
lence ratios. As shown, men who were seropositive were
about three-fourths more likely to report UAS than their
seronegative counterparts. Men who reported being high or
drunk were about 56% more likely to have had UAS. White
men were 54% more likely to engage in UAS. Also (not
shown in table) the mean age of men having UAS was
36.0 years compared to a significantly lower value of
33.9 years among those not reporting UAS, t(389) = 1.93,
p = .05.
The model was significant, χ2(2) = 15.4, p < .01, and
achieved an excellent fit with the data, Goodness of Fit
χ2(2) = .11, p = .95. However only 2 variables retained
significance (Table 2).
The data presented here are from what is, to the best of
our knowledge, the largest venue-based HIV risk-behavior
survey of MSM in the South. One-quarter of the sample
engaged in UAS the last time they had sex with a non-main
partner. These men tended to be white, older, seropositive,
analyses, being HIV positive and substance use were the
is the use of event-level data relative to men’s being high or
drunk during their last sexual encounter with a non-main
AIDS Behav (2006) 10:575–578 577
Dichotomous Correlates and
Engagement in Unprotected
Anal Sex, With Non-Main
Partners, at Last Sexual
anal sex Correlate
High or drunk during last sex
Discussed serostatus before last sex
Know partner’s serostatus before last sex
Recently talked with an HIV counselor
28.4 0.82 0.58–1.15.25
22.8 0.76 0.54–1.06.11
22.2 1.16 0.65–2.06.61
male partner (Prestage et al., 2001; Strathdee et al., 1998;
Van De Ven et al., 1997, 1998). This adds strength to the
proposition that alcohol and/or drug use may lead to risky
sex. However, the same cannot be said about HIV serostatus
because the assessment did not include a timeline for when
men discovered their positive serostatus in contrast to their
last sexual encounter. However, given the likelihood that
men’s last sexual encounters with non-main partners were
relatively recent in contrast to learning their serostatus, the
finding is nonetheless important.
The multivariate findings are particularly instructive. It
may be, for example, that substance use actually predicts
risky sexual behavior which in turn predicts HIV serostatus.
However, the limitation of a cross-sectional study precludes
determining this possible causal sequence. Future research
to determine the causal pathway is critical for understanding
how to construct and prioritize HIV prevention interventions
for MSM frequenting gay venues.
Achieving Bivariate Significance and Engaging in Unprotected Anal
Sex With Non-Main Partners
Significant Multivariate Associations Between Correlates
Seropositive for HIV
High or drunk during last sex
aAdjusted odds ratio—adjusted for the influence of all other variables
in the model.
ship between UAS and the variables such as discussing HIV
serostatus with partners before sex, knowing partner’s HIV
serostatus, and talking with a counselor about HIV preven-
tion. Future research should verify whether these constructs
are truly unrelated to UAS among MSM having non-main
Acknowledgements We acknowledge the support of the Georgia De-
partment of Human Resources, Division of Public Health as well as
CDC for this work.
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