Beyond UAI: The Need for Couple-Level Interventions to Reduce Substance Abuse Among Gay Men in Intimate Relationships

Background: Substance use is a strong predictor of unprotected anal intercourse (UAI) among gay men. Substance abuse poses threats to psychological and physical well-being, housing, and employment, and increases vulnerability to HIV among HIV-negative men and reduces engagement in care among HIV-positive men. This study of gay couples explores substance abuse and its impacts on their primary romantic/sexual relationships.

Methods: Semi-structured, individual qualitative interviews were conducted with both members of 48 same-sex male couples in the San Francisco and New York metropolitan areas (n=96). We utilized purposive sampling to recruit and included Black (n=16), White (n=17) and interracial Black/White (n=15) couples. In each group, about half of couples were HIV-concordant-negative and half were serodiscordant. Grounded theory was used to guide coding and analysis.

Results: UAI was reported more often in couples where at least one partner abused substances, posing multiple health risks. Couples where one or both partners were abusing substances demonstrated poorer emotional and physical health and more often experienced poverty, homelessness, and sometimes incarceration. These findings were particularly pronounced among couples in which both partners had -or historically- abused substances.

Conclusions: Primary partners can enable substance abuse in relationships, however, enablement can be replaced by partner support to reduce and prevent substance abuse. Therefore, interventions for substance-abusing members of gay couples should target both partners to most effectively reduce HIV risk and enhance relationship stability, as well as consider structural factors that may inhibit the success of individual-level and even dyadic prevention approaches.