Sexual risk of HIV transmission is missed by traditional methods of data collection

Brief acts of unprotected anal sex (i.e. ‘dipping') have not been systematically measured in AIDS research. Eleven per cent of HIV-positive men who reported that they had not engaged in any unprotected insertive anal intercourse with an HIV-negative or unknown status partner reported that they did engage in insertive ‘dipping'. Men reported ‘dipping’ an average of 5.1 times, representing 773 acts of insertive intercourse that would have been missed by traditional methods of sexual behavior data collection. Over the past two decades, behavioral surveys assessing sexual practices have been used to describe behaviors that place individuals at risk of acquiring or transmitting HIV, to identify predictors of risk, and to evaluate behavior change. Many methodological considerations are involved with the collection of sexual behavior data, including mode of administration, recall time period, social desirability, literacy and interpretation [1]. Measuring sex behaviors has become increasingly precise by focusing on factors that affect the risk of HIV transmission, including whether the respondent was the receptive or insertive partner, whether or not ejaculation occurred, and the serostatus of an individual and his or her partner [2–5]. The accurate measurement of risk behavior is particularly important when assessing what is considered the highest sexual transmission risk, a known HIV-positive individual having unprotected insertive anal intercourse (UIAI) to ejaculation with a known HIV-negative individual. The present study advances efforts to measure more precisely sexual risk behaviors. Earlier research among heterosexual HIV-positive men who reported ‘consistent’ condom use also reported occasional insertion into their partner's vagina before condom use for the purposes of foreplay [6]. We examined whether this was true for HIV-positive men who have sex with men (MSM) with regard to anal sex. Data are from the Seropositive Urban Men's Intervention Trial (SUMIT), a multi-site, HIV risk-reduction intervention trial targeting HIV-positive MSM in New York and San Francisco. Baseline surveys were completed between March 2000 and June 2001 (n = 1164). Participants responded to a series of detailed sexual behavior questions for seropositive, seronegative, and partners of unknown status that assessed the frequency of receptive and insertive anal sex with condoms, without condoms, with ejaculation, and withdrawal before ejaculation. After all of the sex behavior questions had been asked participants were asked about ‘dipping'. In particular, participants were asked ‘‘In the past 90 days were there times that you ‘dipped’ a (partner) that you did not count in the questions you just answered? ‘Dipping’ refers to teasing or playing with your partner by putting your penis in his ass just once or twice without a condom.’’ Additional measures included: sociodemographics, including age, race/ethnicity, education, partner serostatus, health status and city of residence; condom beliefs, which examined beliefs that condoms interfere with sexual pleasure; perceived responsibility, which examined whether a respondent perceived himself to be responsible for protecting his partner; sexually transmitted diseases (STD) knowledge, which assessed a respondent's knowledge about how STD are transmitted; assumptions, which examined the likelihood of a participant making assumptions about his partner's serostatus; sex under the influence, which examined the frequency of participants engaging in sex when under the influence of drugs or alcohol; number of partners, which examined the number of different sexual partners a participant had in the past 90 days. The focus of this report was to examine the prevalence of insertive ‘dipping’ with an HIV-negative or unknown status partner and to assess whether this approach identified additional acts of UIAI that were not reported in response to specific questions about UIAI. In addition, variables predictive of ‘dipping’ were examined. All participants who reported having an HIV-negative or unknown status partner in the past 90 days were included in the analysis (N = 858). We found that overall, 18% (N = 154/858) of the participants reported insertive ‘dipping’ with an HIV-negative or unknown status partner in the past 90 days. In particular, 11% of those who reported they had not engaged in any UIAI (69/628), reported they had engaged in ‘dipping', whereas 37% of those reporting UIAI (85/230) also reported ‘dipping’ (χ2 = 77.1, P < 0.0001). Participants were asked the number of times they engaged in ‘dipping’ over the past 90 days, and the mean was 5.1 (range 1–53). It is unknown whether these were separate acts of ‘dipping’ over time or occurred in the context of one sexual encounter. Multivariate logistic regression analysis showed that men who reported engaging in UIAI [P < 0.000, odds ratio (OR) 4.150, 95% confidence interval (CI) 2.763, 6.234], Latino men (P = 0.009, OR 2.099, 95% CI 1.202, 3.664) and men who are more likely to believe that condoms interfere with sexual pleasure (P = 0.013, OR 1.353, 95% CI 1.067, 1.715) were more likely to report insertive ‘dipping’ with an HIV-negative or unknown status partner. Existing methods used to assess sexual risk for HIV transmission do not account for men who engage in ‘dipping'. As a result, the current estimates of sexual risk among MSM may be lower than what is actually occurring. In the present study, 11% of HIV-positive MSM reported that they did not engage in UIAI when in fact they did, via ‘dipping'. In particular, 773 acts of ‘dipping’ occurred among HIV-positive men with HIV-negative partners that would not have been reported had we not asked about ‘dipping’ specifically. This suggests that some men do not view ‘dipping’ as unprotected anal sex and could be putting themselves and their partners at risk. Although we may not know the actual risk of ‘dipping’ relative to UIAI, data investigating similar behaviors suggest that there is substantial risk. For example, delayed condom use was the third strongest predictor of seroconversion (after no condom use and condom failure) in a study of MSM in Canada [7]. It is unclear whether MSM consider ‘dipping’ a prevention strategy, as has been found in studies examining ‘withdrawal’ [8]. A large portion of men who engage in UIAI also engage in ‘dipping', which is not surprising, nor well understood. The present study was unable to determine whether men engaged in ‘dipping’ before UIAI, which may explain why it is underreported, or if it is a substitute for UIAI and perceived as less risky. Latino ethnicity was predictive of ‘dipping', which may suggest a systematic bias in existing sex behavior data collection methods. Not taking this into account may underestimate behavioral risk among Latino MSM and potentially reduce opportunities for prevention. These data also suggest greater resistance to consistent condom use among those who believe that condoms interfere with sexual pleasure. Qualitative research is needed to obtain a better understanding of the situations in which ‘dipping’ occurs. Epidemiological research is also needed to assess the association of ‘dipping’ with HIV transmission so that accurate prevention messages can be developed to address this potentially risky behavior that a substantial proportion of MSM may not consider when receiving general prevention messages about unprotected anal intercourse.

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