Self-Efficacy Among Young Men Who have Sex with Men: An Exploratory Analysis of HIV/AIDS Risk Behaviors Across Partner Types

Abstract

HIV infection continues to rise among young men who have sex with men (YMSM). We explored whether unprotected receptive anal intercourse (URAI) occasions and partners, respectively, were associated with YMSM's (N = 194; ages 18-24) self-efficacy for safe sex with regular and casual partners. We created four self-efficacy typologies: high self-efficacy with both partner types [HRHC; N = 73(41.7 %)], high self-efficacy with regular partners but low with casual partners [HRLC; N = 24(13.7 %)], low self-efficacy with regular partners but high with casual partners [LRHC; N = 21(12.0 %)], and low with both partner types [LRLC; N = 57(32.6 %)]. YMSM in the LRHC category reported fewer URAI occasions, whereas those in the HRLC group reported more URAI partner and occasions, respectively. YMSM having serodiscordant partners were more likely to report more URAI partners, and be represented in the LRLC category. These findings underscore the importance of addressing differential self-efficacy across partner types, and highlight an urgent need to enhance YMSM's self-efficacy with casual partners.

Full text

ORIGINAL PAPER
Self-Efficacy Among Young Men Who have Sex with Men:
An Exploratory Analysis of HIV/AIDS Risk Behaviors Across
Partner Types
Jose
´A. Bauermeister •Andrew M. Hickok •
Chrysta Meadowbrooke •Tiffany Veinot •
Jimena Loveluck
ÓSpringer Science+Business Media New York 2013
Abstract HIV infection continues to rise among young
men who have sex with men (YMSM). We explored
whether unprotected receptive anal intercourse (URAI)
occasions and partners, respectively, were associated with
YMSM’s (N=194; ages 18–24) self-efficacy for safe sex
with regular and casual partners. We created four self-
efficacy typologies: high self-efficacy with both partner
types [HRHC; N=73(41.7 %)], high self-efficacy with
regular partners but low with casual partners [HRLC;
N=24(13.7 %)], low self-efficacy with regular partners
but high with casual partners [LRHC; N=21(12.0 %)],
and low with both partner types [LRLC; N=57(32.6 %)].
YMSM in the LRHC category reported fewer URAI
occasions, whereas those in the HRLC group reported more
URAI partner and occasions, respectively. YMSM having
serodiscordant partners were more likely to report more
URAI partners, and be represented in the LRLC category.
These findings underscore the importance of addressing
differential self-efficacy across partner types, and highlight
an urgent need to enhance YMSM’s self-efficacy with
casual partners.
Resumen El VIH continu
´a en aumento en los hombres
jo
´venes que tienen sexo con otros hombres (YMSM). En
este estudio, se examino
´la asociacio
´n entre el nu
´mero de
actos y parejas con las que los YMSM (N=194; 18-24
an
˜os) tuvieron sexo receptivo anal sin condo
´n (URAI), y su
auto-eficacia con parejas regulares y casuales. Creamos
cuatro combinaciones de auto-eficacia: alta en ambas
parejas [HRHC;N=73(41.7 %)], alta en parejas regulares
y baja en parejas casuales [HRLC;N=24(13.7 %)], baja
en parejas regulares y alta en parejas casuales [LRHC;
N=21(12.0 %)], y baja en ambas parejas [LRLC;
N=57;(32.6 %)]. LRHC reportaron menos ocasiones de
URAI, mientras que aquellos en HRLC reportaron un
mayor nu
´mero de actos y parejas, respectivamente. Jo
´venes
con parejas serodiscordantes fueron ma
´s propensos a ser
categorizados como LRLC y a tener mayor nu
´mero de
parejas. Estos hallazgos destacan la importancia de con-
siderar las diferencias en auto-eficacia entre tipos de pareja
y enfatizan la necesidad de mejorar la auto-eficacia en
parejas casuales.
Keywords Gay Prevention Sexual risk Partners
Introduction
Men who have sex with men (MSM) accounted for over
half (61 %) of all new HIV infections in the United States
J. A. Bauermeister A. M. Hickok
Sexuality and Health Lab, University of Michigan
School of Public Health, Ann Arbor, MI, USA
J. A. Bauermeister (&)
Department of Health Behavior and Health Education,
University of Michigan School of Public Health,
1415 Washington Heights, SPH I, Room 3822,
Ann Arbor, MI 48109-2029, USA
e-mail: jbauerme@umich.edu
C. Meadowbrooke
University of Michigan School of Information, Ann Arbor,
MI, USA
T. Veinot
Community Health Informatics Lab, University of Michigan
School of Public Health, Ann Arbor, MI, USA
J. Loveluck
HIV/AIDS Resource Center, Ypsilanti, MI, USA
123
AIDS Behav
DOI 10.1007/s10461-013-0481-5

(US) in 2009. Young men who have sex with men (YMSM)
carried the largest burden (69 %) of new infections among
individuals ages 13–29, and 44 % of infections among
MSM of all ages. Furthermore, while new infections
remained somewhat steady for MSM in other age groups,
YMSM experienced a drastic increase in new infections
between 2006 and 2009, particularly YMSM of color [1].
These data underscore the urgent need to develop effective
HIV/AIDS prevention programs for this population.
Safer sex practices (e.g.; condom use, discussions of HIV
status, and HIV testing) can be enacted in order to avoid
HIV infection through the especially high-risk activity of
unprotected receptive anal intercourse (URAI). However, to
successfully engage in such safer sex practices, YMSM
must feel confident in their ability to negotiate these safer
sex strategies with their partners (i.e., safer sex self-effi-
cacy) [2], particularly when engaging in unprotected sex
with serodiscordant or HIV-unknown partners [3]. Conse-
quently, addressing YMSM’s self-efficacy to negotiate
condoms with partners remains an important priority in
HIV/AIDS prevention. The influence of self-efficacy on
behavior is context specific [4]; thus, it is vital that we
consider the relationship between safer sex self-efficacy and
HIV/AIDS risk behaviors as dependent on partner type.
Recent findings suggest that MSM have difficulty enacting
their safer sex desires with casual and romantic partners,
respectively, albeit for different reasons (e.g., caught in the
heat of the moment vs. foregoing condoms as a sign of trust)
[5–8]. Researchers have also noted that YMSM may be
more likely to negotiate condom use with casual partners
than with a main/regular partner. Recognizing that YMSM
may seek different types of partners (e.g., regular and/or
casual) at any given time [9,10], it is necessary that YMSM
simultaneously feel confident in their ability to negotiate
safer sex across different partner types.
Although self-efficacy is dependent on partner type, and
despite the prevalence of simultaneous regular/casual partner-
seeking, few researchers have examined whether YMSM’s
self-efficacy with casual partners aligns with their self-effi-
cacy with regular partners [11]. Further, researchers have
often focused on only one type of self-efficacy (e.g., self-
efficacy with casual partners) when examining HIV/AIDS
risk behaviors [12–14]. This approach, however, assumes that
safer sex self-efficacy for casual and regular partners are
mutually exclusive or independent processes. YMSM’s sex-
ual decision-making, however, may be informed by their
concurrent perceptions of self-efficacy with regular and
casual partners. It is possible, for example, that YMSM who
report higher levels of self-efficacy with casual and regular
partners negotiate safer sex practices differently (e.g., con-
sistent condom use across both partner types) than counter-
parts who report high self-efficacy with one type ofpartner but
not the other (e.g., condom use with casual partners only).
Similarly, YMSM who report low self-efficacy with both
partner types may be least likely to use condoms. This con-
currency consideration of partner types is a unique contribu-
tion to the current body of literature, and would allow us to
consider whether varied self-efficacy across partner types
differentially influences YMSMs’ risk behaviors.
Study Objectives
The goal of this study was to explore and examine the
relationship between safer sex self-efficacy and sexual risk
behaviors in order to inform ongoing HIV prevention
efforts. We pursued three objectives for this study. First,
we assessed YMSM’s self-efficacy to negotiate safer sex
with casual and regular partners, respectively. Second, we
examined the overlap between these two partner types
scales and created four self-efficacy categories (i.e., low
regular/high casual; high regular/low casual; low regular/
low casual; high regular/high casual). We then examined
whether these self-efficacy categories varied by YMSM’s
sociodemographic characteristics and sexual risk behav-
iors. Finally, we examined whether these self-efficacy
categories were associated with YMSM’s occasions of
URAI in the prior 2 months and number of URAI partners,
respectively, in multivariate models.
Methods
Sample
Data for this paper come from a 2011 study examining the
influences of social and sexual networks on HIV testing
behaviors (the ‘‘Young Men’s Study’’). To be eligible,
recruits had to be male, be between the ages of 18 and 24,
live in the Detroit Metro Area, and report having been
sexually active with a male partner in the past 6 months.
Participants were recruited from venues frequented by
YMSM (e.g., social media websites, dating websites, bars/
clubs, university health centers, health departments, public
postings), and incentivized with a $25 gift card. Promo-
tional materials included the logo of both the University of
Michigan and the HIV/AIDS Resource Center (HARC), our
community partner, and asked young men to verify their
eligibility to participate in an HIV/AIDS survey, a mention
of a $25 gift card incentive, and the survey’s website.
Procedures
The web-survey was developed using current web-survey
recommendations [15], and piloted prior to data collection.
Study data were protected with a 128-bit SSL encryption and
kept within a University of Michigan fire- walled server.
AIDS Behav
123

Upon entering the study site, participants were asked to enter
a valid and private email address, which served as their us-
ername. This allowed participants to save their answers and,
if unable to complete the questionnaire at one sitting, con-
tinue the questionnaire at a later time. Participants were then
asked to answer six questions (i.e., biological sex, age, res-
idential zip code, sexual activity with men, race/ethnicity) to
determine their eligibility. If eligible, participants were
presented with a detailed consent form that explained the
purpose of the study and their rights as participants.
We carried out data quality checks following recom-
mended practices [16] to minimize duplicate or fraudulent
entries following best practices. We used participants’
email, IP address, browser/operating system, and time taken
to complete survey to flag potential fraudulent/duplicative
cases. We also examined the concordance in participants’
answers to key survey questions (e.g., comparing partici-
pants’ self-reported age in years in the screener to their
reported month/year of birth in the survey). We cross-
checked email and IP addresses through web applications
(e.g., Facebook, IP lookup). If verified, we treated a case as
unique; otherwise, we did not use the entered data. We had
824 unique site visitors, as counted by unique IP address.
We recorded 1,034 survey entries, which included 194
eligible and complete cases, 16 incomplete entries, and 264
entries that were ineligible for study participation based on
eligibility criteria. In addition, we detected 559 fraudulent
entries which were removed from our dataset. Our recruit-
ment rate was 79.69 % and, after excluding fraudulent
cases, our completion rate was 92.38 %. After verification,
data were de-identified and transferred into SPSS software.
Consented participants then answered a 30–45 min
questionnaire that assessed their sociodemographic char-
acteristics, attitudes, norms, and intention to get tested for
HIV, previous HIV testing experiences, network charac-
teristics, sexual behavior, substance use, information-
seeking behavior, and Internet use. Participants could
select a $25 iTunes or Amazon e-gift card upon completion
of the questionnaire. We acquired a Certificate of Confi-
dentiality to protect study data. The University of Michigan
Institutional Review Board and our local community
partner (HARC) approved all study procedures.
Measures
We include descriptive statistics for variables included in
this report in Table 1.
Sexual Behavior
Participants were asked to report their sexual behavior with
men and women during the previous 2 months using the
Sexual Practices Assessment Schedule [17,18]. Questions
were asking both in formal language and vernacular (in
italics) to increase comprehension. For this report, we
focus on the questions regarding participants’ number of
sexual encounters where they served as the receptive
partner. Specifically, we report on the number of URAI
occasions and partners, respectively. We assigned a value
of zero to participants who reported not having engaged in
URAI in the past 2 months.
Self-Efficacy
We adapted Fisher et al. [19] self-efficacy scale to ascertain
YMSM’s confidence to discuss safer sex with partners,
refuse to have unprotected sexual intercourse, nonverbally
communicate to a partner a desire for safer sex, tell a
partner through a joke one’s desire for safer sex, refuse sex
if a partner refuses to use a condom, ask a partner their HIV
status, and ask a partner when they were last tested for HIV
[20]. Participants responded these items using on a 5-point
scale (1 =Very confident, 5 =Not confident at all).
Questions were asked separately for regular and casual
partners. Cronbach’s alphas for the self-efficacy for safe
sex scales were a=0.94 for regular partners and a=0.91
for casual partners. Higher scores in each scale reflect less
confidence to negotiate condoms.
HIV Status
We asked YMSM how many times they had tested for HIV,
and whether they had ever tested positive for HIV. We used
these two questions to categorize our sample of YMSM into
HIV-positive, HIV-negative, and HIV-unknown status.
Partner Serodiscordance
Participants who reported having URAI with one or more
partners were asked to report if they had been expressly told
by their sexual partner(s) that they were HIV-negative or
HIV-positive, respectively. Partners who had not expressly
told the participant their HIV status were categorized as
having an unknown HIV status. We created a dummy var-
iable to measure the risk of having one or more potentially
serodiscordant partners during URAI in the prior 2 months
(0 =seroconcordant; 1 =one or more serodiscordant
partners). Among HIV-negative participants, having a se-
rodiscordant partner was operationalized as having one or
more partners who were HIV-positive or of unknown status.
Among HIV-positive participants, a serodiscordant partner
was operationalized as having one or more partners who
were HIV-negative or of unknown status. Among partici-
pants who did not know their HIV status, having a sero-
discordant partner was operationalized as having one or
more partners who were HIV-positive or of unknown status.
AIDS Behav
123

Demographic Characteristics
Participants were asked to report their age in years, highest
level of education completed, sexual orientation, and
transgender identity. Participants also indicated their race
(Black/African American, White, American Indian/Alas-
kan Native, Asian, Native Hawaiian/Pacific Islander, and
other) and Spanish/Hispanic/Latino ethnicity. We com-
bined American Indian/Alaskan Native, Asian, Native
Hawaiian/Pacific Islander, and other race categories given
the limited number of observations, and then created
dummy variables for each race/ethnicity group. White
respondents served as the referent group in our analyses.
We also asked participants to report whether they were
single or in a relationship with another man.
Data Analytic Strategy
After conducting exploratory descriptive analyses, we used
generalized linear models with a Poisson distribution to
accommodate the count nature of our outcome variables.
We included the self-efficacy categories as predictors of
Table 1 Descriptive statistics
of study variables (N=194)
HRHC high self-efficacy with
regular and casual partners,
HRLC high self-efficacy with
regular partners and low self-
efficacy with casual partners,
LRHC low self-efficacy with
regular partners and high self-
efficacy with casual partners,
LRLC low self-efficacy with
regular and casual partners
a
One participant had missing
data on education
b
One participant had missing
data on sexual identity
c
Two participants had missing
data on transgender identity
d
Higher scores reflect less
confidence in negotiating safer
sex
e
14 participants had missing/
incomplete data on self-efficacy
with regular partners
f
16 participants had missing/
incomplete data on self-efficacy
with casual partners
f
Variables presented in original
metric for descriptive purposes.
Given their skewed
distributions, we used each
variable’s log10 transformation
in analysis
Mean SD N%
Age 20.66 1.71
Race/ethnicity
Black 76 39.2
Hispanic 34 17.5
White 50 25.8
Other race 34 17.5
Education
a
Not completed HS 10 5.2
Completed HS/GED 183 94.8
Sexual identity
b
Gay 163 84.5
Bisexual 26 13.5
Heterosexual 7 3.6
Transgender
c
14 7.3
Relationship status
Single 133 68.6
In a relationship 61 31.4
Lifetime HIV testing
Tested 129 66.5
Number of tests 4.14 3.58
Never tested 65 33.5
HIV status
HIV?15 7.7
HIV-114 58.8
HIV unknown 65 33.5
Serodiscordance
Serodiscordant URAI 25 12.9
Self-efficacy
d
Regular partner
e
11.59 6.20
Casual partner
f
12.41 5.97
Low SE w/reg partner, Low SE w/cas partner 57 29.4
Low SE w/reg partner, High SE w/cas partner 21 10.8
High SE w/reg partner, Low SE w/cas partner 24 12.4
High SE w/reg partner, High SE w/cas partner 73 37.6
Sexual behavior (past 2 months)
f
Total number of male partners 1.72 2.26
URAI partners 0.43 0.87
Engaged in URAI 54 27.8
AIDS Behav
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URAI partners and occasions, respectively, after control-
ling for race/ethnicity, and partner serodiscordance. For
purposes of this analysis, we chose to include the sero-
discordance variable rather than HIV status due to the fact
that this report focuses on sexual partnerships and how they
shape YMSM’s risk for HIV transmission. Low self-effi-
cacy for both regular and casual partners (LRLC), and
White race were used as initial reference categories. We
performed post hoc analyses alternating the referent self-
efficacy category in order to identify and contrast addi-
tional sub-group differences in URAI partners and occa-
sions, respectively. No differences in sexual risk behavior
were noted between educational levels (high school com-
pletion versus less than high school) or age; thus, these
variables were excluded from the multivariate models. For
brevity, only statistically-significant findings (p\0.05) are
presented in the text.
Results
Sample Description
Our sample consisted of 194 YMSM with a mean age of
20.66 years (SD =1.71). Over a third (39 %) self-identified
as African-American/Black, followed by Whites (26 %),
Latino/Hispanic (17 %), and mixed or other race (18 %).
The majority of the sample self-identified as gay (84 %) or
bisexual (13 %). Seven percent of the sample identified as
transgender. Most participants (N=133, 68.6 %) reported
being single. A third of our sample reported never having
tested for HIV (N=65, 33.5 %). Among those who had
tested, the mean number of HIV tests reported was 4.14 tests
(SD =3.58). Over half of the sample reported being HIV-
negative (58.8 %), 7.7 % reported being HIV-positive, and
33.5 % did not know their HIV status.
Participants reported an average of two partners in the
past 2 months (M=1.72, SD =2.26), with over a quarter
of the sample reporting having had one or more URAI
partners in the past 2 months. When we examined the
average number of URAI partners in the past 2 months
across race/ethnicity categories (F
3,190
=4.69, p\0.01),
we found that African American participants (M=0.20,
SD =0.52) reported fewer partners than Latinos
(M=0.76, SD =1.08) and participants of other races
(M=0.68, SD =1.27), respectively. We noted no other
racial/ethnic differences in URAI partners. We then
examined the number of URAI partners by HIV status
(F
2,191
=8.78, p\0.001), and found that HIV-negative
YMSM (M=0.49, SD =0.97) reported fewer URAI
partners than HIV-positive partners (M=1.13,
SD =0.83), and more partners than those of an unknown
HIV-status (M=0.17, SD =0.52). YMSM who were
unaware of their HIV status also reported fewer URAI
partners than HIV-positive YMSM in our sample.
Participants reported an average of two URAI occasions
(M=1.94, SD =6.00), with 13 % (N=25) reporting
having at least one serodiscordant partner. We also noted
mean differences in URAI occasions by HIV status (F
2, 191
=
3.07, p\0.05). HIV-negative respondents (M=2.82,
SD =7.56) had more occasions of URAI than those with an
unknown status (M=0.57, SD =1.98). YMSM reporting
serodiscordant partners (M=1.68, SD =1.11) reported
more URAI partners than those who did not report serodis-
cordant partners (M=0.25, SD =0.65), t(192) =-9.21,
p\0.001.
Self-Efficacy Categories
After summing the items for each scale, we noted a neg-
atively skewed distribution in the scores for regular
(skew =-1.26) and casual (skew =-1.18) partner self-
efficacy, respectively. Consequently, acknowledging that
the non-normal distribution could bias our categorization if
we used the mean as the cut-point for each scale, we opted
to do a median split to divide participants into four
meaningful categories: low self-efficacy with both regular
and casual partners (LRLC; N=57), low self-efficacy
with regular partners and high with casual partners (LRHC;
N=21), high self-efficacy with regular partners and low
with casual partners (HRLC; N=24), and high self-effi-
cacy with regular and casual partners (HRHC; N=73).
Serodiscordant Partners
Participants with a serodiscordant partner reported lower self-
efficacy with both casual (M=15.42, SD =7.76; t(176) =
2.70, p\0.01) and regular (M=15.16, SD =6.99;
t(178) =3.18, p\0.01) partners than those without serodis-
cordant partners (Casual: M=11.94, SD =5.52; Regular:
M=11.01, SD =5.89), respectively. Moreover, we noted
that most participants with serodiscordant partners were rep-
resented in the LRLC category (N=13; 54.2 %) compared to
LRHC (N=2; 8.3 %), HRLC (N=3; 12.5 %), and HRHC
(N=6; 25.0 %) categories. A Chi square statistic was not
computed for this difference given the few observations in all
other self-efficacy categories. We noted no other differences
across self-efficacy scores.
URAI Partners
In our multivariate model (v2
(df =8, N=175)
=88.96,
p\0.001), we found no difference in the number of URAI
partners across self-efficacy categories (see Table 2), once
we had accounted for partner serodiscordance. YMSM who
reported at least one serodiscordant partner were more
AIDS Behav
123

likely to report multiple URAI partners. We noted no
association in URAI partners by race/ethnicity or rela-
tionship status.
In post hoc analyses contrasting the other self-efficacy
typologies to one another, we found that YMSM in the
HRLC category (OR =2.92 [95 % CI: 1.06, 8.08], Wald
v
2
=4.27, p\0.05) were more likely than counterparts in
the LRHC group to report multiple URAI partners in the
past 2 months. We noted no other significant contrasts in
our analyses.
URAI Occasions
In a multivariate model (v2
(df =8, N=175)
=127.07,
p\0.001), YMSM in the LRHC category were less likely
to report URAI occasions than YMSM in the LRLC cate-
gory (see Table 3). Conversely, YMSM in the HRLC
category reported more URAI occasions than the referent
group. We also found significant differences in URAI
occasions by race/ethnicity categories and HIV status.
Compared to White YMSM, Black, Latino or Other Race
participants reported fewer URAI occasions. Single par-
ticipants were less likely to report URAI occasions than
YMSM in relationships. We noted no relationship between
URAI occasions and partner serodiscordance.
In post hoc analyses contrasting the other self-efficacy
typologies to one another, we found that YMSM in the LRLC
(OR =0.47 [95 % Confidence Interval (CI): 0.36, 0.62],
Wald v
2
=27.68, p\0.001), HRHC (OR =0.47 [95 %
CI: 0.35, 0.62], Wald v
2
=28.69, p\0.001), and LRHC
(OR =0.19 [95 % CI: 0.11, 0.34], Wald v
2
=31.41,
p\0.001) were less likely than those in the HRLC category
to report URAI occasions in the past 2 months. Conversely,
YMSM in the LRLC (OR =2.50 [95 % CI: 1.40, 4.46],
Wald v
2
=9.56, p\0.01), HRHC (OR =2.50 [95 % CI:
1.40, 4.46], Wald v
2
=9.74, p\0.01), and HRLC
(OR =5.31 [95 % CI: 2.96, 9.53], Wald v
2
=31.41,
p\0.001) report greater URAI occasions than those in the
LRHC group. Contrasts using HRHC as the referent group
were comparable to those presented in Table 3.
Discussion
Self-efficacy is a vital ingredient in promoting safer sex
behavior; however, the negotiation of safer sex behaviors
has been noted to vary across partner types [6,11,21]. At
present, however, it remains unclear whether YMSM’s
concurrent perceptions of partner-specific self-efficacy are
associated with different HIV/AIDS risk outcomes. This
Table 2 Poisson regression of URAI partners (N=175)
Odds ratio 95 % Confidence
interval
Wald v
2
statistic
Self efficacy
LRLC Ref
HRHC 0.93 (0.51, 1.70) 0.06
LRHC 0.51 (0.20, 1.32) 1.92
HRLC 1.49 (0.81, 2.72) 1.64
Race/ethnicity
White Ref
Black 0.53 (0.26, 1.08) 3.08
Latino 1.35 (0.72, 2.53) 0.89
Other race 1.78 (0.94, 3.39) 3.09
Serodiscordance
Seroconcordant Ref
Serodiscordant 5.86*** (3.60, 9.53) 50.67
Relationship status
In a relationship Ref
Single 0.74 (0.45, 1.22) 1.38
HRHC high self-efficacy with regular and casual partners, HRLC high
self-efficacy with regular partners and low self-efficacy with casual
partners, LRHC low self-efficacy with regular partners and high self-
efficacy with casual partners, LRLC low self-efficacy with regular and
casual partners, Ref denotes use of category as referent
*p\0.05; ** p\0.01; *** p\0.001
Table 3 Poisson regression of URAI occasions (N=175)
Odds ratio 95 % Confidence
interval
Wald v
2
statistic
Self-efficacy
LRLC Ref
HRHC 1.00 (0.77, 1.31) 0.01
LRHC 0.40** (0.22, 0.72) 9.56
HRLC 2.13*** (1.61, 2.82) 27.68
Race/ethnicity
White Ref
Black 0.64*** (0.50, 0.83) 11.82
Latino 0.50*** (0.35, 0.71) 15.14
Other race 0.41*** (0.29, 0.59) 23.05
Partner serodiscordance
Seroconcordant Ref
Serodiscordant 1.13 (0.83, 1.53) 0.57
Relationship status
In a relationship Ref
Single 0.57*** (0.45, 0.71) 24.55
HRHC high self-efficacy with regular and casual partners, HRLC high
self-efficacy with regular partners and low self-efficacy with casual
partners, LRHC low self-efficacy with regular partners and high self-
efficacy with casual partners, LRLC low self-efficacy with regular and
casual partners, Ref denotes use of category as referent
*p\0.05; ** p\0.01, *** p\0.001
AIDS Behav
123

concurrency consideration of partner types is a unique
contribution to the current body of literature, and would
allow us to consider whether varied self-efficacy across
partner types differentially influences YMSMs’ risk
behaviors. Our results suggest that YMSM express differ-
ent levels of self-efficacy with casual and regular partners,
being categorized into one of four groups: low self-efficacy
with both regular and casual partners (LRLC), low self-
efficacy with regular partners and high with casual partners
(LRHC), high self-efficacy with regular partners and low
with casual partners (HRLC), and high self-efficacy with
regular and casual partners (HRHC). These typologies, in
turn, were associated with different HIV/AIDS risk out-
comes. Below, we discuss the implications of these find-
ings, highlighting opportunities for HIV/AIDS prevention
and intervention development.
Participants in the LRLC category did not have a dif-
ferent number of URAI partners than their counterparts in
other self-efficacy categories. The absence of such a rela-
tionship, however, may be attributable to the inclusion of
serodiscordance in our regression model. Given that most
serodiscordant URAI partnerships were identified among
those in the LRLC category, it may be possible that the
serodiscordance variable suppressed our ability to identify
mean differences in URAI partners across self-efficacy
categories. Statistical considerations aside, the overlap
between low self-efficacy across both partner types and
having one or more serodiscordant partners aligns with
prior research suggesting that YMSM with low self-effi-
cacy are less likely to negotiate safer sex and reduce their
HIV/AIDS risks [2]. Given that one third of our sample
were represented in the LRLC category and accounted for
most serodiscordant partnerships, our findings underscore
the need to focus on YMSM who do not feel confident in
their ability to negotiate with partners, both regular and
casual, and equip them with skills and strategies that help
them negotiate sexual encounters safely.
YMSM’s perceptions of having self-efficacy to negoti-
ate safer sex with only one partner type were also found to
be associated with HIV/AIDS risk. YMSM who reported
low self-efficacy with regular partners and high self-effi-
cacy with casual partners (LRHC) reported fewer URAI
occasions than any other self-efficacy category. These
findings align with prior research suggesting that YMSM
are more likely to negotiate condom use with casual part-
ners than with regular partners [11]. Although we are
unable to assess YMSM’s partner-seeking behaviors, one
potential explanation for this finding may be that YMSM in
the LRHC category are more likely to seek out casual
partners than regular partners. As a result, these YMSM
may have had a greater number of opportunities to enhance
their self-efficacy. It may also be possible that YMSM in
the LRHC category are aware that they feel less confidence
with regular partners, and take active steps to protect their
sexual safety by minimizing their HIV/AIDS risk through
condom negotiation strategies with casual partners. While
intriguing, we are unable to examine these proposed rela-
tionships in our study; consequently, future research
examining the sexual decision-making of YMSM in the
LRHC category is warranted.
While self-efficacy with casual sex partners was associated
with fewer HIV/AIDS risks even though self-efficacy with a
regular partner may be lowfor some YMSM (e.g., LRHC),the
same cannot be stated for YMSM on the other side of the
spectrum. YMSM in the HRLC category had a higher risk
behavior profile, reporting a greater number of URAI occa-
sions in the past 2 months than any other group and being
three times more likely than YMSM in the LRHC to have had
multiple URAI partners. These trends persisted even after
accounting for relationship status and partner serodiscor-
dance. Consequently, YMSM in the HRLC group may per-
ceive themselves to be efficacious with regular partners, yet
have difficulty enacting their confidence in another relational
context. In a qualitative study of YMSM’s safer sex negotia-
tions, for example, Eisenberg et al. [11] noted that YMSM
wanted to engage in safer sex practices, yet communicated
trust and pursued intimacy by foregoing condoms. Similarly,
Bauermeister et al. [22] noted that single YMSM were more
likely to report multiple URAI partners if they expressed
symptoms of romantic obsession and believed that foregoing
condoms would help them achieve an emotional connection
with a partner. Having lower self-efficacy with casual part-
ners, YMSM in the HRLC group may also have a difficult time
adapting their sexual negotiation strategies for regular part-
ners to casual encounters. Taken together, these findings
underscore the need to understand how and when YMSM in
the HRLC group engage in safer sex practices, and develop
tailored HIV prevention strategies that increase their ability to
translate their self-efficacy with regular partners into actual
practice across partner types.
Although we noted different sexual risk behaviors
between YMSM in the HRLC and LRHC categories, we
noted no differences between YMSM in the HRHC and
LRLC categories. This finding was unexpected as we would
anticipate from a theoretical standpoint that YMSM who
report high self-efficacy with both regular and casual part-
ners should present with the lowest risk profile. We posit four
possible interpretations for future research. First, it is pos-
sible that YMSM who believe themselves to be highly effi-
cacious across partner types have an excessively optimistic
outlook on their HIV susceptibility and, as a result, engage in
sexual behaviors that resemble those in the LRLC category.
In essence, being overly confident may nullify the protective
effects expected from having self-efficacy. An alternative
explanation may be that YMSM in the HRHC group are
unable to discern between regular and casual partners,
AIDS Behav
123

resulting in an inability to enact partner-specific condom
negotiation skills. Third, self-efficacy to practice safe sex
may not perfectly correlate with YMSM’s behavioral capa-
bility to actually enact safer sex practices. YMSM may know
what they have to do in order to have safe sex, and be con-
fident in these actions, but ultimately may decide to forego
such behaviors for any number of reasons, including desires
for increased pleasure and intimacy [5,11] or inability to
negotiate condom use due to substance use impairment [23–
26]. Finally, it is plausible that our measure of self-efficacy
may not perfectly discriminate between groups and, as a
result, lead to a limited correlation with YMSM’s safer sex
practices. Future research examining the plausibility of these
interpretations is warranted, as it may point to different
strategies in HIV/AIDS prevention.
It is also worth noting that single YMSM were also less
likely to report URAI occasions than YMSM in relation-
ships. While foregoing condoms with a regular partner may
be a suitable expression of intimacy and trust for YMSM, it
is vital that YMSM and their partners be tested prior to
foregoing condoms [27]. MacKellar et al. [28] for example,
found that YMSM forewent condoms before the HIV
infection window had passed. Consequently, it is vital that
we provide YMSM opportunities to sustain their condom
use self-efficacy with regular partners until they have
achieved this milestone. Although we were unable to assess
the duration of YMSM’s relationships, we found a third of
YMSM in our sample had never tested for HIV. This
proportion of YMSM who are unaware of their HIV status
is consistent with prior research [29,30]. Given that most
new infections are attributable to undiagnosed HIV cases
[31] and attributable to a regular partner [32], it is neces-
sary that we continue to promote and sustain intervention
strategies focused on increasing HIV status awareness for
YMSM in and out of relationships.
While our study provides important insight into HIV risk
among YMSM, there are several limitations that must be
noted. First, a significant proportion of the sample identified
as gay or bisexual, limiting the generalizability of our
findings to YMSM who do not identify as gay or bisexual.
Second, we did not ascertain how participants found out
about our study (e.g., online vs. bars), making difficult to
document the diversity of our recruitment efforts and
sample. Third, our study is also geographically limited to
the Detroit Metro Area and may not be generalizable to
YMSM living in other communities. Fourth, the survey
offered no definition of casual or regular partners, allowing
YMSM to respond with their own definition in mind;
however, we must recognize that there are varying defini-
tions for these terms, including a growing body of literature
recognizing that a dichotomized distinction between partner
types may be artificial and not as easily delineated in young
men’s lives [33]. Consequently, we encourage future
research to examine whether condom self-efficacy mea-
sures may be more discriminant by focusing on the timing
of a relationship (e.g., ‘‘getting to know someone’’ vs.
‘‘dating for a while’’) and/or the traits of a relationship (e.g.,
sex with a partner in a relationship with high intimacy vs.
one with a partner where there is little or no intimacy). Fifth,
our analyses focus on URAI, limiting our ability to examine
how self-efficacy may influence YMSM’s decisions to
engage in unprotected insertive anal intercourse with dif-
ferent partner types. Future research examining whether our
self-efficacy findings may differ as a function of sexual role
is warranted in order to portray a full picture of YMSM’s
HIV risks. Finally, social desirability bias may influence
how participants answered survey questions referring to
sexual risk behavior; however, we sought to minimize
social desirability with the use of a web-based survey and
previously validated sexual behavior assessments with this
age group. These limitations notwithstanding, our study
contributes to the literature by acknowledging that self-
efficacy for safer sex with both regular and casual partners
concurrently influences YMSM’s HIV/AIDS risks. These
findings underscore the need to formulate new and inno-
vative strategies to promote safer sex strategies for YMSM,
including activities that simultaneously take into account,
and are tailored for, different partner types.
Strategies that increase YMSM’s safe sex self-efficacy
across partner types are warranted. Our findings provide
some evidence that differing self-efficacy typologies may
underscore different risk profiles among YMSM; however,
it remains unclear whether these partner-based self-efficacy
typologies inform different partner-seeking behaviors,
behavioral skills, or communication styles. Future research,
qualitative and quantitative, examining these processes is
needed in order to strengthen ongoing prevention efforts.
Acknowledgments This project was funded by the National Insti-
tutes of Health, National Center for Research Resources, Grant
UL1RR024986. Dr. Bauermeister is supported by a Career Devel-
opment K01 (K01-MH087242) from the National Institutes of Mental
Health.
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