AIDS and Behavior, Vol. 9, No.

2, June 2005 (

C 2005)

DOI: 10.1007/s10461-005-3897-8

Partner Awareness of the Serostatus of HIV-Seropositive

Men Who Have Sex With Men: Impact on Unprotected
Sexual Behavior

Trevor A. Hart,1,5 Richard J. Wolitski,2 David W. Purcell,2 Jeffrey T. Parsons,3

Cynthia A. Gómez,4 and the Seropositive Urban Men’s Study Team

Prior research has provided conflicting evidence about the association between partner
awareness of an HIV-seropositive person’s serostatus and HIV transmission behavior via
unprotected intercourse. The current study examined partner awareness of participant HIV-
seropositive status and sexual behavior in a multiethnic sample of HIV-seropositive men
who have sex with men. Most HIV-seropositive men reported that their primary partners
are aware, and most reported that at least some non-primary partners are aware the par-
ticipant was HIV-seropositive before first having sex. Partner awareness of participant HIV-
serostatus was related to unprotected sexual behavior during the past 3 months in a non-linear
fashion, as men with partners who were inconsistently aware had higher rates of unprotected
receptive anal intercourse than men with partners who were consistently aware or consis-
tently unaware. Men with partners who were inconsistently aware also had higher rates of
insertive oral intercourse than men with partners who were consistently aware. However,
there were no differences in HIV transmission risk behavior between men with partners who
were consistently aware and men with partners who were consistently unaware a participant
was HIV-seropositive.
KEY WORDS: HIV; awareness; seropositive; men who have sex with men.

INTRODUCTION Stein and Samet, 1999), it is also possible that if safer

A continuing debate exists as to the importance
of awareness of serostatus among sex partners of
HIV-seropositive persons and its relationship to sex-
ual risk behaviors. Although some have argued that
HIV-seropositive individuals always need to ensure
that potential partners are aware that they are having
sex with an HIV-seropositive individual so that non-
infected partners can make informed decisions about
their risk of HIV infection (Marks and Crepaz, 2001;
1 York University.
2 Centers for Disease Control and Prevention.
3 City University of New York.
4 University of California at San Francisco.
5 Correspondence should be directed to Trevor A. Hart, Depart-
ment of Psychology, York University, 4700 Keele St., Toronto,
ON M3J 1P3: Canada; e-mail: Thart@yorku.ca.
sex is practiced then partner awareness would not
further reduce the risk of HIV transmission. From a
public health perspective, the literature has provided
conflicting evidence about the association between
partner awareness that an individual is seropositive
and practicing unprotected intercourse. Some stud-
ies have found that partner awareness was associated
with increased unprotected intercourse (Kalichman
and Nachimson, 1999; Niccolai et al., 1999), while
others have not (Marks and Crepaz, 2001; Ostrow
et al., 1989; Wolitski et al., 1998). The vast majority
of the literature on partner awareness has examined
the role of overt disclosure of serostatus of the HIV-
seropositive partner. The relation of overt disclo-
sure and unprotected intercourse has been examined
during a specific sexual encounter (e.g., Marks and
Crepaz, 2001) or with one partner (e.g., De Rosa and

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C 2005 Springer Science+Business Media, Inc.
156 Hart, Wolitski, Purcell, Parsons, Gómez, and the Seropositive Urban Men’s Study Team
Marks, 1998). Other studies have employed a ret-
rospective self-report across a specified timeframe,
and assessed differences between HIV-seropositive
individuals who disclosed to all partners or not (e.g.,
Stein et al., 1998) or those who disclosed to at
least one partner or none of their partners (e.g.,
Kalichman and Nachimson, 1999; Wolitski et al.,
1998). Although each of these methods have added
significantly to understanding of disclosure, none of
them allows comparison of respondents who have
partners who are inconsistently aware with respon-
dents who report that all of their partners or none
of their partners were aware that the respondent was
HIV-seropositive prior to risky sexual behavior.
Several behavioral, psychological, and medical
variables have been examined as predictors of HIV
disclosure. Contextual behavioral variables previ-
ously associated with non-disclosure among men
who have sex with men (MSM) include greater num-
ber of partners (Niccolai et al., 1999; Wolitski et al.,
1998), and having anonymous or casual sex partners
(Semple et al., 2000). Qualitative data on the context
in which disclosure occurs also suggest a possible
association between non-disclosure and meeting
partners at sex venues such as bathhouses or public
sex venues (Stirratt, 2005). Having partners in the
context of a less emotionally intimate context may
therefore be associated with less disclosure and/or
partner awareness of serostatus. Psychological vari-
ables have included discomfort with a gay sexual
identity (Simoni et al., 1997; Perry et al., 1994), low
disclosure self-efficacy (Kalichman and Nachimson,
1999), and low disclosure intention (Stirratt, 2005).
Medical variables associated with non-disclosure
have included having a non-symptomatic HIV
infection and lower number of years since being
diagnosed (Crepaz and Marks, 2003; Mansergh et al.,
1995; Marks et al., 1992; Simoni et al., 1997).
Most studies (e.g., Zea et al., 2003) have exam-
ined partner awareness by examining verbal disclo-
sure. However, qualitative data suggests that many
HIV-seropositive MSM report their sexual partners
become aware by other means, such as attending so-
cial events or other programs for HIV-seropositive
individuals also attended by the participant (Stirratt,
2005). Verbal disclosure may therefore fail to capture
all instances in which an individual has been made
aware that a partner is HIV-seropositive.
The current study attempted to answer four pri-
mary research questions. First, the study extended
the findings of previous disclosure research by ex-
amining awareness of HIV serostatus among sexual
partners and sexual behavior in a multiethnic sample
of HIV-seropositive MSM. Second, the current study
sought to examine partner awareness and HIV trans-
mission risk with non-primary partners. HIV trans-
mission risk behaviors were defined as unprotected
insertive and receptive anal intercourse, and unpro-
tected insertive oral intercourse with HIV-negative
or unknown serostatus partners. Men were catego-
rized by overall pattern of partner awareness into
three groups: men with all HIV-negative or unknown
serostatus non-primary partners who were aware
(consistently aware), men with no HIV-negative or
unknown serostatus non-primary partners who were
aware (consistently unaware), and men with some
but not all partners who were aware (inconsistently
aware) that the participant was HIV-seropositive be-
fore sex. Third, given the lack of literature on sexual
partners’ inconsistent versus consistent awareness
or non-awareness of serostatus of HIV-seropositive
MSM, it was of interest to explore differences among
groups regarding variables previously found to be
associated with greater awareness: a) psychological
variables, such as disclosure self-efficacy, disclosure
intention, comfort discussing HIV-serostatus, com-
fort with a gay sexual identity, b) contextual behav-
ioral variables including lower number of male part-
ners, lower number of HIV-negative or unknown
serostatus partners, having less than all non-primary
partners being one-night stands, and not attending
relatively anonymous sex venues (e.g., bathhouses,
public sex venues) to search for sex partners in the
past 3 months, and c) medical variables including
having an AIDS diagnosis and greater number of
years since HIV diagnosis. Fourth, in order to ex-
amine if awareness was an independent predictor of
HIV transmission risk, it was of interest to explore
if patterns of awareness would predict HIV trans-
mission risk even when controlling for psychologi-
cal and behavioral correlates of awareness and sexual
behavior.
METHODS
Participants
The sample consisted of 456 participants re-
cruited from June 1997 to September 1998 in
New York City and San Francisco for the Seroposi-
tive Urban Men’s Study (Purcell et al., 2001; Wolitski
et al., 2001). This study was designed to examine fac-
tors associated with safer sex behaviors among HIV-
seropositive men who have sex with men. Eligibility
Partner Awareness of HIV Serostatus
requirements consisted of being at least 18 years of
age, male (or having male genitalia if self-identified
as transgender), self-identifying as HIV-positive, re-
porting having sex with another man in the past year,
and living in the study catchment area.
Recruitment quotas resulted in approximately
equal numbers of African-Americans (29%), Latinos
(24%), and Caucasians (30%), with the remainder of
the sample consisting of Asian or Pacific Islanders
(6%), men of mixed race (8%), or others (3%). Age
ranged from 20 to 66 years with a mean of 37.4 (SD =
8.0). Approximately 61% were from New York and
39% from San Francisco. Regarding sexual orienta-
tion, 83% identified as gay, homosexual, or queer,
10% identified as bisexual, 1% identified as hetero-
sexual, and 4% were unsure or reported none of the
above. The vast majority (98%) identified as male,
with the remainder identifying as transgender. The
sample was primarily low-income, with 44% making
less than $10,000 a year, 25% making $10,000–19,999
a year, and the remainder (31%) making $20,000 or
more. Only 20% were employed full-time, and 13%
were employed part-time. Approximately 35% were
receiving unemployment due to disability, 4% were
unemployed students, and 28% were unemployed for
other reasons. Approximately 7% of the men did not
complete high school, 19% completed high school,
38% attended some college, 24% completed college,
and 11% received a graduate degree.
The mean time that participants knew of their
HIV-positive status was 6.8 years (SD = 4.0), and
44% of the men had been diagnosed with AIDS.
The vast majority (97%) of men reported knowing
their CD4 count (mean CD4 count = 396, SD = 274).
Most (92%) had their viral load tested, with 42%
reporting an “undetectable” viral load. Most (79%)
were taking HIV medications, with 81% of these tak-
ing a regimen including a protease inhibitor.
Measures
Partner Awareness of Respondents’
HIV-Positive Serostatus
Participants were asked about partner aware-
ness of participant HIV-positive serostatus among
primary sexual partners and non-primary partners
with whom the participant had sex in the last
3 months. Regarding primary partners, participants
were asked if they had a primary partner “that is, a
partner you would call your boyfriend, spouse, signif-
157
icant other, or life partner.” Participants were then
asked about the serostatus of the primary partner,
and if the primary partner “knew your HIV status be-
fore you had sex together for the first time.” Regard-
ing non-primary partners, participants were asked
how many HIV-seropositive, HIV-seronegative, and
unknown serostatus partners they had in the past
3 months. A partner’s serostatus could be unknown
to the respondent because a) it was unknown to the
partner or b) the partner did not report his serosta-
tus to the respondent. Participants were then asked
separately by partner serostatus how many partners
of that serostatus were aware of the participants’
serostatus before having sex for the first time. For
participants reporting non-primary partners, partic-
ipant responses were categorized into three groups:
those for whom all non-primary HIV-negative or un-
known serostatus partners were aware (consistently
aware), those for whom some but not all non-primary
HIV-negative or unknown serostatus partners were
aware (inconsistently aware), and those for whom
none of their non-primary HIV-negative or unknown
serostatus partners were aware (unaware) the partic-
ipant was HIV-seropositive.
Disclosure Self-Efficacy
Participants were asked how much they agreed
with statements regarding their perceived ability to
disclose their HIV-seropositive status to sex partners
across 5 situations (e.g., “I can disclose my HIV sta-
tus before having sex even to a really hot new sex
partner.”). Participants indicated agreement using a
5-point Likert-type scale (1 = absolutely sure I can-
not, 5 = absolutely sure I can). The measure was
internally consistent, α = .90.
Disclosure Intention
Participants were asked how much they agreed
with the following statement: “I plan on telling my
HIV status to all of my new partners before we have
sex.” Participants answered this question using a 5-
point Likert-type scale (1 = strongly disagree, 5 =
strongly agree).
Preferences for Nonverbal Versus Verbal Disclosure
Participants were asked if they “prefer to tell
new sex partners about your HIV status using verbal
158 Hart, Wolitski, Purcell, Parsons, Gómez, and the Seropositive Urban Men’s Study Team
(i.e., tell them directly) or non-verbal communication
(i.e., tell them without words).”
Comfort Talking About HIV Serostatus
Participants were asked how comfortable they
were talking to close friends, casual sex partners,
or health care providers about their HIV serostatus.
Items were treated separately to examine differences
in disclosure behavior for different types of relation-
ships. Participants indicated their comfort using a 5-
point Likert-type scale (1 = very uncomfortable, 5 =
very comfortable).
Comfort Regarding Gay Identity
Comfort regarding gay sexuality among this
MSM sample was operationalized via gay self-
identification and internalized homophobia. Regard-
ing gay self-identification, participants were asked if
they self-identified as 1) gay, homosexual, or queer,
2) bisexual, 3) heterosexual, or 4) unsure of their sex-
ual orientation. The internalized homophobia mea-
sure contains 5-items assessing degree of discom-
fort with one’s own homosexuality. Most items are
reverse coded (e.g., “I feel extremely comfortable
about being sexually attracted to men”). The scale
was adapted from Ross and Rosser’s (1996) internal-
ized homophobia scale and demonstrates acceptable
internal consistency (α = .77).
Attended Sex Venues to Meet Sex Partners
Participants were asked if they went to sex clubs,
bathhouses or public cruising areas where men look
for sex (e.g., parks) to meet new sex partners in the
past 3 months.
One Night Stands
Participants were asked what proportion of their
non-primary partners were one-time partners (i.e.,
one night stands) using a 5-point Likert-type scale
(1 = none, 5 = all or almost all). Because the vast
majority (89%) of men who had non-primary part-
ners reported having had one-night stands and 36%
reported all or almost all non-primary partners were
one-night stands, responses were dichotomized to in-
dicate whether all/almost all partners were one night
stands or not.
Social Desirability Response Bias
Participants completed the Marlowe-Crowne
Social Desirability Scale-Short Form (Crowne and
Marlowe, 1964; Reynolds, 1992) to assess for so-
cial desirability reporting bias. This instrument con-
sists of 13 items such as “I’m always willing to
admit when I make a mistake.” The Marlowe-
Crowne Social Desirability Scale has demonstrated
high test-retest reliability and internal consistency
in the general population (Crowne and Marlowe,
1964; Reynolds, 1992) and high internal consis-
tency in a study of unprotected sexual behavior
among MSM (DiFranceisco et al., 1998). It demon-
strated similar internal consistency in the present
sample, α = .71.
Sexual Behavior and HIV Transmission
Risk Behavior
Participants were asked about sexual activi-
ties in the past 3 months with their primary sex
partner and non-primary partners who were HIV-
seropositive, HIV-seronegative, or of unknown
serostatus. Questions included the frequency of
insertive anal intercourse and receptive anal inter-
course. HIV transmission risk behavior was assessed
by asking participants about the number of times
they had unprotected insertive and receptive anal
intercourse with partners of HIV-negative or un-
known serostatus in the last 3 months. Participants
were also asked about the number of times they
had unprotected insertive oral intercourse in the
last 3 months. To be consistent with the previous
literature on disclosure and unprotected sex, and
because any act of unprotected intercourse between
serodiscordant partners is a potential risk for HIV
transmission and is therefore of public health con-
cern, number of occasions was then dichotomized to
indicate presence or absence of an unprotected be-
havior (e.g., unprotected receptive anal intercourse).
This dichotomization also served to avoid violating
assumptions regarding normal distribution for linear
regressions. The proportion of each group engaging
in an unprotected sexual behavior was calculated by
dividing the number of participants engaging in an
unprotected behavior by the total number of par-
ticipants engaging in any instance of that behavior
(e.g., number engaging in unprotected receptive
anal intercourse divided by number engaging in any
receptive anal intercourse).
Partner Awareness of HIV Serostatus
Setting and Procedure
Sampling quotas were established to ensure the
representation of key ethnic/racial groups recruited
from three types of community settings: AIDS ser-
vice organizations, mainstream gay venues such as
gay bookstores, bars, and gay pride events, and pub-
lic sex environments (e.g., bathhouses, outdoor cruis-
ing areas, parks). Participants were actively recruited
by field staff who approached potential participants
in community venues and passively recruited through
flyers placed in the venues and gay-oriented publi-
cations. Recruitment materials described the study
and asked interested individuals to call a toll-free
number to obtain additional information about the
study. Interested participants were informed that the
study examined a variety of issues relevant to HIV-
seropositive men, including feelings and experiences
regarding sex, medical care, mental health and sub-
stance use. To eliminate the need for men to report
their HIV status in the venue, potential participants
were told, “If this does not apply to you, please give it
to someone you know.” As a result, some (20%) men
were referred to the study by friends and recruited
into the study through snowball sampling. Men who
met the eligibility criteria completed a paper-and-
pencil survey, which required approximately 1 hr on
average to complete. An incentive of $30 was given
to those completing the survey.
Analyses
Chi-square analyses were conducted to inves-
tigate differences in proportion of seropositive,
seronegative, and unknown serostatus primary part-
ners who were aware the participant was HIV-
seropositive before first sexual contact. Proportion of
seropositive, seronegative, and unknown serostatus
non-primary partners aware was also calculated, with
a generalized estimating equation (GEE) used to ex-
amine differences between rates of partner aware-
ness 1) among primary partners versus non-primary
partners and 2) among primary partners and non-
primary partners by partner serostatus (seroposi-
tive, seronegative, and unknown serostatus). Anal-
yses then examined psychological, behavioral, and
medical differences between participants with non-
primary HIV-negative or unknown serostatus part-
ners who were consistently aware, inconsistently
aware, and consistently unaware. Chi-square analy-
ses were conducted to investigate whether partner
awareness group was associated with differences in
159
categorical variables, with follow-up chi-square anal-
yses conducted when significant findings were found
in the omnibus test. The continuity correction statis-
tic was employed to determine significance in all
2 × 2 tables. Analyses of variance (ANOVAs) were
conducted to investigate whether partner awareness
group was associated with differences in continu-
ous variables, with significant differences followed
by Scheffe post hoc tests. Data regarding number of
partners were highly positively skewed, and there-
fore were log-transformed (Kirk, 1968; Winer, 1971)
using the formula log10 (x + 1) for all parametric anal-
yses using number of partners as the dependent vari-
able. Variables significantly associated with partner
awareness group were then entered together as pre-
dictors in a multinomial logistic regression model
with awareness group as the dependent variable.
Hierarchical binary logistic regressions were com-
puted with all significant correlates of partner aware-
ness group entered on the first block and partner
awareness group on the second block and an HIV
transmission behavior as the dependent variable. All
analyses were repeated selecting the 253 men who
preferred to disclose verbally to examine whether
differences among partner awareness groups differed
as a function of preferences for verbal versus nonver-
bal disclosure. All differences found among partner
awareness groups were significant at p < .05 unless
stated otherwise.
RESULTS
Disclosure to Primary Versus Non-Primary Partners
Thirty-nine percent of participants (n = 178)
reported having sex with a primary partner in the
last 3 months, compared to 80% (n = 363) who
reported having sex with a non-primary partner.
A quarter (n = 109) of the sample reported both
primary and non-primary partners. Of the 178
participants who had sex with their primary partner
in the last 3 months, more than three quarters (79%)
reported their primary partner was aware they were
HIV-seropositive before having sex with him for
the first time. Primary partner awareness was not
associated with the length of the relationship. The
association between partner awareness and sexual
practices with primary partners in the last 3 months
could not be assessed because of the small number
of men who reported their partner was not aware of
the participant’s serostatus. Of the 363 participants
who had sex with a non-primary partner in the last
160 Hart, Wolitski, Purcell, Parsons, Gómez, and the Seropositive Urban Men’s Study Team
Table I. Mean Number of Partners and Proportion of Partners Aware By Serostatus of Partner (n = 456)
Men with a primary partner (n)
Proportion primary partners aware prior to first sexual contact
Men with at least one non-primary partner (n)
Number of non-primary partners (SD)
Number of non-primary partners aware prior to first sexual contact (SD)
Proportion non-partners aware prior to first sexual contact
Note. SD = standard deviation.
3 months, study participants reported that 41% of
their non-primary partners were aware the partic-
ipant was HIV-seropositive before having sex with
the participant for the first time (see Table I). Analy-
ses indicated that primary partners were more likely
to be aware than non-primary partners, OR = 1.70,
95% CI = 1.49–2.53, and seropositive partners,
OR = 2.07, 95% CI = 1.38–3.11, and seronegative
partners, OR = 3.29, 95% CI = 2.16–5.01, were
more likely to be aware than were partners of un-
known serostatus. The interaction between partner
type and serostatus was not significant.
HIV-Negative and Unknown Serostatus Partner
Awareness and HIV Transmission Risk
Partner Awareness and Demographic Variables
Because of the potential risk of HIV trans-
mission to uninfected partners, we conducted ad-
ditional analyses that addressed awareness among
non-primary partners whom the participant believed
were HIV-seronegative or whose HIV serostatus
was not known by the participant. Most (85%; n =
309) participants with non-primary partners had sex
with an HIV-seronegative or unknown serostatus
non-primary partner. Of these 309 participants, 282
participants with complete data on all psychologi-
cal, behavioral, and medical variables were included
in analyses examining differences between partner
awareness groups (See Table II). There were no
differences between participants with and without
complete data on demographic, psychological, be-
havioral, or medical variables. Among the 282 par-
ticipants with complete data, 127 (45%) had non-
primary HIV-seronegative or unknown serostatus
partners who were consistently unaware, 83 (29%)
had non-primary HIV-seronegative or unknown
serostatus partners who were inconsistently aware,
and 72 (26%) had non-primary HIV-seronegative
Serostatus of partner
Positive Negative Unknown Total
91 72 15 178
87% 71% 50% 79%
198 146 285 363
2.46 (6.38) 1.48 (4.30) 8.82 (17.09) 12.65 (19.75)
2.02 (5.71) 1.07 (3.76) 2.30 (8.61) 5.19 (12.48)
84% 71% 26% 41%
or unknown serostatus partners who were consis-
tently aware of the participant’s HIV serostatus. Men
whose partners were inconsistently aware reported
that 40% (M = 0.40; SD = 0.27) of these partners
on average were aware (range 2–98%). The three
partner awareness groups did not differ in age, in-
come, education, employment, racial/ethnic back-
ground, recruitment city, or religion, years since test-
ing HIV-positive, or in social desirability response
bias. Participants with partners who were unaware
were significantly less likely to have been diagnosed
with AIDS than those with partners who were con-
sistently aware or inconsistently aware.
Partner Awareness and Psychological Variables
Among men with one or more non-primary
partners, partner awareness groups differed sig-
nificantly in disclosure self-efficacy and disclosure
intention, with those with partners who were consis-
tently aware scoring higher than those with partners
who were inconsistently aware, and those with part-
ners who were inconsistently aware scoring higher
than those with partners who were unaware. Groups
also differed in comfort talking about HIV with
non-primary partners, with those with partners who
were consistently or inconsistently aware reporting
greater comfort than those with partners who were
unaware. Partner awareness groups did not differ
in preferences of disclosing nonverbally versus ver-
bally, comfort talking about HIV with close friends
or with physicians or nurses, gay self-identification,
or internalized homophobia.
Partner Awareness and Sexual Practices
Differences among partner awareness groups in
sexual behavior related to HIV transmission risk and
in use of venues to meet sexual partners were also
Partner Awareness of HIV Serostatus 161

Table II. Psychological, Behavioral, and Medical Differences Among Partner Awareness Groups of Men With Non-Primary
Partners of HIV-Negative or Unknown Serostatus (n = 282‡ )
Partner awareness group

Unaware Inconsistently aware Consistently aware

F or χ2 (n = 127) (n = 83) (n = 72)
Psychological variables
Disclosure self-efficacy (SD) 39.71∗∗∗ 2.98 (0.99)a 3.66 (0.87)b 4.18 (0.90)c
Disclosure intention (SD) 45.46∗∗∗ 2.43 (0.94)a 2.89 (1.06)b 3.90 (1.20)c
Prefer to disclose nonverbally 4.57 18% 14% 7%
Comfort talking about HIV serostatus
With close friends (SD) 0.58 3.94 (1.23) 4.11 (1.18) 4.08 (1.35)
With doctors or nurses (SD) 0.01 4.38 (1.02) 4.39 (1.06) 4.35 (1.16)
With non-primary partners (SD) 22.02∗∗∗ 2.45 (1.15)a 3.14 (1.22)b 3.60 (1.33)b
Internalized homophobia (SD) 1.01 2.04 (0.79) 1.88 (0.71) 2.01 (0.90)
Gay self-identification 1.47 94% 92% 89%
Behaviors in the past 3 months
Number of male partners 2.51∗∗∗ 15.39 (23.28)a 21.42 (24.04)b 14.82 (21.44)c
Number of negative or unknown
serostatus male partners (SD) 4.39∗∗ 12.99 (19.46)a 19.42 (22.77)b 10.43 (16.79)a
All partners were one-night-stands 10.78∗∗ 46%a 29%b 24%b
Attended a sex venue to meet sex partners 13.81∗∗ 83%a 85%a 65%b
HIV transmission behavior
Unprotected receptive anal 8.40 32%a 49%b 28%a
Unprotected insertive anal 1.53 22% 32% 25%
Unprotected insertive oral 18.44∗ 75%a 84%a 61%b
Medical variables
AIDS diagnosis 10.49∗∗ 35%a 50%b 58%b
Years since testing HIV+ 0.64 6.56 (3.95) 7.18 (3.96) 6.63 (3.95)
Note. df = 2 for each omnibus test; SD = standard deviation; numbers with different superscripts in a given row differ signifi-
cantly at p < 0.05. F-test used for numeric data and χ2 test used for percentage data.
‡ Total n = 282 due to missing data.
∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.

explored (see Table II). Those with partners who
were inconsistently aware had a greater number of
male partners and number of HIV-negative or un-
known serostatus partners than those in the other
two groups. Men with partners who were unaware
had a higher number of male partners than those
with partners who were consistently aware. Men with
partners who were unaware were more likely to re-
port all of their non-primary partners were one-night
stands than those with partners who were consis-
tently or inconsistently aware. Regarding places that
men went to meet sex partners, those with part-
ners who were unaware and inconsistently aware
were more likely to have met a sex partner at sex
venues than those with partners who were consis-
tently aware.
Multivariate Analyses Predicting Partner Awareness
Number of male sex partners and number of
HIV-negative and unknown sex partners were cor-
related at r = .87. To avoid multicollinearity, only
the variable of most relevance to HIV transmission,
number of HIV-negative and unknown sex partners,
was included in the multivariate model. Variables
found to be associated with partner awareness group
were entered in as a group into a multinomial logis-
tic regression with partner awareness group as the
dependent variable (see Table III). The model was
significant, χ2 (14, N = 282) = 133.13, p < .01. Com-
pared to men with partners who were unaware, men
with partners who were consistently aware continued
to have higher disclosure self-efficacy, have greater
disclosure intention, have greater comfort talking
about their HIV status, and be more likely to have
an AIDS diagnosis. Compared to men with part-
ners who were inconsistently aware, men with part-
ners who were unaware had lower disclosure self-
efficacy, slightly fewer non-primary HIV-negative
or unknown serostatus partners (OR = 0.98) were
more likely to report that all partners were one night
stands and were less likely to have an AIDS diagno-
sis. Further, men with partners who were consistently
162 Hart, Wolitski, Purcell, Parsons, Gómez, and the Seropositive Urban Men’s Study Team
Table III. Multinomial Logistic Regression Predicting Differences Between Partner Awareness Groups of Men With Non-Primary
Partners of HIV-Negative or Unknown Serostatus (n = 282)
Predictors
Psychological variables
Disclosure self-efficacy
Disclosure intention
Comfort talking about HIV to non-primary partners
Sexual behaviors in the past 3 months
Number of HIV-negative or unknown serostatus
non-primary partners
Attending sex venues to meet partners
All partners one night stands
AIDS diagnosis
Note. Table compares men with non-primary HIV-seronegative or unknown serostatus partners who were consistently aware, incon-
sistently aware and unaware the participant was HIV-seropositive. The last category in each column is the reference group. n = 282.
∗ p < 0.05; ∗∗ p < 0.01; ∗∗∗ p < 0.001.
aware had greater disclosure intention than those
with partners who were inconsistently aware. There
were no differences in number of HIV-seronegative
or unknown serostatus partners between men with
partners who were consistently aware and inconsis-
tently aware. To examine the effect of preferences
for verbal disclosure upon analyses predicting part-
ner awareness, analyses were repeated selecting only
those men who preferred to disclose verbally. An
identical pattern of results emerged for both univari-
able and multivariate analyses.
Partner Awareness and HIV Transmission Behavior
with Non-Primary Partners
We examined differences in unprotected in-
sertive and receptive anal intercourse and insertive
oral intercourse with HIV-seronegative or unknown
serostatus non-primary partners (see Table II).
Men with partners who were inconsistently aware
were more likely to engage in unprotected receptive
anal intercourse than those whose partners were
consistently aware or unaware. Although a similar
pattern was observed for insertive anal intercourse,
differences between groups were not significant.
Regarding insertive oral intercourse, men with
partners who were inconsistently aware and men
with partners who were unaware were more likely to
engage in unprotected insertive oral intercourse than
those with partners who were consistently aware.
Given that men with partners who were inconsis-
tently aware ranged widely from 2 to 98% partner
OR (95% CI)
Consistently aware Unaware versus Consistently aware versus
versus unaware inconsistently aware inconsistently aware
2.02 (1.22–3.34)∗∗ 0.59 (0.41–0.86)∗∗ 1.46 (0.92–2.34)
2.33 (1.58–3.44)∗∗∗ 0.75 (0.55–1.03) 1.89 (1.34–2.67)∗
1.53 (1.06–2.19)∗ 0.77 (0.58–1.01) 1.14 (0.84–1.54)
1.01 (0.99–1.04) 0.98 (0.96–0.99)∗∗ 0.99 (0.97–1.01)
0.64 (0.25–1.63) 1.13 (0.48–2.66) 0.55 (0.24–1.27)
0.39 (0.17–1.01) 2.51 (1.28–4.92)∗∗ 0.94 (0.41–2.14)
2.41 (1.06–5.49)∗ 0.50 (0.27–0.96)∗ 1.24 (0.60–2.57)
awareness among HIV-seronegative or unknown
serostatus partners, we conducted a sensitivity anal-
ysis by excluding outliers by 5% on each side. This
resulted in the inconsistent partner awareness group
including only those who disclosed 7 to 93% of the
time. An identical pattern of results emerged when
analyses were conducted excluding outliers from the
inconsistent partner awareness group. Proportion of
aware partners relative to total partners was also as-
sessed as a potential predictor of sexual transmission
risk. Proportion of aware partners was not associated
with sexual transmission risk variables.
Multivariate analyses examined whether partner
awareness group would predict unprotected sexual
behavior controlling for variables found to be asso-
ciated with partner awareness group in the previous
multinomial logistic regression. Regarding unpro-
tected receptive anal intercourse, variables associ-
ated with partner awareness group were entered as
a group in block 1 and this block failed to reach sig-
nificance, χ2 (6, N = 282) = 12.22, n.s. Partner aware-
ness group was entered in block 2 and was signifi-
cant, χ2 (2, N = 282) = 9.42, p < 0.01. Compared to
men with partners who were inconsistently aware,
men with partners who were unaware continued to
be less likely to have unprotected receptive anal in-
tercourse, OR = 0.36, 95% CI = 0.18–0.70, but men
with partners who were consistently aware were no
longer less likely to have unprotected receptive anal
intercourse, OR = 0.57, 95% CI = 0.27–1.19.
An identical procedure was conducted exam-
ining unprotected insertive anal intercourse and
insertive oral intercourse. Regarding insertive anal
Partner Awareness of HIV Serostatus
intercourse, block 1 was significant, χ2 (6, N = 282) =
20.10, p < .01, with number of HIV-negative and
unknown serostatus partners associated with in-
creased likelihood of unprotected insertive anal in-
tercourse, OR = 1.02, 95% CI = 1.01–1.04. Partner
awareness was entered in block 2 and was signifi-
cant, χ2 (2, N = 282) = 6.133, p < .05. Partner aware-
ness group continued to be a significant predictor,
with those with partners who were unaware being
less likely to engage in this behavior than those with
partners who were inconsistently aware, OR = 0.40,
95% CI = 0.19–0.84.
Regarding insertive oral intercourse, block 1
was significant, χ2 (6, N = 282) = 40.07, p < .01, with
disclosure self-efficacy, OR = 1.77, 95% CI = 1.22–
2.56, disclosure intention, OR = 0.73, 95% CI =
0.54–0.99, number of HIV-negative or unknown
serostatus partners, OR = 7.88, 95% CI = 3.31–
18.81, and all partners being one-night stands, OR =
0.46, 95% CI = 0.23–0.91, predicting unprotected
insertive oral intercourse. AIDS status and com-
fort talking about HIV failed to predict unpro-
tected insertive oral intercourse. Partner awareness
was entered in block 2 and was not significant,
χ2 (2, N = 282) = 1.24, p < .05, with partner aware-
ness no longer predicting unprotected insertive oral
intercourse in the final model for unprotected in-
sertive oral intercourse. Given the strong association
of number of HIV-negative or unknown sersosta-
tus partners with insertive oral intercourse, post-hoc
analyses were conducted excluding this variable as
a predictor. Excluding this variable, when partner
awareness was entered in block 2 this block became
significant, χ2 (2, N = 282) = 7.68, p < .05. Partner
awareness predicted unprotected insertive oral in-
tercourse, as men with partners who were consis-
tently aware, OR = 0.38, 95% CI = 0.16–0.92, and
men with partners who were unaware, OR = 0.37,
95% CI = 0.15–0.83, being less likely to engage in
this behavior than those with partners who were in-
consistently aware.
To examine the effects of reported preference
for verbal disclosure, analyses were repeated select-
ing only those men who preferred to disclose ver-
bally. An identical pattern of results emerged for
both univariate and multivariate analyses.
DISCUSSION
Findings from the current study indicate that
although serostatus disclosure is common for most
163
seropositive MSM, only 68% of HIV-negative or
unknown serostatus primary partners in the past
3 months were aware the participant was HIV-
seropositive before having sex with him for the first
time. Regarding non-primary partners, only 26% of
HIV-seropositive MSM reported all non-primary
HIV-negative or unknown serostatus partners were
aware. There are important differences between
men with non-primary partners who are HIV-
seronegative or of unknown serostatus partners
who are all aware, some of whom are aware and
none of whom are aware the participant was HIV-
seropositive. These groups significantly differed in
disclosure self-efficacy, disclosure intention, comfort
in talking about one’s HIV status, having all of
one’s non-primary partners being one-night stands,
AIDS diagnosis, and, most importantly, risk of HIV
transmission.
The current study presents a novel method for
examining HIV serostatus partner awareness. Find-
ings suggest that assessment of disclosure as a bi-
nary variable (e.g., who disclosed to all partners or
not) may be insufficient, as more than a quarter
of the participants reported their non-primary HIV-
negative or unknown serostatus partners were incon-
sistently aware. as more of a quarter of those HIV+
participants reported their non-primary HIV- or un-
known serostatus partners were inconsistently ware
of their HIV+ serostatus. The relation between part-
ner awareness and unprotected intercourse also does
not appear to be linear, as inconsistency in partner
awareness was related to increased sexual transmis-
sion risk but proportion of aware partners was not.
Participants with partners who were inconsistently
aware were more likely to report unprotected sex-
ual behavior than those with partners who were con-
sistently aware or unaware. Specifically, men with
partners who were inconsistently aware were more
likely to have had unprotected receptive anal and
insertive anal intercourse. For insertive anal inter-
course, partner awareness was significantly associ-
ated with this behavior only after controlling for cor-
relates of partner awareness. Partners may be less
likely to become aware when an HIV-seropositive
MSM is engaging in sexual practices that carry a
lower risk of HIV transmission than insertive anal
intercourse.
Inconsistency in partner awareness may explain
discrepant findings in the literature, with some sug-
gesting a link between disclosure and unprotected
sex (De Rosa and Marks, 1998; Niccolai et al.,
1999; Stein et al., 1998) and some failing to find an
164 Hart, Wolitski, Purcell, Parsons, Gómez, and the Seropositive Urban Men’s Study Team
association (Kalichman and Nachimson, 1999; Marks
and Crepaz, 2001; Wolitski et al., 1998). That is,
among studies examining disclosure in one sexual
event (Marks and Crepaz, 2001) or to one sexual
partner (Niccolai et al., 1999), men with partners who
were inconsistently aware could have a partner who
was made aware in one situation, thereby entering
the “disclosed” group in one study, and not make
their partners aware in another situation, thereby en-
tering the non-disclosed group in a 2nd study. Incon-
sistent partner awareness may also explain null find-
ings in studies comparing men who disclosed to all
partners versus those who did not in a certain time
period (De Rosa and Marks, 1998; Kalichman and
Nachimson, 1999; Stein et al., 1998; Wolitski et al.,
1998) because the higher rates of unprotected in-
tercourse found among men who disclosed to some
partners would be combined with the relatively lower
rates of unprotected intercourse among men who dis-
closed to no partners. However, more research is
needed to explicitly examine how inconsistent verbal
disclosure is associated with risky sexual behavior, as
the present study assessed partner awareness and not
disclosure behavior.
Assessment of partner awareness as a binary
variable also may be insufficient because non-
awareness of HIV-serostatus is not automatically as-
sociated with increased risk behavior. In fact, those
with partners who were consistently aware and un-
aware did not differ in unprotected insertive or re-
ceptive anal intercourse. Further, those with partners
who were unaware and those with partners who were
inconsistently aware did not differ in unprotected in-
sertive oral intercourse.
Men with partners who were inconsistently
aware occupied an intermediate position between
the unaware and consistently aware groups on psy-
chological variables relevant to disclosure. Men with
partners who were inconsistently aware reported sig-
nificantly lower disclosure self-efficacy and disclosure
intention than those with consistently aware part-
ners, but significantly higher disclosure self-efficacy
and disclosure intention than men with unaware part-
ners. These findings, combined with the increased
sexual transmission behavior among the inconsistent
partner awareness group even when controlling for
psychological and behavioral correlates, suggest that
increased disclosure-facilitating cognition is not nec-
essarily associated with decreased sexual risk. Alter-
natively, other psychological variables not assessed
in the present study may be more strongly implicated
in the increased risk among those with partners who
were inconsistently aware (e.g., impulsivity; Wulfert
et al., 1999).
Previous research has found that HIV-
seropositive MSM with anonymous partners had
lower disclosure self-efficacy relative to those with
other types of casual or steady partners (Semple
et al., 2000). Thus, many MSM who do not believe
they will disclose may also choose to have anony-
mous partners, one-night stands, or meet partners in
sex venues because they do not believe it is necessary
to make partners aware in these contexts (Stirratt,
2005). Alternatively, HIV-seropositive men who
have had sexual intercourse without their partners
becoming aware of their serostatus may be less likely
to continue sexual relationships (Schnell et al., 1992)
because of fear associated with negative reactions
upon disclosure (Gielen et al., 1997; Hays et al., 1993;
Mansergh et al., 1995; Serovich, 2001; Stein et al.,
1998). However, the present study examined overall
patterns of partner awareness across a 3-month time
period and cannot assess cognitions and emotions
associated with one’s partner becoming aware or
partner awareness versus lack of awareness in
individual sexual situations.
In sum, most HIV-seropositive men report their
primary partners are aware and most men report
at least some non-primary partners are aware the
participant was HIV-seropositive before first having
sex. Men appeared to differ in their overall pattern
of partner awareness regarding HIV-negative or un-
known serostatus non-primary partners. Those with
partners who were consistently unaware had lower
disclosure self-efficacy, disclosure intention, were
more likely to report all partners were one-night
stands, and were less likely to have an AIDS diag-
nosis than those with partners who were consistently
and inconsistently aware. A much different pattern
emerged regarding partner awareness and HIV
transmission risk, suggesting partner awareness is re-
lated to safer sexual behavior in a non-linear fashion.
Men with non-primary HIV-negative or unknown
partners who were inconsistently aware had higher
rates of unprotected receptive anal intercourse
than those with partners who were consistently
aware or consistently unaware and higher rates of
insertive oral intercourse than those with partners
who were consistently aware. However, there were
no differences between those in the consistent
partner awareness and partner unawareness groups.
Assessments of partner awareness or overt disclo-
sure as a linear variable (e.g., number of disclosure
occasions, proportion of aware partners) or binary
Partner Awareness of HIV Serostatus
variable (e.g., disclosure to recent partner or not)
therefore may have failed to account for differences
in HIV transmission behavior related to partner
awareness. Further research is recommended to
more fully explore possible relations between part-
ner awareness inconsistency and HIV transmission
risk.
ACKNOWLEDGMENTS
This research was conducted as part of the
Seropositive Urban Men’s Study (SUMS). It was
supported by the Centers for Disease Control and
Prevention through cooperative agreements with
New Jersey City University (U62/CCU213605), Rut-
gers University (U62/CCU2133607), and University
of California, San Francisco (U62/CCU913557). The
authors acknowledge the following SUMS collabora-
tors for their contributions: Michael Stirratt, Robert
Remien, Jeffrey Parsons, Ann O’Leary, Colleen
Hoff, Robert Hays, James Carey, and Timothy
Ambrose. The authors also gratefully acknowledge
Gary Marks and Nicole Crepaz for comments on an
earlier version of the manuscript. In addition, the au-
thors thank the members of the SUMS community
advisory boards in New York City and San Francisco
for their guidance and thoughtful feedback.
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