Young men who have sex with men (YMSM) are disproportionally affected by HIV, and main partnerships account for a large proportion of new HIV infections. HIV prevention is largely focused on urban YMSM, and less is known about sexual health of rural male couples. The present study used data from a randomized controlled trial of a relationship education and HIV prevention program for male couples to test associations of rurality with HIV/STI testing, PrEP use, number of sexual partners, and condomless anal sex (CAS) acts. Participants were 430 YMSM in relationships. Rural YMSM were less likely to have been tested for HIV/STIs, and to have used PrEP, compared to urban YMSM. Although higher rurality was associated with fewer CAS acts, CAS was not infrequent among rural YMSM, highlighting the need for increased HIV prevention geared toward young male couples living in rural, less resourced areas.
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Centers for Disease Control and Prevention. HIV Surveillance Report 2017. Atlanta: Centers for Disease Control and Prevention; 2018.
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2018. Atlanta: Centers for Disease Control and Prevention; 2019.
Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(9):1153–62.
Goodreau SM, Carnegie NB, Vittinghoff E, Lama JR, Sanchez J, Grinsztejn B, et al. What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS ONE. 2012;7(11):e50522.
Newcomb ME, Ryan DT, Garofalo R, Mustanski B. The effects of sexual partnership and relationship characteristics on three sexual risk variables in young men who have sex with men. Arch Sex Behav. 2014;43(1):61–72.
Whitfield THF, John SA, Rendina HJ, Grov C, Parsons JT. Why I quit pre-exposure prophylaxis (PrEP)? A mixed-method study exploring reasons for PrEP discontinuation and potential re-initiation among gay and bisexual men. AIDS Behav. 2018;22(11):3566–75.
Perez-Figueroa RE, Kapadia F, Barton SC, Eddy JA, Halkitis PN. Acceptability of PrEP uptake among racially/ethnically diverse young men who have sex with men: the P18 study. AIDS Educ Prev. 2015;27(2):112–25.
Chakravarty D, Hoff CC, Neilands TB, Darbes LA. Rates of testing for HIV in the presence of serodiscordant UAI among HIV-negative gay men in committed relationships. AIDS Behav. 2012;16(7):1944–8.
Stephenson R, White D, Darbes L, Hoff C, Sullivan P. HIV testing behaviors and perceptions of risk of HIV infection among MSM with main partners. AIDS Behav. 2015;19(3):553–60.
Grey JA, Bernstein KT, Sullivan PS, Purcell DW, Chesson HW, Gift TL, et al. Estimating the population sizes of men who have sex with men in US states and counties using data from the American Community Survey. JMIR Public Health Surveill. 2016;2(1):e14.
Gallagher KM, Sullivan PS, Lansky A, Onorato IM. Behavioral surveillance among people at risk for HIV infection in the US: the National HIV Behavioral Surveillance System. Public Health Rep. 2007;122(1_Suppl):32–8.
MacKellar DA, Gallagher KM, Finlayson T, Sanchez T, Lansky A, Sullivan PS. Surveillance of HIV risk and prevention behaviors of men who have sex with men—a national application of venue-based, time–space sampling. Public Health Rep. 2007;122(1_Suppl):39–47.
Ohl ME, Perencevich E. Frequency of human immunodeficiency virus (HIV) testing in urban vs. rural areas of the United States: results from a nationally-representative sample. BMC Public Health. 2011;11(1):681.
Franks J, Hirsch-Moverman Y, Loquere AS Jr, Amico KR, Grant RM, Dye BJ, et al. Sex, PrEP, and stigma: experiences with HIV pre-exposure prophylaxis among New York City MSM participating in the HPTN 067/ADAPT Study. AIDS Behav. 2018;22(4):1139–49.
Snowden JM, Chen Y-H, McFarland W, Raymond HF. Prevalence and characteristics of users of pre-exposure prophylaxis (PrEP) among men who have sex with men, San Francisco, 2014 in a cross-sectional survey: implications for disparities. Sex Transm Infect. 2017;93(1):52–5.
Morgan E, Ryan DT, Moran K, D’Aquila R, Newcomb ME, Mustanski B. Trends in PrEP uptake, adherence, and discontinuation among YMSM in Chicago. In: Conference on retroviruses and opportunistic infections, Boston, 2018.
Preston DB, D'Augelli AR, Kassab CD, Cain RE, Schulze FW, Starks MT. The influence of stigma on the sexual risk behavior of rural men who have sex with men. AIDS Educ Prev. 2004;16(4):291–303.
Preston DB, D’Augelli AR, Kassab CD, Starks MT. The relationship of stigma to the sexual risk behavior of rural men who have sex with men. AIDS Educ Prev. 2007;19(3):218–30.
Whitton SW, Dyar C, Newcomb ME, Mustanski B. Romantic involvement: a protective factor for psychological health in racially-diverse young sexual minorities. J Abnorm Psychol. 2018;127(3):265–75.
Wienke C, Hill GJ. Does the “marriage benefit” extend to partners in gay and lesbian relationships? Evidence from a random sample of sexually active adults. J Fam Issues. 2009;30(2):259–89.
Feinstein BA, Latack JA, Bhatia V, Davila J, Eaton NR. Romantic-relationship involvement as a minority stress buffer in gay/lesbian versus bisexual individuals. J Gay Lesbian Ment Health. 2016;20:237–46.
McKenney J, Sullivan PS, Bowles KE, Oraka E, Sanchez TH, DiNenno E. HIV risk behaviors and utilization of prevention services, urban and rural men who have sex with men in the United States: results from a National Online Survey. AIDS Behav. 2018;22(7):2127–36.
Kakietek J, Sullivan PS, Heffelfinger JD. You’ve got male: Internet use, rural residence, and risky sex in men who have sex with men recruited in 12 U.S. cities. AIDS Educ Prev. 2011;23(2):118–27.
Rosenkrantz DE, Black WW, Abreu RL, Aleshire ME, Fallin-Bennett K. Health and health care of rural sexual and gender minorities: a systematic review. Stigma Health. 2017;2(3):229.
Bowen A, Williams M, Horvath K. Using the Internet to recruit rural MSM for HIV risk assessment: sampling issues. AIDS Behav. 2004;8(3):311–9.
Hubach RD, Dodge B, Li MJ, Schick V, Herbenick D, Ramos WD, et al. Loneliness, HIV-related stigma, and condom use among a predominantly rural sample of HIV-positive men who have sex with men (MSM). AIDS Educ Prev. 2015;27(1):72–83.
Schnarrs PW, Rosenberger JG, Satinsky S, Brinegar E, Stowers J, Dodge B, et al. Sexual compulsivity, the Internet, and sexual behaviors among men in a rural area of the United States. AIDS Patient Care STDs. 2010;24(9):563–9.
Horvath KJ, Bowen AM, Williams ML. Virtual and physical venues as contexts for HIV risk among rural men who have sex with men. Health Psychol. 2006;25(2):237–42.
Rosenberger JG, Schick V, Schnarrs P, Novak DS, Reece M. Sexual behaviors, sexual health practices, and community engagement among gay and bisexually identified men living in rural areas of the United States. J Homosex. 2014;61(8):1192–207.
Hubach R, Dodge B, Cola T, Battani P, Reece M. Assessing the sexual health needs of men who have sex with men (MSM) residing in rural and mixed rural areas. Health Educ Monogr. 2014;31(2):33–9.
Hubach RD, Currin JM, Sanders CA, Durham AR, Kavanaugh KE, Wheeler DL, et al. Barriers to access and adoption of pre-exposure prophylaxis for the prevention of HIV among men who have sex with men (MSM) in a relatively rural state. AIDS Educ Prev. 2017;29(4):315–29.
Newcomb ME, Moran K, Li DH, Mustanski B. Demographic, regional, and political influences on the sexual health care experiences of adolescent sexual minority men. LGBT Health. 2019;7(1):1–9.
Noble M, Jones AM, Bowles K, DiNenno EA, Tregear SJ. HIV testing among Internet-using MSM in the United States: systematic review. AIDS Behav. 2017;21(2):561–75.
Whitehead J, Shaver J, Stephenson R. Outness, stigma, and primary health care utilization among rural LGBT populations. PLoS ONE. 2016;11(1):e0146139.
Nelson KM, Pantalone DW, Gamarel KE, Carey MP, Simoni JM. Correlates of never testing for HIV among sexually active Internet-recruited gay, bisexual, and other men who have sex with men in the United States. AIDS Patient Care STDs. 2018;32(1):9–15.
Traynor SM, Brincks AM, Feaster DJ. Correlates of unknown HIV status among MSM participating in the 2014 American Men’s Internet Survey (AMIS). AIDS Behav. 2018;22(7):2113–266.
Metheny N, Stephenson R. Disclosure of sexual orientation and uptake of HIV testing and hepatitis vaccination for rural men who have sex with men. Ann Fam Med. 2016;14(2):155–8.
Petroll AE, Mosack KE. Physician awareness of sexual orientation and preventive health recommendations to men who have sex with men. Sex Transm Dis. 2011;38(1):63–7.
Qiao S, Zhou G, Li X. Disclosure of same-sex behaviors to health-care providers and uptake of HIV testing for men who have sex with men: a systematic review. Am J Mens Health. 2018;12(5):1197–214.
Workowski KA. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2015;61(Suppl 8):S759–S762762.
Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States—2017 update: a clinical practice guideline. Atlanta: Centers for Disease Control and Prevention; 2018.
Finlayson T, Cha S, Xia M, Trujillo L, Denson D, Prejean J, et al. Changes in HIV preexposure prophylaxis awareness and use among men who have sex with men—20 urban areas, 2014 and 2017. Morb Mortal Wkly Rep. 2019;68(27):597–603.
Powell VE, Gibas KM, DuBow J, Krakower DS. Update on HIV preexposure prophylaxis: effectiveness, drug resistance, and risk compensation. Curr Infect Dis Rep. 2019;21(8):28.
Weiss K, Bratcher A, Sullivan P, Siegler A. Geographic access to PrEP clinics among US MSM: documenting PrEP deserts. In: Conference on retroviruses and opportunistic infections, Boston, 2018.
Shaver J, Sharma A, Stephenson R. Rural primary care providers’ experiences and knowledge regarding LGBTQ health in a Midwestern state. J Rural Health. 2018;35(3):362–73.
Owens C, Hubach RD, Williams D, Lester J, Reece M, Dodge B. Exploring the pre-exposure prophylaxis (PrEP) health care experiences among men who have sex with men (MSM) who live in rural areas of the Midwest. AIDS Educ Prev. 2020;32(1):51–66.
Owens C, Hubach RD, Williams D, Voorheis E, Lester J, Reece M, et al. Facilitators and barriers of pre-exposure prophylaxis (PrEP) uptake among rural men who have sex with men living in the Midwestern US. Arch Sex Behav. 2020;49(6):1–13.
Waldorf BS. A continuous multi-dimensional measure of rurality: moving beyond threshold measures. In: AAEA annual meeting, 2006.
Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. Am J Public Health. 2005;95(7):1149–55.
Newcomb ME, Sarno EL, Bettin E, Carey J, Ciolino JD, Hill R, et al. Relationship education and HIV prevention for young male couples administered online via videoconference: protocol of a national randomized controlled trial of 2GETHER. J Med Internet Res. 2020;9(1):e15883.
Waldorf B, Kim A. The index of relative rurality (IRR): US county data for 2000 and 2010. Purdue University Research Repository; 2018.
Swann G, Newcomb ME, Mustanski B. Validation of the HIV Risk Assessment of Sexual Partnerships (H-RASP): comparison to a 2-month prospective diary study. Arch Sex Behav. 2018;47(1):121–31.
Centers for Disease Control and Prevention. Diagnoses of HIV infection among adolescents and young adults in the United States and 6 dependent areas, 2011–2016. Atlanta: Centers for Disease Control and Prevention; 2018.
Ostrow D, DiFranceisco W, Wagstaff D. The coping and change study of men at risk of AIDS: sexual behavior and behavior change questionnaire. In: Handbook of sexuality-related measures. Thousand Oaks: Sage; 1998. p. 547–553.
Marhefka SL, Iziduh S, Fuhrmann HJ, Lopez B, Glueckauf R, Lynn V, et al. Internet-based video-group delivery of Healthy Relationships—a “prevention with positives” intervention: report on a single group pilot test among women living with HIV. AIDS Care. 2013;25(7):904–9.
Stephenson R, Freeland R, Sullivan SP, Riley E, Johnson BA, Mitchell J, et al. Home-based HIV testing and counseling for male couples (Project Nexus): a protocol for a randomized controlled trial. JMIR Res Protoc. 2017;6(5):e101.
Gamarel KE, Darbes LA, Hightow-Weidman L, Sullivan P, Stephenson R. The development and testing of a relationship skills intervention to improve HIV prevention uptake among young gay, bisexual, and other men who have sex with men and their primary partners (We Prevent): protocol for a randomized controlled trial. JMIR Res Protoc. 2019;8(1):e10370.
White House Office of National AIDS Policy. National HIV/AIDS strategy for the United States: updated to 2020. White House Office of National AIDS Policy; 2015.
Silapaswan A, Krakower D, Mayer KH. A narrative review of provider behavior and interventions to increase PrEP implementation in primary care. J Gen Intern Med. 2017;32(2):192–8.
Rao D, Elshafei A, Nguyen M, Hatzenbuehler ML, Frey S, Go VF. A systematic review of multi-level stigma interventions: state of the science and future directions. BMC Med. 2019;17(1):41.
Charlton BM, Hatzenbuehler ML, Jun H-J, Sarda V, Gordon AR, Raifman JRG, et al. Structural stigma and sexual orientation-related reproductive health disparities in a longitudinal cohort study of female adolescents. J Adolesc. 2019;74:183–7.
This study was funded by the National Institute on Drug Abuse (DP2DA042417). Elissa Sarno’s time was supported by a Grant from the National Institute on Alcohol Abuse and Alcoholism (F32AA028194; PI: Sarno). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
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The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the Institutional and/or National Research Committee (Northwestern University Institutional Review Board; STU00202802) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
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Sarno, E.L., Bettin, E., Jozsa, K. et al. Sexual Health of Rural and Urban Young Male Couples in the United States: Differences in HIV Testing, Pre-exposure Prophylaxis Use, and Condom Use. AIDS Behav (2020). https://doi.org/10.1007/s10461-020-02961-8
- Pre-exposure prophylaxis (PrEP)