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An investigation of relationship power in HIV-positive individuals

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An investigation of relationship power in HIV-positive individuals
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Lance, Shannon Perschbacher
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English
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ix, 74 leaves : ; 28 cm

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HIV-positive persons -- Social networks ( lcsh )
Interpersonal relations ( lcsh )
AIDS (Disease) -- Prevention -- Social aspects ( lcsh )
AIDS (Disease) -- Prevention -- Social aspects ( fast )
HIV-positive persons -- Social networks ( fast )
Interpersonal relations ( fast )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Bibliography:
Includes bibliographical references (leaves 70-74).
General Note:
Department of Psychology
Statement of Responsibility:
by Snannon Perschbacher Lance.

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|University of Colorado Denver
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Auraria Library
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ocn519442198
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Full Text
AN INVESTIGATION OF RELATIONSHIP POWER IN HIV-POSITIVE
INDIVIDUALS
by
Shannon Perschbacher Lance
B.S., Colorado State University, 2006
A thesis submitted to the
University of Colorado Denver
in partial requirements for the degree of
Master of Arts
Psychology
2009


Shannon Perschbacher Lance
All rights reserved.


This thesis for the Master of Arts
degree by
Shannon Perschbacher Lance
has been approved
by
Eric Benotsch
Elizabeth Allen
Evelinn Borrayo
J7-
Date


Lance, Shannon P. (Master of Arts, Psychology, College of Liberal Arts and Sciences)
An Investigation of Relationship Power in HIV-Positive Individuals
Thesis directed by Associate Professor Eric Benotsch
ABSTRACT
The concept of relationship power refers to the relative ability of one partner to act
independently, to dominate decision making, or to control a partners actions
(Pulerwitz, Gormaker, & DeJong, 2000). While this concept has been studied
thoroughly in HIV prevention research, little information exists regarding the concept
in HTV-positive populations. The body of literature concerning relationship power in
HIV prevention, as well as the relationship between social support and HTV are
reviewed. The present study aimed to compare relationship power across subgroups
of HIV-positive individuals receiving care at a metropolitan infectious disease clinic.
Consistent condom use and social support measures were compared to power ratings.
One hundred thirty-three HIV-positive individuals from diverse backgrounds took a
paper and pencil survey assessing condom use, social support, demographics, and
power. The sample predominantly endorsed sharing power with their primary partner.
Individuals were compared on power ratings based on gender/sexual orientation and
partners HIV status. Results indicate that overall, power is associated with the
availability of social supports and with the number of unprotected sexual acts with an
HIV-negative or unknown status partner. Differing results for power between
homosexual men, heterosexual men, and heterosexual women were found.
Implications of results are discussed and future investigation of this topic is
suggested.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication
Sign
Eric Benotsch


DEDICATION
I dedicate this thesis to my mother-in-law, Beth, who taught me how to handle
relationships and responsibilities with grace and laughter. I also dedicate this to my
husband, Alexander, who is my unwavering source of social support. Finally, this
thesis is dedicated to my family for providing an encouraging foundation to build
upon.


ACKNOWLEDGEMENT
I would like to thank my advisor, Eric Benotsch, for providing the opportunity
to conduct this research. Additionally, I would like to thank all the members of my
committee -Eric, Beth, & Evelinn- for their time and generous contributions. Thanks
to Toby LeRoux and Stuart Cooper for collecting the data used in this study.


TABLE OF CONTENTS
Tables................................................................ix
CHAPTER
1. INTRODUCTION.......................................................1
Relationship Power and HIV Risk.................................3
Relationship Power in HIV-Positive Populations..................8
Social Support in HIV-Positive Populations.....................10
Physical Health Outcomes and Social Support....................12
Mental Health Outcomes and Social Support......................15
Sexual Risk Behaviors and Social Support.......................16
Need for Present Study.........................................17
2. METHOD............................................................21
Participants................................................. 21
Materials......................................................22
Procedure......................................................28
Data Analysis..................................................29
3. RESULTS...........................................................31
4. DISCUSSION........................................................42
Limitations....................................................49
vii


Future Studies
51
Conclusions.......................................53
APPENDIX
A. ABBREVIATED SURVEY MALE VERSION...................55
B. ABBREVIATED SURVEY FEMALE VERSION.................63
REFERENCES...................................................70
viii


LIST OF TABLES
Table
1 Sociodemographic and health related variables...............................23
2 Relationship and sexuality demographics.....................................25
3 Sexual Relationship Power Scale results.....................................32
4 Power averages by group.....................................................34
5 Satisfaction with social support............................................36
6 Power and social support correlations by group..............................37
7 Power and sexual behavior correlations by group.............................40
ix


CHAPTER 1
INTRODUCTION
In 2006, the Centers for Disease Control estimate that over one million people
in the United States are living with HTV infections (CDC, 2008). Of these, it is
estimated that 48% were infected through male-to-male sexual contact, and 27% were
through high-risk heterosexual contact. While condoms are 90 to 95% effective in
preventing HIV when used consistently, high risk sexual contact continues to be the
major transmission route of HIV infections (Pinkerton & Abramson, 1997).
Nevertheless, the majority of prevention theory and research has an individualistic
focus, assuming that an individual has complete control over behavior (Harvey, Bird,
Galavotti, Duncan, & Greenberg, 2002). However, the field has moved towards
looking more at the interactional dynamic between partners during sexual intercourse.
While many cases of HIV transmission occur within casual relationships, research
indicates that individuals are less likely to practice safer sex with close relationship
partners, whether they are heterosexual or homosexual (Misovich, Fisher, & Fisher,
1997).
While being in a relationship may present behavioral risk for HIV
transmission through unprotected sexual acts, the psychosocial variables related to
being in a relationship may affect physical health, psychological health, and
1


behavioral outcomes for individuals already infected with HIV. Social support, a
variable largely believed to be associated with positive outcomes for individuals with
HIV, tends to be higher, in general, for individuals in relationships (Kurdek &
Schmitt, 1987). Having healthy relationships, as indicated by secure adult
attachment, has been linked to less stress and depression in HIV-positive adults
(Riggs, Vosvick, & Stallings, 2007). However, a lack of relationship power has been
linked to behaviors that increase the likelihood of transmitting HIV in a number of
studies. When one partner is dominant in a relationship, the less powerful partner
may be blocked in asserting his or her wishes for safer sex (Canin, Dolcini, & Adler,
1999). Relationship power has yet to be investigated thoroughly in a sample of HIV
positive individuals, despite the fact that researchers have endorsed a need for this
information (Crepaz & Marks, 2002).
Currently, relationship power and social support are found within two separate
bodies of literature: research investigating the relationship between interpersonal
relationship power and HIV risk, and research investigating the relationship between
social support and HIV related outcomes. While it is important to understand what is
known about these two areas, the focus of this study is to additionally address the gap
between the two and present a study aimed at bringing the two areas together.
Specifically, relationship power and social support may be found to be related in
2


HIV-positive individuals, and relationship power may also have an influence on
behavioral health outcomes fof HIV-positive individuals and theif partners.
Relationship Power and HIV Risk
Theoretically, many researchers in the area of HTV prevention have been
interested in the idea of relationship power as a risk factor for the disease. As HIV
transmission predominantly occurs through sexual intercourse, relationship dynamics
remain a topic of increasing interest. While this concept has been investigated
thoroughly in prevention research with HIV-negative women, information is still
lacking about how relationship power may affect men in both heterosexual and
homosexual relationships. Additionally, there is a significant lack of data regarding
how power dynamics are manifested in individuals who are HIV positive.
Pulerwitz, Gortmaker, and DeJong (2000), the developers of a scale
measuring relationship power, defined power as the relative ability of one partner to
act independently, to dominate decision making, to engage in behavior against the
other partners wishes, or to control a partners actions. Blanc (2001) notes that while
the conceptualization of power is based on traditional gender roles, and has been
studied primarily within heterosexual relationships, the issues of power should apply
to all sexual relationships. Blanc described the impact of power on sexual health
3


through three pathways: one direct and two indirect. Directly, it influences the ability
of partners to negotiate condom use and indirectly, it may be influential through its
relationship with partner violence and its influence on the use of health services. For
instance, a mans attempt to appear powerful may prevent him from discussing health
problems with his partner and/or a health professional, or he may avoid getting tested
for sexually transmitted illnesses. Additionally, gender-based power may contribute
to the low amount of communication between partners about reproductive health,
specifically in developing countries (Blanc, 2001). Women may have the personal
skills and knowledge about HIV, but may not be able to enact them without feeling
that they can communicate these concerns in their relationship.
Pulerwitz, Gortmaker, and DeJong (2000) note that power differences may
result in different sexual behaviors for men compared to women. For instance, males
may have more sexual partners than women. Amaro (1995) indicates that this may
place women in a position where they are at greater risk for HIV, because men also
have traditionally had more influence regarding when and how sex will happen with
their partners.
Numerous empirical studies have investigated the relationship between power
and HIV risk. The bulk of studies looked at HIV prevention within samples of
minority women (typically of Hispanic origin). Pulerwitz, Amaro, DeJong,
Gortmaker, and Rudd (2002) used the Sexual Relationship Power Scale (SRPS) to
4


examine the relationship between power and condom use in a sample of 388
primarily Latina women at a community health center. They found that women with
high levels of relationship power were six times as likely as women with low levels
of power to report using condoms consistently. Women with medium levels of power
were three times more likely to report using condoms consistently, although this
finding was not significant. Assuming there is a causal relationship between the two,
they attribute 52% of the lack of consistent condom use in this population to low
levels of relationship power. Another study investigated 69 separate focus groups
with Latina women. In three-fourths of these focus groups, both power and gender
roles were mentioned as a key barrier to HIV risk reduction (Amaro & Gomemann,
1992).
An assessment conducted with an ethnically diverse group of women
receiving services at a STD treatment clinic examined the relationship between
perceived power (specifically related to condom use), high risk sexual behavior, self-
efficacy for future condom use, hopelessness, and experiences of partner abuse
(McCardle, Espil, Cabral, Nettles, et al, 2007). They found that women reporting
having control over condom use reported significantly fewer acts of unprotected
vaginal and anal sex in the previous four months compared to women reporting low
control. Additionally, women with low power perceptions had significantly lower
self-efficacy for using condoms in future relationships, as compared to women who
5


endorsed having power over condom use. Women with low perceived power were
also more likely to report being hit by a partner and were more likely to display
higher scores on an abbreviated version of the Beck Hopelessness Scale. These
results indicate that low perceptions of power are not just related to current condom
use, but also projections of future use.
Harvey, Bird, Galavotti, Duncan, and Greenberg (2002) conducted face-to-
face interviews with 112 young women (primarily minorities) from clinics in four
U.S. cities to determine how women perceive power in their relationships. They
found that women who believed that they shared power with their partner or had more
power in their relationship were more likely to report that they alone, or with their
partner, made decisions about condom use, whether to have sex, the type of sexual
activities, and birth control use as compared to women who believed that their partner
had more power. Relationship power, in general, was not significantly associated with
actual condom use, but women reporting that they share or make decisions
themselves about using condoms did use condoms more frequently.
There is evidence, however, that women gain power through sexual activity.
Harvey, Beckman, Browner and Sherman (2002) interviewed 39 sexually active
couples of Mexican origin about what power is, what makes men and women
powerful, and partners roles in sexual decision making. They found that while
couples tend to share decision making about contraceptive use and sexual activities,
6


women are more likely to suggest condom use and men are more likely to initiate
sexual activity. These findings afe somewhat contradictory to other findings, but this
may be due to the fact that both partners were interviewed and data were qualitative
in nature. Another pertinent finding from this study was that some of the women
mentioned that they felt powerful through sex and that they feel powerful when they
please their partners sexually or when they withhold sex. Based on these results, it
could be argued that women participate in high-risk behavior because either they lack
power in general, or because it increases their perceptions of having power within
their relationship.
Harvey, Bird, DeRosa, Montgomery, and Rohrbach (2003) conducted a study
looking specifically at young women who were injection drug users (IDUs) or
partners of IDUs a population that is at increased risk of HIV infection. Harvey and
colleagues investigated the relationship between self-reported sexual decision
making, condom use, contraceptive use, and relationship demographics. They found
that the majority of women reported participating in sexual decision making.
Participation in sexual decision making was not related to relationship type (primary
or non-main partner). But, for decisions on birth control and decisions on when to
have sex, women who reported that either I or we make the decisions tended to be
in longer sexual relationships. After adjusting for covariates, women were 7 or 19
7


times more likely to report recently using condoms if they reported participating in
decisions about condom use or when to have sex, respectively.
Relationship Power in HIV-Positive Populations
While the majority of published studies focus on populations at risk for HIV, a
few studies have investigated power within samples of HIV-positive individuals.
Stevens and Galvao (2007) peffonned ten interviews over a two year period with 55
HIV-positive women. Out of these women, ten had reported having unprotected
intercourse with a primary partner (Nine of these women had serodiscordant partners,
one had a seroconcordant partner). The authors wanted to investigate whether it was
more difficult for women with HIV to introduce condoms into sexual activity and
found that although women tend to initiate condom use, they participate in
unprotected sex with partners after their partners insist. Because the women were
aware of the risks involved for their partner, this caused self-reported distress (guilt,
sadness, fear) for the participants. The women reported a pattern of continually
bringing up the importance of condoms, which started arguments, leading to the
women giving into her partners demands and giving up. The authors compared the
women with serodiscordant partners to nine women who always practiced safe sex
8


with their serodiscordant partners and couldnt find any significant differences in
physical health or other variables. The only factor differentiating the two groups was
the interpersonal dynamics of their relationship. The authors emphasize that their
findings provide further evidence that women are not intentionally harming their
partners or are unaware of risks, but that they are simply unable to negotiate condom
use in their primary relationship. This study is important to consider as it is the first to
investigate these factors in an HIV-positive sample.
Qualitative research has also been conducted with both HIV-positive black
men and women living in the United Kingdom. In this study, interviews conveyed
information about power for both genders. Results indicated that the idea that men
possess the power in relationships was not absolute (Ridge, Ziebland, Anderson,
Williams, & Elford, 2007). Male participants reported feeling a lack of power for a
number of reasons, including the means in which they were infected with the virus
(specifically an individual who was sexually assaulted by another man), feelings that
they could not negotiate safe sex with female partners, and because of the idea that
not being able to have sex is denying you are no longer a man (p.762). These
results indicate that power can vary for both men and women with HIV.
One quantitative study has explored concepts related to power within a sample
of HIV-positive gay men in concordant primary relationships. Halkitis, Wilton, and
Parsons compared the occurrence of unprotected anal intercourse with both
9


relationship attachment and autonomy (2004). While those that didnt participate in
unprotected anal intercourse had slightly higher ratings of both attachment and
autonomy than participants who did participate in unprotected anal intercourse, this
result was not significant. These results imply that power may not be an important
factor related to unprotected sex in this demographic group, however, they did not
measure relationship power per se, and no known studies have investigated
serodiscordant homosexual relationships in terms of power.
While these studies indicate that power is at play with condom use in some
HIV-positive populations, we still do not have quantitative evidence of how
relationship power operates in HIV-positive women or heterosexual men, nor do we
have much information on how power plays out in homosexual relationships as well.
Social Support in HIV-Positive Populations
While relationship power has not been thoroughly examined within HIV-
positive populations, social support is commonly investigated in HIV/AIDS research
and has been found to be related with quality of life ratings, health outcomes, mental
health outcomes, behavioral risk factors, and self efficacy. While some of the
evidence is mixed, in general, social support is indicative of positive outcomes for
individuals with HTV or AIDS.
10


For HIV-positive individuals in relationships, partners tend to be a key source
of social support (Derlega, Winstead, Olfield, & Barbee, 2003). Support from an
intimate partner is typically perceived as more helpful than assistance from family
(Barbee, Derlega, Sherburne, & Grimshaw, 1998). Research also indicates that social
support does not vafy between individuals in seroconcofdant of serodiscordant
relationships (Kalichman, Rompa, Luke, & Austin, 2002).
Friedland, Renwick, and McColl (1996) investigated self-reported social
support, coping, and quality of life in a survey administered in waiting rooms of drop-
in centers and hospital-based HIV clinics to male participants with various sexual
orientations. They found that quality of life was significantly related to three types of
social support: tangible (practical), appfaisal (informational), and emotional
(belonging and self-esteem related) support. Additionally, they investigated which
types of support were seen as important to participants, where they received the
support, and which types of support were seen as most needed. Participants viewed
emotional support as the most important, and also believed that it was the type of
support that was most lacking. They viewed practical support to also be very
important and endorsed partners/spouses as the most helpful people in tefms of
practical support. In general, both partners and close friends were reported to provide
the majority of support.
11


Physical Health Outcomes and Social Support
In terms of health-related outcomes, research is plentiful. Patterson, Shaw,
Semple, Chemer, McCutchan, et al. (1996) found that men with larger social
networks wefe more likely to survive longer with the disease during a five year study.
In men with both HIV and hemophilia, lower availability of social supports was
associated with a more rapid deterioration of CD4 counts (Theorell, Blomvist,
Jonsson, Schulman, Bemtopr, & Stigendal, 1995).
Ashton, Vosvick, Chesney, Gore-Felton, Koopman, et al. (2005) asked a
broad sample of HTV positive men and women to complete measures of social
support and HIV-related health symptoms at baseline, and three, six, and 12 month
intervals. Individuals who reported more satisfaction with social support in
instrumental and emotional domains (both specifically focused on HIV-related
stressors) were less likely to report increases in symptoms over time. The more
satisfied the participant was at baseline, the smaller increase seen in physical health
symptoms. This effect was independent of baseline medical status. The authors
suggest that social support should be viewed as a buffer for illness, and argue that the
longitudinal design supports this as a possibility.
Leserman, Petitto, Golden, Gaynes, Gu, et al. (2000) conducted a longitudinal
study to investigate factors that may lead to faster profession to AIDS in a sample of
12


82 homosexual men. They found that lower cumulative satisfaction with social
support was associated with a fastef progression from HIV to AIDS. They measured
support satisfaction using a six point scale, the Brief Social Support Questionnaire,
and found that a one point increase in satisfaction decreased the risk of AIDS
progression by 62%.
Interventions on the couple level have been shown to have an effect on social
support as well. Remien, Stirratt, Dolezal, Dognin, Wagner, et al. (2005) randomly
assigned both heterosexual and homosexual, ethnically diverse, low-income, HIV-
serodiscordant couples to either a four session couple-focused adherence intervention
or care as usual. In order to qualify, the HIV-positive partner had to have low
adherence on their HIV medications (< 80%). The couples intervention addressed
increasing partner support, communication, problem-solving, barriers to adherence,
and building confidence. The main focus was building partner support and helping
address the issues of sex and intimacy within the relationship. Two weeks after the
intervention adherence was measured again. They found that participants in the
couple focused intervention showed better adherence to their medication regimen
than controls, both in the proportion of doses taken (76% compared to 60%) and
taking their doses during the appropriate time period (58% compared to 35%).
Unfortunately, the differences were not seen at three and six month follow-up
periods. Although not long term, this study does indicate that partner support could
13


improve health outcomes of individuals with HIV. The authors suggest that including
partners in medical appointments and treatment decisions may be a cost-effective way
to improve adherence and increase support for the patient.
Obviously, HIV related symptoms and social support have been investigated
in a number of studies, but health enhancing behaviors have also been researched.
Vosvick, Gore-Felton, Ashton, Koopman, et al. (2004) investigated the relationship
between pain, stress, social support, and sleep disturbance in a diverse sample of
HIV-positive adults through self report. The relationship found between social
support and sleep was a complex one. More assistance from friends correlated with
more sleep disturbance, but more understanding about HIV related stressors and
listening from colleagues was related to less sleep disturbance. Thus, social support
cannot be viewed as having a completely positive or negative relationship with sleep
quality; it must be considered in terms of the type of support received. The authors
suggest that it is important to consider both the source and type of support when
investigating the topic. Individuals who need more instrumental assistance may also
suffer from more health conditions (which was not assessed in this study), thus
leading to poor sleep quality.
Social support may also be related to the role that individuals with HIV play
in researching their condition and health outcomes. Kalichman, Benotsch, Weinhardt,
Austin, Luke, and Cherry (2003) found that using the internet for health-related
14


information correlated with perceived social support (availability and validation).
These individuals were also better informed about HIV and used more active coping
mechanisms, all of which have been shown to have health benefits.
Mental Health Outcomes and Social Support
In addition to physical health outcomes, social support has also been related to
mental health outcomes for individuals with HIV. Again, the findings indicate that
not all forms of social support are beneficial. McDowell & Serovich (2007) surveyed
both women and men with a diagnosis of either HIV or AIDS and measured
perceived social support, actual social support, and mental health (specifically
depression and loneliness). They found that perceived social support was a significant
predictor of better mental health, but actual social support did not have a significant
relationship with depression or loneliness.
Of course, psychological variables and health variables interact on a number
of levels. Luszczynska, Sarkar and Knoll (2007) attempted to explain the relationship
between received social support, self efficacy, finding benefits in having HIV,
physical functioning, and adherence to antiretroviral regimens in a sample of HIV
positive men and women attending HIV clinics in India. For this particular study,
social support was measured based on the person closest to the participant- although
15


not stated specifically, it could be assumed that many participants would choose their
partnef as this source. The researchers used path analyses and mediation analyses to
determine how these variables are related. Social support had a direct effect on self-
efficacy, finding benefits, and physical functioning. They found that while received
social support was not directly related to adherence, effects were significant if
mediated by self-efficacy.
Sexual Risk Behaviors and Social Support
In addition to physical and mental health outcomes, research has also been
conducted regarding the relationship between social support and sexual risk behaviors
for individuals who are HIV-positive. Darbes and Lewis (2005) gave self-
administered surveys to 47 gay male couples during a baseline period and a six month
follow-up. The researchers measured both general and HIV-specific social support
and sexual risk behaviors, including monogamy and frequency of unprotected anal
sex with both primary and secondary partners. While general social support was not
a significant predictor of HIV risk behavior, greater HIV-specific social support
within the couple was related to less HIV risk behaviors longitudinally. At baseline,
HIV-specific social support explained 12% of the variance in risk behavior, while it
explained 25% at follow-up.
16


However, there is some contradictory evidence that social support could have
a negative relationship with social support as well. Ironson and Hayward (2008)
reviewed a number of studies investigating the relationship between HIV progression
and social support. They indicate that individuals with higher social support tend to
also be more sexually active, which could potentially increase the likelihood of HIV
progression as well as the likelihood of spreading HIV to partners (if activity is not
protected).
Need for Present Study
While there is some variance in the results, in general, these previous studies
demonstrate that low relationship power is associated with higher risk for HIV
transmission and that social support, in general, is associated with positive
psychosocial, behavioral, and health related outcomes. Variance in results is likely
due to differences in two major components of the research: operational definitions of
variables and differing sample demographics. While power may manifest itself in
various ways, definitions tend to differ across studies. It has been suggested that the
difference in conceptualization of power may impact varying results (Harvey, Bird,
Galavotti, Duncan, Greenberg, et al., 2002). However, many researchers agree that
17


the Sexual Relationship Power Scale (SRPS) may change this by providing a standard
instrument to be used to measure power.
One of the most striking differences between the studies involves the sample
compositions. While most studies are conducted within community clinics and drop
in centers, the majority of participants come from low income environments. For
power studies, the focus is on women, especially minority women. This obviously
limits generalizability to men. The lack of research investigating power in
homosexual relationships also leaves a significant hole in the literature. Of particular
interest for this investigation is the lack of quantitative research investigating
relationship power in individuals who are HIV-positive.
Considering the information already available, and acknowledging the gaps in
the evidence, the present study aimed to investigate relationship power in a broad
sample of HIV-positive individuals, in order to assess whether it continues to be
predictive of high-risk sexual behaviors and to investigate whether relationship power
relates to perceptions of social support for HIV-positive individuals. In order to
address these questions, a survey investigating these variables was administered to a
diverse sample of HIV-positive individuals, who report having a primary partner and
were receiving services from an infectious disease clinic in a metropolitan hospital.
The current study investigated four different research objectives, all exploring
various factors of relationship power within this population. First, perceptions of
18


power were compared between heterosexual males, heterosexual females, and
homosexual males to see if power varies systematically between these subgroups. It
was hypothesized that perceptions of power would be higher for heterosexual males
than heterosexual females or homosexual males, based on the structure of power
theory (Blanc, 2001). Next, individuals whose primary partner is HIV-negative
(serodiscordant) were compared to individuals whose partner is also HIV-positive
(seroconcordant) to investigate if perceptions of power vary between the two types of
relationships. For this question, it was predicted that individuals in serodiscordant
relationships would have significantly lower perceived power levels than individuals
in seroconcordant relationships. The basis for this hypothesis relates findings that
individuals in discordant relationships experience distress related to the potential of
infecting their partner (Beckerman, 2002). Third, perceived power was compared to
perceptions of social support (both perceived amount and satisfaction) in order to
investigate if there is a relationship between the two. It was predicted that individuals
with lower perceived power would also have lower ratings of both general social
support and satisfaction with supports. Both healthy relationship qualities, such as
secure attachment, and social support have been found to have positive health
outcomes for individuals with HIV, thus it is likely that social support and
relationship power may be positively related. (Ashton et al., 2005; Riggs, Vosvick, &
Stallings, 2007). Finally, perceived power was compared to condom use to investigate
19


whether power is related to consistent use, as has been seen in HIV prevention
research. It was predicted that relationship power will be positively related to
consistent condom use in this population, although the relationship would not be as
strong as evidenced in primary prevention research.
20


CHAPTER 2
METHOD
Participants
Participants for this study were drawn from a sample of 300 HIV-positive men
and women receiving services at the Denver Health infectious disease clinic. Only
individuals who report having someone they consider being a spouse, partner, or
significant other were included in this analysis. The final sample included 133 HIV-
positive men and women.
In order to be eligible to take the survey, participants needed to be 18 years of
age or older, be diagnosed as HIV-positive, and have basic English reading ability.
Reading ability was not formally assessed during screening, but participants would be
excluded from analysis if they perform poorly on the literacy portion of the survey
itself. No participants were excluded for this reason. Participants having difficulty
with understanding study materials had the opportunity to receive assistance from
study staff; however they were not be able to receive assistance from family members
or partners as this may bias their responses. Additionally, participants did not receive
assistance from staff on portions of the survey assessing their literacy, numeracy (the
ability to understand probabilities), and HIV knowledge. Monolingual Spanish
21


speakers were excluded from the study. Participants were also excluded if they
displayed obvious sigis of intoxication or have obvious cognitive impairment. In
total, 189 potential participants refused to participate in the study: 64 reported not
being interested in the study, 99 did not have enough time, and 26 refused for other
reasons (not specified). Thus, 61% of those approached agreed to participate in the
study.
The 133 participants included in the final analysis included a diverse group of
HIV-positive individuals. Mean age for participants was 43.28 (SD = 9.19). On
average, participants have been living with HIV for 10.76 years (SD = 7.59). For
other health and demographic variables, refer to Table 1. Relationship characteristics
were also varied for the sample. Average length of relationship was 7.05 years (SD =
7.62). Other relationship and sexuality demographics can be found in Table 2.
Materials
For this study, a 10 page paper-and-pencil survey was administered to eligible
participants. The survey included measures assessing demographics, medication
adherence, power in relationships, social support, self-efficacy for communication
with health provider, patient-provider communication, HIV treatment knowledge,
numeracy, literacy, personality disorder psychopathology, substance use, and sexual
22


Table 1 Sociodemographic and health related variables
n__________________________%
Gender (n = 132')
Male 104 78.2
Female 28 21.1
Transgender 1 0.8
Orientation (w = 127)
Heterosexual 39 30.7
Bisexual 14 11.0
Homosexual 74 58.3
Race/Ethnicity (n = 132)
White 71 53.8
African American 29 22.0
Latino 21 15.9
Native American 5 3.8
Other 3 4.5
Years of Education (n = 133)
Less than 12 26 19.5
12 47 35.4
13-15 45 33.8
16+ 15 11.3
Employment Status (n = 133)
Employed 34 25.6
Unemployed 41 30.8
Student 5 3.7
Disabled 50 37.6
Other 3 2.3
23


Table 1 Sociodemographic and health related variables (Cont.)
n__________________________%
Income (n = 131)
$0- 15,000 101 77.1
$16-30,000 24 18.3
$31-45,000 2 1.5
$46-60,000 4 3.1
Self-Reported Viral Count (n = 87)
Undetectable 55 63.2
Less than 10,000 21 24.1
10,001-49,999 2 2.3
50,000 99,999 5 5.7
100,000+ 4 4.6
Self-Reported CD4 Count (n = 81)
Less than 200 16 19.8
201-499 34 42.0
500+ 31 38.2
24


Table 2 Relationship and sexuality demographics
n
%
Partner Gender (n = 132)
Male 110 83.3
Female 22 16.7
Relationship Type (n = 130)
Dating, non -exclusive 30 23.1
Dating, exclusive 40 30.8
Engaged 7 5.4
Common law married 23 17.7
Married 25 19.2
Other 5 3.8
Partners HIV status (n = 125)
HIV-positive 57 45.6
HIV-negative 53 42.4
Dont know 15 12.0
Number of recent sexual partners (n= 131)
No sexual partners 55 42.0
One sexual partner 51 38.9
2+ sexual partners 25 19.1
Condom use with primary partner (w = 127)
All of the time 66 52.0
Some of the time 26 20.5
Never 35 27.5
25


risk behaviors. For this analysis, only the demographic, power, social support, and
sexual risk behavior scales were utilized. Abbreviated versions (only showing
questions used in this analysis) of both the male and female version of the survey can
be found in Appendix A and B respectively.
In order to understand background characteristics, the demographic section
included questions assessing gender, age, race/ethnicity, educational level, income
level, employment status, relationship status, length of current relationship, partners
serostatus, sexual orientation, and years since HIV diagnosis.
Power was assessed using the Sexual Relationship Power Scale (SRPS)
created by Pulerwitz, Gortmaker, and DeJong (2000). The scale was developed to
measure relationship power dynamics in HIV/STD prevention research. The measure
contains good predictive and construct validity and good internal reliability (alpha
=.84 for the full version) within the original validation sample (females only). The
measure is divided into two scales: Relationship Control and Decision Making
Dominance scale. For this study, only the Decision Making Dominance scale was
used. According to the authors, the two scales of the SRPS are sufficiently reliable to
use independently. For the sample in this study, the internal reliability for the
Decision Making Dominance scale was lower than with the original validation
sample (a = .72), most likely due to the fact that this sample was composed of both
males and females. More specifically, the subgroups of homosexual males,
26


heterosexual males, and heterosexual females all displayed lower internal reliability
on the scale than the original validation sample (a = .70, .80, .73 respectively).
Social support was assessed using the Brief Social Support Questionnaire
(SSQ3) (Sarason, Sarason, Shearine, & Pierce, 1987). The Social Support
Questionnaire was developed to measure perceived social support on two levels:
Number/Perceived Availability of Support and Satisfaction with Support. The items
included in this instrument are intended to assess the various functions of social
networks and were compiled through factor analysis. The SSQ has good test-retest
reliability and high concurrent validity with structured interviews. As the original
instrument takes 15-20 minutes to administer, a brief measure was created to assess
social support in situations where time is limited, specifically medical settings. The
three item version (SSQ3) retains high test-retest reliability for both subscales (.84
and .85 respectively) and also correlates highly with the original version (.81 and .85
respectively). An additional question was added to the instrument assessing health
specific support for this survey. With the addition of the extra question, the internal
reliability of both subscales for this sample was .91 and .94 respectively.
Sexual risk behavior was assessed by asking participants to report the number
of times they had engaged in unprotected anal or vaginal sex in the past three months.
Participants were asked to record the number of sexual partners with whom they had
engaged in each behavior in the previous three months along with their partners HIV
27


status. Open response formats are used for these measures in order to reduce
response bias and minimize measurement error (Benotsch, Mikytuck, Ragsdale, &
Pinkerton, 2006). Similar measures have been found to be reliable in self-reported
sexual behavior assessments (Kauth, St Lawrence, & Kelly, 1991) and to provide
similar results to more specific partner-by-partner sexual behavior assessments
(Pinkerton, Benotsch, & Mikytuck, 2007).
Procedure
Participants were recruited in the infectious disease clinic and invited to
participate in the study. Informed consent forms were provided that explained the
purpose of the study, potential risks and benefits of participating, confidentiality
information, and contact information. If eligible, participants completed the 10 page
paper-and-pencil questionnaire. The survey was self-administered, but trained staff
members were available to answer questions mid help when needed. Staff did not
assist participants on the numeracy, literacy, or HIV knowledge portions of the
survey. Only participants reporting having a primary partner were asked to complete
the SRPS. Participants received compensation of $10 when they completed the
survey.
28


Data Analysis
After examining data for inconsistencies and invalid responses, survey data
was entered into SPSS for analysis. A total of 178 cases were removed from this
analysis based on study criteria and missing data: five due to incomplete surveys, 165
participants were excluded because they did not report being in a relationship, six did
not complete power questions, and two reported being HIV-negative. Scale scores
fof relationship power were computed by creating a mean score for all items, then
rescaling from a 3 point scale to a 4 point scale as recommended by the Sexual
Relationship Power Scale authors (Pulerwitz, Gortmaker, & DeJong, 2000).
The Brief Social Support Scale was modified for this study; in addition to the
original three items, a fourth item was added to assess support specifically related to
the participants health. Scores on the three item scale and the four item scale were
compared to ensure the additional question did not affect the scales reliability. Alpha
scores revealed higher values for the four item scale than the original on both number
of supports (a = .91 and .88 respectively) and satisfaction with supports (a = .94 and
.93 respectively), so the four item scale was used for analyses.
Power scores did not fit the assumptions for parametric methods, so non-
parametric analyses were used. Kruskal-Wallis tests were used to investigate whether
relationship power differs systematically for heterosexual males, heterosexual
29


females, and homosexual males and to investigate whether relationship power differs
systematically for seroconcordant and serodiscordant partners. Correlations, Mann-
Whitney analyses, and chi squares were used to assess consistent condom use and
perceptions of social support in relation to relationship power. With a sample size of
133 individuals, analyses achieved adequate levels of statistical power (Field, 2005).
One-tailed significance tests were used for all analyses.
30


CHAPTER 3
RESULTS
Overall, relationship power ratings for this sample fell into the moderate
range, with the majority of participants endorsing having equal levels of power with
their partner. On the four point scale, the sample mean was 2.51 (SD = 0.50). For
results on each individual power item, refer to Table 3.
In order to determine if power levels varied systematically between gender
and sexual orientation, a Kruskal-Wallis test was conducted between heterosexual
women, heterosexual men, and homosexual men. Groups were formed based on the
gender of the participants partner, not on their overall self-identified sexual
orientation. There was no significant difference between groups, H{2) = 4.47, p >
.05. Group means are displayed in Table 4.
Another Kruskal-Wallis analysis was conducted to determine whether power
levels varied between individuals with serodiscordant and seroconcordant partners. A
fair amount of the sample also reported not knowing their partners HIV status, so
this group was included in the analysis as well. There was no significant difference
between groups, H(2) = 3.30, p > .05. For mean comparisons, refer to Table 4.
Two dimensions of social support were compared to the four-point SRPS
score to determine if there was a relationship between number of available supports
and satisfaction with supports and relationship power. Across the four social support
31


Table 3 Sexual Relationship Power Scale results
n %
Whether you have sex? (n = 133)
Your partner 24 18.0
Both of you equally 82 61.7
Both of you/You 1 0.8
You 26 19.5
What you do together (n = 133)
Your partner 22 16.5
Both of you equally 93 69.9
Both of you/Y ou 1 0.8
You 17 12.8
How often you see one another (n = 130)
Your partner 13 10.0
Both of you equally 105 80.8
Both ofyou/You 1 0.8
You 11 8.4
When you talk about serious things ( = 133)
Your partner 23 17.3
Both of you equally 87 65.4
You 23 17.3
Whether use condoms {n =131)
Your partner 13 9.9
Both of you equally 99 75.6
You 19 14.5
Types of sexual acts ( = 132)
Your partner 19 14.4
Both of you equally 98 74.2
You 15 11.4
32


Table 3 Sexual Relationship Power Scale results (Cont.)
n %
In general, who has more power? (n = 133)
Your partner 19 14.3
Both of you equally 90 67.7
You 24 18.0
33


Table 4 Power averages by group
M___________________SD
Gender & Orientation
Heterosexual male (n = 23) 2.43 0.60
Homosexual male (n = 81) 2.48 0.49
Heterosexual female (n = 26) 2.67 0.45
Partners HIV Status
HIV-negative (n = 53) 2.46 0.50
HIV-positive (n = 57) 2.55 0.46
Dont know (n = 15) 2.73 0.43
34


items, participants reported having an average of eight people supporting them (SD =
11.16) and reported an average satisfaction rating of 3.88 on a 5 point scale, with 5
meaning very satisfied (SD = 1.26). For specific data on support satisfaction scores,
refer to Table 5. Number of supports was significantly related to satisfaction with
supports, rs = .\9,p< .05. Average number of supports was also significantly related
to relationship power scores, r,= .18,/? < .05. However, satisfaction with supports
was not related to power ratings, rs = .03, p > .05.
For more specific data on the relationship between social support and
relationship power, additional analyses were conducted for the subgroups of
gender/orientation and partners serostatus. Results for these analyses are presented in
Table 6. Overall, relationships were not significant, with the exception of a strong
positive correlation between available supports and power for heterosexual women.
In order to investigate whether there was a relationship between power and
consistent condom use in an HIV-positive population, comparisons were made
between the number of reported unprotected sexual acts in the past three months
(both vaginal and anal acts with either male or female partners) and the number of
reported times having unprotected vaginal and/or anal sex with an HIV-negative or
unknown status partner. There was no significant relationship between the total
number of unprotected sexual acts and power ratings, rs = -.29, p > .05. However,
35


Table 5 Satisfaction with social support
n %
Accepts you totally ( = 128)
Very unsatisfied 13 10.2
Somewhat unsatisfied 12 9.4
Neither satisfied nor unsatisfied 9 7.0
Somewhat satisfied 36 28.1
Very satisfied 58 45.3
Provides feedback in thoughtful manner (n = 128)
Very unsatisfied 12 9.4
Somewhat unsatisfied 13 10.2
Neither satisfied nor unsatisfied 16 12.4
Somewhat satisfied 34 26.6
Very satisfied 53 41.4
Truly loves you deeply (rt = 133)
Very unsatisfied 19 14.3
Somewhat unsatisfied 2 1.5
Neither satisfied nor unsatisfied 16 12.0
Somewhat satisfied 34 25.6
Very satisfied 62 46.6
Health related support (n = 132)
Very unsatisfied 13 9.8
Somewhat unsatisfied 10 7.6
Neither satisfied nor unsatisfied 11 8.3
Somewhat satisfied 27 20.5
Very satisfied 71 53.8
36


Table 6 Power and social support correlations by group
r. df P
Average number of available supports
Homosexual males .04 74 .36
Heterosexual males .20 21 .18
Heterosexual females .71 20 .00*
Average satisfaction with supports
Homosexual males -.02 80 .43
Heterosexual males .02 22 .47
Heterosexual females .18 25 .19
Average number of available supports
HIV-negative partner .17 48 .17
HIV-positive partner .17 51 .11
Unknown status partner -.13 14 .33
Average satisfaction with supports
HIV-negative partner .12 52 .20
HIV-positive partner .03 56 .42
Unknown status partner -.06 14 .42
Significant at.05 level
37


there was a significant relationship between power and unprotected sex with an HIV-
negative or unknown status partner, rs=-A9,p< .05.
In terms of variables specifically related to condom use with the participants
primary partner, there were no significant findings. Those reporting that they always
use condoms with theif partner (M= 2.51, SD = 0.45) did report slightly higher power
ratings than those who did not always use condoms with their primary partner (M=
2.48, SD = 0.57). This difference was not significant, U= 1927.00,/? > .05.
Additionally, thefe was no difference between those who reported using a condom the
last time they had sex with their partner (M= 2.53, SD = 0.46) and those reporting not
using a condom (M= 2.42, SD = 0.56). Again the difference was no significant, U=
1658.00,/? >05.
In order to ascertain more specific information about unprotected sexual
behavior and power, more specific correlations were conducted using the sub-groups
of heterosexual males, heterosexual males, and heterosexual females separately.
Separate correlations were also analyzed for seroconcordant, serodiscordant, and
individuals with a partner with unknown serostatus. Results of these analyses are
presented in Table 7. Significant negative correlations were found between total
unprotected sexual acts for homosexual males, as well as for unprotected sexual acts
with a partner of unknown or negative status for this subgroup. Heterosexual females
38


exhibited a positive correlation between total unprotected acts and power. Finally,
unprotected acts with a partnef of unknown or negative status were negatively
correlated with power for individuals in serodiscordant relationships.
In an additional effort to understand the specifics of the interplay between
high-risk sexual behavior and relationship power, pertinent items related specifically
to sexual power were compared with condom use with the participants primary
partner. For these analyses, power was dichotomized with sharing power equally and
the participant endorsing having more power combined, as both involve the
participant feeling empowered in that domain. Endorsing a possession of power
regarding whether or not the couple uses condoms, whether or not the couple has sex,
and having more power overall in the relationship were not significantly associated
with using condoms in the primary relationship. However, there was a significant
association between individuals dichotomous power ratings on decisions regarding
what types of sexual acts they do and whether individuals reported using condoms
with their primary partner all of the time or not, x2(l)= 5.89, p < .05. Individuals who
reported possessing power or sharing power with their partner were 3.61 times more
likely to report always using a condom with their partner. There was also a
significant relationship between individuals perceptions of the likelihood they will
use condoms every time, in the next six months, with their primary partner and
individuals dichotomous power ratings on decisions regarding what types of sexual
39


Table 7 Power and sexual behavior correlations by group
r, df V
Total unprotected acts
Homosexual males -.22 80 .03*
Heterosexual males .13 21 .28
Heterosexual females .43 19 .03*
Unprotected acts with HIV-/unknown status partner Homosexual males -.29 78 .01*
Heterosexual males .04 22 .42
Heterosexual females -.25 24 .11
Total unprotected acts
HIV-negative partner -.05 47 .37
HIV-positive partner -.08 54 .29
Unknown status partner -.02 14 .47
Unprotected acts with HIV-/unknown status partner HIV-negative partner -.30 50 .02*
HIV-positive partner -.17 55 .20
Unknown status partner -.33 14 .12
Significant at.05 level
40


acts they do, %(4) = 10.37,p< .05. Individuals who felt they possessed power
individually or shared it were 4.24 times more likely to report being sure (either
extremely or slightly) that they would use condoms every time with their primary
partner in the next six months.
41


CHAPTER 4
DISCUSSION
The purpose of this study was to examine the concept of relationship power in
a varied population of HIV-positive individuals receiving care at a metropolitan
infectious disease clinic. Overall, participants predominantly reported sharing
decision making power with their main partner. Power was compared to participants
gender and sexual orientation, partners HIV status, social support, and consistent
condom use. The results found were surprising and presented mixed results both
supporting the overarching theory and the specific hypotheses for this investigation
and not supporting them in other cases.
While there was not a significant difference in power ratings for heterosexual
males, heterosexual females, and homosexual males, the findings were unexpected. It
was hypothesized that heterosexual males would endorse higher power levels than
females or homosexual males, but there was no significant difference between
groups. These results could be due to the fact that the sample was disproportionately
composed of homosexual men, so the heterosexual subgroups were more affected by
each individual case. However, it is also possible that the dynamics of power shift
when looking at an HIV-positive population. For instance, males, specifically
heterosexual males, may be more disenfranchised by this diagnosis and may feel less
ability to assert themselves in their relationships. The qualitative interviews
42


conducted by Ridge, et al. (2007) support the idea that males perceptions of power
can be low for many reasons: including an inability to negotiate condom use with
female partners and through restrictions on sexuality.
The comparison between individuals with seroconcordant, serodiscordant, and
unknown status partners again yielded unexpected results. It was predicted that
individuals with HIV-negative partners would report significantly lower power than
individuals with HIV-positive partners. Again, there was no significant difference
between the j^oups. Previous studies indicate that individuals experience
psychological distress in serodiscordant relationships, including fear of transmission
and changes in emotional intimacy (Beckerman, 2002), this may affect the slightly
lower (albeit non-significant) ratings of power.
Unexpectedly, participants reporting that they did not know their partners
HIV status displayed the highest mean on power scores. The reasons behind this
finding could be related to this being a smaller subgroup of participants, or there
could be true differences in the perception of power for those unaware of their
partners status. Perhaps because these individuals feel that they possess more
authority in their relationships, they may not be as open in communication with their
partner about serostatus issues. Of course, the difference in means is very small, so
sweeping conclusions should be avoided based on this data.
43


In terms of social support, results were mixed. A significant positive
relationship was found between mean number of available social supports and
reported power, however no relationship was found between satisfaction with support
and the SRPS score. These findings indicate that those with more autonomy in their
relationship also tended to have more people to rely on in their lives. It is important
to note that in individual subgroup analyses, the only significant correlation was
found for women on this construct. As this correlation was so strong, it is likely that
that the finding across all groups was mostly due to the influence of this subgroup
alone. It appears that power relates to number of social supports for women with HIV,
but not for men. As this is a correlation, it is not possible to know whether one affects
the other, or if there is a third variable at play. It may be possible that those who feel
more independence in their relationship also tend to be more outgoing or attract more
people. They also may perceive more supports because they do not solely rely on
their partner to provide guidance or affection.
The fact that there was no correlation with satisfaction with supports was
unexpected. There was only a small correlation between satisfaction and number of
supports, indicating that quantity does not equal quality of support. As the literature
states, not all forms of social support may be seen as beneficial for this population
(Vosvick, et al., 2004). Satisfaction with supports not only refers to the individuals
intimate relationship, but all relationships in their lives. Thus, perceiving power in
44


one relationship may not have much bearing on the individuals satisfaction with all
relationships. Additionally, while it can be assumed that individuals in relationships
have a built-in support system, it is not necessarily the case that that support is viewed
as helpful. One study found that only 50% of supportive acts from intimate partners
were viewed as helpful by persons living with HIV (Barbee, et al., 1998). While
individuals with HIV may be more likely to rely on intimate partners for support, the
complexity of these relationships may result in more emotional and indirect ways of
asking for support with a partner; this may influence the possibility that their partner
may react with avoidance to those requests (Derlega, et al., 2003).
In terms of consistent condom use and relationship power, overall there was
not a consistent relationship between the two constructs. It was hypothesized that
power would relate to consistent condom use, although the relationship was predicted
to be weaker than in prevention research findings. Variables specific to condom use
solely within the primary relationship revealed no significant difference based on
power scores overall. However, means on the SRPS for the individuals reporting
consistent condom use were slightly higher than those who did not report using
condoms consistently. Specific analyses revealed that possessing power in terms of
the types of sexual acts that are performed related to both consistent condom use in
the present, and to predictions of use in the future. According to the present results,
having a say in the types of sexual acts is more pertinent to actual condom use than
45


the feeling of having control over condom use itself, as well as feeling powerful in
terms of when the couple has sex. Perhaps the dynamics and decisions regarding
condom use have already been predetermined based on previous discussion, including
at the time of disclosure of the diagnosis, so individuals do not feel that control over
use is a current issue. For some couples, the type of sexual act performed may dictate
whether condoms are used.
Power did not relate to the total number of unprotected anal or vaginal sex
acts reported in the past three months for the overall sample. In contrast, homosexual
males in the sample exhibited a negative relationship between power and number of
unprotected acts, while females displayed a positive relationship between the two
concepts. These results indicate that power may have very different meanings across
gender and sexual orientation.
For women, the findings oppose the results from the bulk of primary
prevention research, indicating that HIV-positive women with high levels of power
tend to have more unprotected sex. It is possible that there is a shift in power
following diagnosis. Likewise, these results could be due to the differing sexual
dynamics of individuals at risk for contracting the disease, and those that already have
it. Without fear of contracting the disease themselves, the present sample may feel
more empowered to practice unprotected sex. One previous study has indicated that
46


some women endorse feeling powerful through sex, and this may play a part in the
cufrent results (Harvey, Beckman, Browner, & Sherman, 2002)
Interestingly, homosexual men displayed the opposite pattern: higher power
was related to lower reported instances of unprotected sex. This possibly indicates
that either power, unprotected sex, or both have different meanings for heterosexual
women and homosexual men in this population. For the homosexual men in the
study, the number of unprotected sexual acts was significantly related to number of
partners (r = .22,/? < 05), but not for the women in this study. Thus, higher power for
the homosexual men may be indicative of a monogamous relationship, but not
necessarily for females. In comparison to the only other published study
investigating these constructs in a population of men who have sex with men, the
results show different patterns, as no relationship was found between relationship
attachment, autonomy and unprotected anal intercourse (Halkitis, et al., 2004). These
findings warrant further investigation.
Individuals reporting lower relationship power tended to have more
unprotected sex with HIV-negative or unknown status partners. While this coincides
with the finding that individuals in serodiscordant relationships have slightly lower
power ratings than those in seroconcordant relationships, it challenges the finding that
those with partners of unknown status report the highest mean scores on the SRPS.
However, those averages only pertain to the primary relationship, whereas the amount
47


of unprotected sexual acts could be with the primary partner or other sexual partners.
Individuals with lowef power in their relationship may be more likely to have
additional partners due to the lack of decision making power, or perhaps because they
are less satisfied in the partnership.
With regards to specific subgroup analyses, both the homosexual male and the
serodiscordant relationship subgroup displayed significant negative correlations
between SRPS scores and the number of unprotected acts with an HIV-negative or
unknown status partner. The subgroup of serodiscordant partners also displayed a
significant relationship between number of partners and total number of unprotected
acts (r = .36, p < .05). Again, this could point toward higher power being indicative of
monogamous relationships, and subsequently more unprotected sex with their HIV-
negative partner. Conversely, this relationship could be related to findings indicating
that individuals in serodiscordant relationships experience guilt and distress related to
the possibility of infecting their partner (Stevens and Galvao, 2007). These negative
feelings could therefore result in lower feelings of power in serodiscordant
relationships.
In addition to the topic of consistent condom use, abstinence within the
sample should be addressed as well. Many individuals participating in this study did
not report any sexual activity in the past three months (42%), thus the number of
sexually active individuals in the study was limited. Sexual activity is discontinued
48


after HIV diagnosis for a number of reasons. In particular, one study found that a
primary reason women with HIV choose not to have sex due to a desife to focus on
themselves instead of male partners (Siegel, Schrimshaw, & Lekas, 2006). Thus, it is
possible that power has some influence on the discontinuation of sexual activity as
well.
Limitations
While some intriguing findings have resulted from this investigation, there are
limits to the information provided. The assessments provided to participants were
brief given the setting of the study. Additional information on relationship power,
specifically the Relationship Control scale of the Sexual Relationship Power Scale
would have provided extra data on this construct. Similarly, an extended evaluation of
social support would make comparisons between support provided solely by the
participants partner and other sources feasible.
In addition to the issue of brevity of scales, the appropriateness of the scales
used needs to be addressed as well. As the Sexual Relationship Power Scale was
developed from a sample of HIV-negative women, primarily minorities, the use of
this scale with diverse HIV-positive populations may not be appropriate. While alpha
levels were acceptable for the population assessed in this study, they were lower than
those of the original validation sample. Additionally, the use of a global measure of
49


social support does not yield specific data on the social support provided from the
primary partner solely. While power has been found to be related to both global
measures of condom use, as well as more specific current relationship use (McCardle,
et al., 2007), it may be likely that both global and specific measures of support would
yield similar results, however it would have been useful to assess both types of social
support in this analysis.
Results of this study are correlational in nature, and thus, cannot imply
causation or eliminate the possibility that other variables affect the relationship.
Extraneous variables were not assessed, and multiple relationship characteristics and
psychological constructs could mediate the results. For instance, variables such as
relationship satisfaction, trust, or self-efficacy ratings could play a part as well.
While the sample of this study was diverse, there were a disproportionate
number of homosexual males in the current analysis. While this is not inappropriate
given the rates of infection (CDC, 2008), heterosexual males and females were
underrepresented in this analysis. Another limitation of the present study involves the
lack of partner data. Only collecting data from the participant provides an incomplete
picture of the relationship dynamics as a whole.
Finally, surveys were self-administered with staff available for assistance
when needed. While this provides a comfortable environment for participants and
provides the opportunity for assistance, some participants may not ask questions if
50


they have them. For some of the variables in the present study, a number of
participants chose not to answer the question, thus resulting in missing data.
Future Studies
As has been noted previously, multiple research studies have been conducted
on the concept of relationship power within HIV prevention research. This
exploratory study aimed to investigate relationship power within a population of
HIV-positive individuals. Results indicate that more information would be useful to
further understand this concept. Further studies should address the limitations of this
study, specifically by expanding the investigation of both power and social support,
and additionally looking into other relationship related constructs, such as
relationship satisfaction and roles within the individuals relationship. Additionally,
the results involving power specifically related to choosing the types of sexual acts
performed and the difference in power patterns in relation to unprotected sex between
homosexual males and heterosexual females should be investigated further in order to
understand the current results in more depth.
Qualitative interviews in addition to quantitative data would be useful to get
more detailed information about individuals perceptions of power in the context of
living with HIV. Information looking at comparisons of relationship dynamics before
51


and after HIV diagnosis may provide interesting insights on the topic. Previous
research with heterosexual couples indicates that couples report a negative impact on
their sexual relationship following infection (VanDevanter, Thacker, Bass, & Arnold,
1999), with this adjustment, issues with power are likely to shift as well.
Additionally, dyadic methods should be used to investigate relationship power
in the context of a relationship. Specifically, it would be useful to compare power
ratings between partners to ascertain more complex patterns in how partnerships
function. It may be useful to compare ratings of both partners to further understand
the differences in power, if any, between seroconcordant and serodiscordant pairings,
and between heterosexual and homosexual relationships.
Additionally, power should be compared to health related outcomes to see if
this affects medical health as well. Obviously, social support has been shown to have
a close relationship with health related outcomes, such as progression from HIV to
AIDS, symptom changes over time, and survival time with the disease (Aston, et al.,
2005; Leserman, et al., 2000; Patterson, et al., 1996; Theorell, et al., 1995). It may
prove interesting to investigate whether relationship power relates to those same
health outcomes, as well as ARV medication adherence and HIV knowledge.
Finally, while the sample for this survey was diverse in nature, it may not be
representative of all HIV-positive individuals. Those who do not regularly seek
medical care would not have visited the clinic in order to take this survey.
52


Additionally, those who are not aware of their own serostatus were not included, nor
were individuals in other countries, specifically developing countries. Efforts should
be made to investigate relationship power in these groups as well as dynamics may
vary by population.
Conclusions
While this investigation provided a broad overview of relationship power in a
diverse sample of HIV-positive individuals, much still remains unanswered. It
appears that power relates significantly to perceptions of availability of social
support, as well as to number of unprotected sexual acts performed with HIV-
negative and unknown status partners for this diverse sample. While there were no
significant differences between participants based on sexual orientation/gender or
based on partners serostatus overall, more specific analyses revealed differences in
patterns between subgroups regarding the relationship between power and
unprotected sex. It appears that power has a different interplay with unprotected sex
based on both gender and sexual orientation. Power specifically related to
determining the types of sexual acts performed seems to play a significant role in both
current condom use and projections of future use with a primary partner as well.
While these findings are quite varied, they indicate that relationship power is a
53


relevant construct to research in HIV-positive populations, and should be investigated
further.
Overall, the findings of this study are reassuring in terms of both social
support and relationship power. The majority of participants reported sharing decision
making with their partner, a feature that should encourage equality within the
relationship. Additionally, participants reported having quite a few people they felt
they could rely on and satisfaction with social support was high overall. While much
still remains to be answered regarding relationship power, sexual behaviors, and
social support, hopefully the information gleaned from this investigation can serve as
a launching point.
54


APPENDIX A
Abbreviated Survey Male Version
Please answer each question below.
1. What is your age?___________years
2. What is your gender? Male Female Transgender
3. Which best describes you?
White African-American Hispanic/Latino Asian-American Native
American Other___________
4. Circle the highest grade or year of school that you completed.
6 7 8 9 10 11 12 13 14 15 16
17+
5. Circle one of the following that is closest to your current yearly income.
$0 $15,000 $16 30,000 $31 $45,000 $46 $60, 000 Over $60,000
6. What is your current employment status?
Working Unemployed Student Receiving Other
Disability
7. How would you describe your sexual orientation?
Heterosexual Bisexual Gay / Homosexual
55


8. How long have you known that you are HIV-positive?
and months
years
9. Do you have someone you consider to be a spouse, partner, or significant other?
(circle one)
Yes No (If no, go to the next page.)
IF YES:
What is your primary partners gender? (circle one)
Male Female Transgender
How would you describe your relationship?
a. Dating, but not exclusive
b. Dating exclusively
c. Engaged
d. Common law marriage
e. Married
How long have you been in this relationship?
______________Years _______________Months
What is your primary partners HIV status? (circle one)
HIV negative HIV positive Dont know
Do you know your most recent viral load?
was it?
Yes No (IF YES) What
Do you know your most recent CD4 count?
was it?
Yes No (IF YES) What
56


Please think carefully about the past 3 months, and fill in the spaces below. Please
be sure to write a number in every space. If you did not do a behavior, write a zero
(0) in the space. Give each answer your best estimate of how many times you have
done the followinz things:
How many women have you had vaginal or anal sex with in the past 3 months?
_______Total # of women in past 3 months
How many men have you had anal sex with in the past 3 months?
_______Total # of men in past 3 months
The next section asks about sex with WOMEN over the past 3 months.
In the past 3 months. how many times have you had...
Vaginal sex with a woman, no condom used _________Times past 3 months
_____Number of women past 3 months
Vaginal sex with a woman, condom used ______Times past 3 months
______Number of women past 3 months
Anal sex with a woman, no condom used ______Times past 3 months
______Number of women past 3 months
Anal sex with a woman, condom used ______Times past 3 months
______Number of women past 3 months
57


The next section asks about sex with MEN over the past 3 months.
In the past 3 months, how many times have you had...
Anal sex with a man, no condom used, my partner inserted his penis in me (I was
bottom).
_______Times past 3 months
_______Number of men past 3 months
Anal sex with a man, no condom used, I inserted my penis in my partner (I was top).
_______Times past 3 months
_______Number of men past 3 months
Anal sex with a man, condom used, my partner inserted his penis in me (I was
bottom).
_______Times past 3 months
_______Number of men past 3 months
Anal sex with a man, condom used. I inserted my penis in my partner (I was top).
_______Times past 3 months
_______Number of men past 3 months
How often do you use condoms when having vaginal or anal sex with your primary
partner? (Circle one)
All of the time Some of the time None of the time
58


Did you use a condom the last time you had vaginal or anal sex with your primary
partner
Yes No
In the most recent sexual relationship with someone other than your primary partner,
how often did you use condoms? If youre not sure please give your best estimate.
(Choose one).
All of the time Some of the time None of the time
The last time you had vaginal or anal sex with a new partner, did you use a condom?
Yes No
When you have vaginal or anal sex with a new partner, how often do you use a
condom? (Choose one)
Every time Almost every time Sometimes Almost never
In the next six months, how likely do you think it is that you will use a condom every
time you have vaginal or anal sex with your primary partner?
Extremely Sure Slightly Sure Undecided Slightly Sure Extremely Sure
I will I will I wont I wont
In the next six months, how likely do you think it is that you will use a condom every
time you have vaginal or anal sex with a new partner?
Extremely Sure Slightly Sure Undecided Slightly Sure Extremely Sure
I will I will I wont I wont
Please circle your answer to the following questions:
In the past 3 months have you disclosed your HIV status to all of your sexual
partners?
YES NO
59


Since you were diagnosed as having HIV, have you ever misled a sexual partner
about your HIV status?
YES NO
Has someone ever given you money, drugs, or a place to stay in exchange for sex?
YES NO
Have you ever given someone else money, drugs, or a place to stay in exchange for
sex?
YES NO
Have you been diagnosed with a sexually transmitted disease such as herpes,
gonorrhea, or chlamydia in the past 12 months?
YES NO
1. How many people in your life accept you totally, including both your worst and
your best points? ____people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
2. How many people in your life can you really count on to tell you, in a thoughtful
manner, when you need to improve in some way?________people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
60


3. How many people in your life do you feel truly love you deeply?____people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
4. How many people in your life are supportive and helpful to you in terms of your
medical health?_____people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
The following questions refer to your relationship with your primary partner. For
each question, your options are: Your Partner, Both of You Equally, or You.
1. Who usually has more say about whether you have sex? (circle one)
Your Partner Both of You Equally You
2. Who usually has more say about what you do together? (circle one)
Your Partner Both of You Equally You
3. Who usually has more say about how often you see one another? (circle one)
Your Partner Both of You Equally You
4. Who usually has more say about when you talk about serious things? (circle one)
Your Partner Both of You Equally You
5. Who usually has more say about whether you use condoms? (circle one)
Your Partner Both of You Equally You
61


6. Who usually has more say about what types of sexual acts you do? (circle one)
Your Partner Both of You Equally You
7. In general, who do you think has more power in your relationship? (circle one)
Your Partner Both of You Equally You
62


APPENDIX B
Abbreviated Survey Female Version
Please answer each question below.
1. What is your age? __________years
2. What is your gender? Male Female Transgender
3. Which best describes you?
White African-American Hispanic/Latino Asian-American Native
American Other___________
4. Circle the highest grade or year of school that you completed.
6 7 8 9 10 11 12 13 14 15 16
17+
5. Circle one of the following that is closest to your current yearly income.
$0 $15,000 $16 30,000 $31 $45,000 $46 $60, 000 Over $60,000
6. What is your current employment status?
Working Unemployed Student Receiving Other
Disability
7. How would you describe your sexual orientation?
Heterosexual Bisexual Gay / Homosexual
63


8. How long have you known that you are HIV-positive?
and months
years
9. Do you have someone you consider to be a spouse, partner, or significant other?
(circle one)
Yes No (If no, go to the next page.)
IF YES:
What is your primary partners gender? (circle one)
Male Female Transgender
How would you describe your relationship?
f. Dating, but not exclusive
g. Dating exclusively
h. Engaged
i. Common law marriage
j. Married
How long have you been in this relationship?
______________Years _______________Months
What is your primary partners HIV status? (circle one)
HIV negative HIV positive Dont know
Do you know your most recent viral load?
was it?
Yes No (IF YES) What
Do you know your most recent CD4 count?
was it?
Yes No (IF YES) What
64


Please think carefully about the past 3 months. and fill in the spaces below. Please
be sure to write a number in every space. If you did not do a behavior, write a zero
(0) in the space. Give each answer your best estimate of how many times you have
done the following things:
How many men have you had vaginal or anal sex with in the past 3 months?
_______Total # of women in past 3 months
How many women have you had anal sex with in the past 3 months?
_______Total # of men in past 3 months
In the vast 3 months, how many times have you had...
Vaginal sex, no condom used
_______Times past 3 months
_______Number of women past 3 months
Vaginal sex, condom used
_______Times past 3 months
_______Number of women past 3 months
Anal sex, no condom used
_______Times past 3 months
_______Number of women past 3 months
Anal sex, condom used _______Times past 3 months
_______Number of women past 3 months
65


How often do you use condoms when having vaginal or anal sex with your primary
partner? (Circle one)
All of the time Some of the time None of the time
Did you use a condom the last time you had vaginal or anal sex with your primary
partner
Yes No
In the most recent sexual relationship with someone other than your primary partner,
how often did you use condoms? If youre not sure please give your best estimate.
(Choose one).
All of the time Some of the time None of the time
The last time you had vaginal or anal sex with a new partner, did you use a condom?
Yes No
When you have vaginal or anal sex with a new partner, how often do you use a
condom? (Choose one)
Every time Almost every time Sometimes Almost never
In the next six months, how likely do you think it is that you will use a condom every
time you have vaginal or anal sex with your primary partner?
Extremely Sure Slightly Sure Undecided Slightly Sure Extremely Sure
I will I will I wont I wont
In the next six months, how likely do you think it is that you will use a condom every
time you have vaginal or anal sex with a new partner?
Extremely Sure Slightly Sure Undecided Slightly Sure Extremely Sure
I will I will I wont I wont
66


Please circle your answer to the following questions:
In the past 3 months have you disclosed your HIV status to all of your sexual
partners?
YES NO
Since you were diagnosed as having HIV, have you ever misled a sexual partner
about your HIV status?
YES NO
Has someone ever given you money, drugs, or a place to stay in exchange for sex?
YES NO
Have you ever given someone else money, drugs, or a place to stay in exchange for
sex?
YES NO
Have you been diagnosed with a sexually transmitted disease such as herpes,
gonorrhea, or chlamydia in the past 12 months?
YES NO
1. How many people in your life accept you totally, including both your worst and
your best points? ___people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
2. How many people in your life can you really count on to tell you, in a thoughtful
manner, when you need to improve in some way?_______people
67


How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
3. How many people in your life do you feel truly love you deeply?______people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
4. How many people in your life are supportive and helpful to you in terms of your
medical health?______people
How satisfied are you with the support you receive in this area? (circle one)
Very unsatisfied Somewhat unsatisfied Neither satisfied nor unsatisfied
Somewhat satisfied Very satisfied
The following questions refer to your relationship with your primary partner. For
each question, your options are: Your Partner, Both of You Equally, or You.
1. Who usually has more say about whether you have sex? (circle one)
Your Partner Both of You Equally You
2. Who usually has more say about what you do together? (circle one)
Your Partner Both of You Equally You
3. Who usually has more say about how often you see one another? (circle one)
Your Partner Both of You Equally You
4. Who usually has more say about when you talk about serious things? (circle one)
Your Partner Both of You Equally You
68


5. Who usually has more say about whether you use condoms? (circle one)
Your Partner Both of You Equally You
6. Who usually has more say about what types of sexual acts you do? (circle one)
Your Partner Both of You Equally You
7. In general, who do you think has more power in your relationship? (circle one)
Your Partner Both of You Equally You
69


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