A sexual agreement is a mutual understanding between two partners regarding sexual and relational behaviors both within and outside of their relationship. Sexual agreements have been central to research and programming efforts around HIV prevention, primarily for male couples. A comprehensive scoping review of the primary literature on sexual agreements, including negotiated safety, was performed to identify what is known about sexual agreements among couples (n = 66). Results indicate a wide range of prevalence of agreements and measurements used to characterize sexual agreements. Findings also report associations between sexual agreements and health and relational outcomes. Several knowledge gaps were identified; specifically, the need to expand sexual agreements research beyond MSM populations and the need to better understand agreement breaks, break disclosure, and how variation in agreement categorization may impact reported prevalence. This review demonstrates the importance of broadening the evidence-base of sexual agreements research and programmatic focus.

Keywords

Couples Sexual agreements Negotiated safety 

Introduction

Recent research has drawn attention to the role of male dyads in the U.S. HIV epidemic, with primary male partners identified as the source of approximately one-third [1] to two-thirds [2] of new HIV infections. The identification of being in a partnership as an important risk for HIV infection among men who have sex with men (MSM) represents a significant paradigm shift in HIV prevention thinking. Prevention efforts have traditionally focused on MSM as individuals and have messaged the HIV risks associated with casual sex [3]. Recent research findings have illustrated high rates of sexual risk behavior for HIV (with primary and casual partners), low rates of disclosure of potentially risky episodes with casual partners to primary partners, and reduced frequency of HIV testing among male couples [4, 5, 6]. In addition, intimate relationships may convey a misplaced sense of protection, to some degree created by the historical prevention focus on reducing numbers of sexual partners.

Central to research and programming efforts around HIV prevention for male couples has been a focus on sexual agreements. A sexual agreement is a mutual understanding between two partners regarding sexual and relational behaviors both within and outside of their relationship [7, 8]. Types of sexual agreements are mostly described as either open (allowing sex with outside partners) or closed (not allowing sex with outside partners), often referred to as monogamous. An open agreement may further be defined as open with or without rules or conditions. Rules refer to clearly defined parameters for the agreement, that may include condom use, types of sex allowed, or may be linked to HIV/STI testing behavior [9]. A specific form of sexual agreement that has received much research attention is negotiated safety, in which sero-concordant HIV-negative partners in a committed relationship agree to use condoms for anal intercourse outside of the relationship but not within the relationship [10].

There is now a wealth of evidence demonstrating the high prevalence of sexual agreements among male couples, with recent studies estimating that 58 to 99% percent of male couples report having a sexual agreement with their primary male partner [7, 11]. The most commonly reported agreement is a closed agreement (monogamy), with a prevalence between 13 and 82% [11, 12] compared to open agreements, which range in prevalence from 2 to 64% [13, 14]. There is also increasing evidence of associations between sexual agreement formation and HIV risk and prevention behaviors. Couples with closed agreements have lower odds of engaging in condomless anal intercourse with an outside partner when compared to couples with an open agreement [15, 16, 17, 18]. However, the formation of sexual agreements has also been associated with other HIV risk behaviors: couples with an open agreement are more likely to use alcohol and drugs during sex [19]. Furthermore, while some couples will form sexual agreements on their own over the course of their relationships, without health protective models such agreements may not reduce risk. In one study which compared types of agreements (e.g., open, closed, negotiated safety), researchers found that some agreements were unsafe—that is, agreements permitted high risk sexual behavior such as condomless anal sex both within and outside the partnership [16]. Another study found that, among sero-discordant couples, partners formed and adhered to sexual agreements without intervention but nearly half of agreements did not incorporate HIV protective strategies such as condom use [20]. The formation of sexual agreements is also related to HIV prevention behaviors. Two recent studies demonstrated that couples with an open agreement were more likely to have been tested for HIV recently [21, 22], suggesting that the formation of an agreement may provide parameters for also discussing and partaking in HIV prevention activities. However, associations between sexual agreement formation and HIV prevention and risk go beyond just the presence of agreements: the amount of investment, commitment and satisfaction with the agreement reported by the couples are also significantly associated with the breakage of agreements, condomless sex outside of the partnership and HIV testing behaviors [14, 15, 17, 18, 23, 24, 25, 26, 27, 28, 29]. Considering that many male couples form sexual agreements and are willing to discuss sexual risk behavior with their partners [30], an understanding of agreement formation and differences in outcomes across types of agreements may be beneficial to inform the content of programmatic efforts to reduce HIV transmission within male dyads.

Despite growing research attention to sexual agreements, such attention has remained largely focused on male couples, with a dearth of research examining sexual agreements in other populations (e.g., couples in which one or both members are transgender or opposite gender couples). This scoping review aims to fill several gaps in our current understanding of the evidence-base for sexual agreements. First, the review is not limited to research on male couples, and includes and contrasts research examining sexual agreements among couples of all gender and sexual identities. The review is also not limited to studies that have focused on HIV risk or prevention outcomes, and rather includes studies that have examined any physical or mental health outcome, or any relationship characteristic outcome. The scoping review builds and extends upon previous reviews that have focused either only on male couples [31] or focused only on negotiated safety [32]. Fundamental to the development of dyadic HIV prevention interventions that incorporate sexual agreement discussions or formations is a thorough understanding of the current status of evidence for sexual agreements. This scoping review aims to provide this evidence by providing an evaluation of what is currently known about sexual agreements, with the aim of identifying gaps in research and presenting recommendations for future research foci.