When Condoms Aint Enuf...

via TheBody, by Allen Kwabena Frimpong and Michael Terry Everett

"I also want to mention that we are increasingly becoming better at incorporating conversations about 'harm reduction' into the realms of substance use (needle exchanges, safe injection sites, pill testing, etc.), but we often fail to adequately translate this model when speaking of communicating risk reduction in sex (strategic positioning, sero-sorting, viral load suppression, etc.). My question back to the group then is, how do we more effectively communicate to young people the abstract concept of 'harm reduction' for sex within the context of a sex phobic society?"

This was a question posed by Jamie Forrest of Vancouver, Canada in the North America, Western Europe, and Caribbean CrowdOutAIDS Open Forum on Facebook. CrowdOutAIDS is UNAIDS new collaborative online youth-led project.

He posed this question to the group after people were discussing what they considered to be the main reasons for HIV infection among young people.

Reading the responses on Facebook gave us one of those jolted reactions.

The dominant message about sexual health in relation to HIV prevention has been focusing on condom usage. Jamie's question was one that I saw as challenging; given the propaganda that the HIV/AIDS field has been pushing around what it means to have safer sex.

My colleague at the Harm Reduction Coalition, Michael T. Everett, was also raising this same question especially among young men who have sex with men (YMSM) of color given that their rates of infection have been steadily increasing while rates of infection among injection drug users has been on the decline.

The question for us became what (besides the exchange of needles) was accounting for the decrease in transmission of HIV among injection drug users, and how could we use what works in harm reduction messaging and education when it comes to drug use (if anything) for other high-risk populations greatly affected by the epidemic through sexual transmission.

We considered this in light of the following:

1. We cannot exchange condoms like we do syringes.
2. We know people are not using condoms all the time, and the possibilities of HIV and other STI's has not scared enough people into doing so, and so ...
3. If people have been harboring condom use as the dominant end all be all harm reduction response- well then something is terribly wrong with this picture.

The place to begin the conversation around the idea of prevention of at-risk behaviors like having unprotected sex is a great place to start.

We need to engage an intentional conversation concerning the reality that the message of safe-sex, by way of condom usage, may not resonate with people because it is limited and does not allow one to ponder the spectrum of other possible harm reduction practices.

The point is: we want people to still live a healthy life without causing further harm to themselves and others. The spectrum of harm reduction practices includes everything from prevention to helping those who are most affected by the collateral consequences of their at-risk behavior.

The spectrum does not begin or end with condom usage only.


Read the rest

Hmmmm, so serosorting may actually work?

[Interesting item, especially in light of the fact so much of the discussion around this prevention strategy has focused on the downsides... Seems it's a bit more complex than that.]

Serosorting Is Associated with a Decreased Risk of HIV Seroconversion in the EXPLORE Study Cohort

via PlosONE

Philip SS, Yu X, Donnell D, Vittinghoff E, Buchbinder S (2010) Serosorting Is Associated with a Decreased Risk of HIV Seroconversion in the EXPLORE Study Cohort. PLoS ONE 5(9): e12662. doi:10.1371/journal.pone.0012662

Abstract

Background

Seroadaptation strategies such as serosorting and seropositioning originated within communities of men who have sex with men (MSM), but there are limited data about their effectiveness in preventing HIV transmission when utilized by HIV-negative men.

Methodology/Principal Findings

Data from the EXPLORE cohort of HIV-negative MSM who reported both seroconcordant and serodiscordant partners were used to evaluate serosorting and seropositioning. The association of serosorting and seropositioning with HIV seroconversion was evaluated in this cohort of high risk MSM from six U.S. cities. Serosorting was independently associated with a small decrease in risk of HIV seroconversion (OR = 0.88; 95%CI, 0.81–0.95), even among participants reporting ≥10 partners. Those who more consistently practiced serosorting were more likely to be white (p = 0.01), have completed college (p = <0.0002) and to have had 10 or more partners in the six months before the baseline visit (p = 0.01) but did not differ in age, reporting HIV-infected partners, or drug use. There was no evidence of a seroconversion effect with seropositioning (OR 1.02, 95%CI, 0.92–1.14).

Significance

In high risk HIV uninfected MSM who report unprotected anal intercourse with both seroconcordant and serodiscordant partners, serosorting was associated with a modest decreased risk of HIV infection. To maximize any potential benefit, it will be important to increase accurate knowledge of HIV status, through increased testing frequency, improved test technology, and continued development of strategies to increase disclosure.

Read the full paper.

Get Your Game On, Play Smart

Rally the team
Suit up
Know your stats
PEP Talk

Play Smart trading cards were created by artists, commissioned by Visual AIDS and designed by John Chaich. It's an honest and straight-forward approach to promote harm reduction, HIV testing and post-exposure prophylaxis.

The back of each trading card features information you need to know to Get Your Game On and Play Smart.

Peter, this is my first time at IML and I'm planning on marathon sex sessions. Any pointers?

[Peter Pointers is here 4 YOU, as a service to LifeLube readers - whatever question you may have regarding sexual health, physical health, mental/emotional and spiritual health - ask him. He will find the answers you are looking 4. helped by a team of experts. Below is a recent Q&A you may be interested to read.]

Question:  Hi Peter -  This is my first time experiencing IML and I'm planning on having a couple of marathon sex sessions (12-24hrs) with friends and with people I don't know. Other than playing safe and not using drugs, what other pointers can you give me to reduce any type of harm to myself.

Answer: Thank you for checking out my service and for submitting a question. IML (International Mister Leather, May 28 - 31, Chicago)  can be a really great and fun experience. Make sure to visit the Howard Brown booth at the leather mart to stock up on all your safer sex supplies for free!

In regards to reducing harm to yourself during a marathon sex session - you hit it on the head... the best place to start is by playing safe and not using drugs. However, it sounds like to want something a little more.

One of the best pieces of advice that I can give is to develop a plan for keeping yourself safe (in whichever way that means for you) and communicating that plan to every partner. For example, if you want to avoid being topped bareback, then have that be a hard boundary line for yourself and tell your partners about that line. Having a set plan will increase the chances of you sticking to it when things get hot and heavy or if your mind is otherwise distracted.

Another thing to communicate with someone about is their HIV status and how that relates to your status. However, since many people do not know their true HIV status (research shows us that up to 50 percent of gay men who are positive don't know they are positive), make sure you ask more about their behaviors than their status. For example, if you are HIV-negative and want to have sex with someone else who is HIV-negative, asking "when were you last tested and what was the result?" may give you better information than "are you neg?" There is still no guarantee but it may help you to identify people who are of the same status as you.

Outside of that, make sure you drink lots of water to stay well hydrated. Eat well, to keep energy supplies high. And let a trusted friend know where you are and who you are with, for your general safety.

Also, getting tested for and treated for any STDs before IML will reduce the risk of HIV infection. Let me know if you need help finding a testing location!

Of course, if you choose to use condoms, change up condoms frequently and use LOTS of lube!


Be Well,
Peter
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Bluebelly harm reduction from Down Under

Bluebelly / blue.bel.ly / n.
1. slang term for meth/amphetamine.
2. a diverse community of interested individuals seeking to gather and deliver high quality harm-reduction information.

Bluebelly is a collaborative, harm-reduction project from Down Under that aims to gather and provide concise, relevant information about amphetamine-type stimulants for people of all backgrounds/identities.

Check out the following example of clear, no-nonsense, user-friendly info from their wiki/website blend:

Drug Combinations

People combine drugs for a range of reasons including:

- Potentiation of pleasurable effects

- To mitigate the unpleasurable effects of another drug

- To achieve separate but simultaneous effects.

While combining particular drugs can prove to be a pleasurable experience for people, in some instances it can be highly dangerous. It should also be stated that different people will respond differently to different drugs and drug combinations, and the same person can have a different response on different occasions.

The table found here provides a summary of some known drug combinations and possible implications.

Bluebelly

Peter, I keep having men that are undetectable tell me that unprotected sex with them is ok. What makes them think that?

[Peter Pointers is here 4 YOU, as a service to LifeLube readers - whatever question you may have regarding sexual health, physical health, mental/emotional and spiritual health - ask him. He will find the answers you are looking 4. Below is a recent Q&A you may be interested to read.]

Question: I keep having men that are undetectable tell me that unprotected sex with them is ok.....What statistics are out there that make them think that????? I have always took the opposite stanz with these folks....but it has been thrown at me so many times by different men....that I am assuming they are getting some sort of stats somewhere making them think that.....

Answer: This is such a great question and, frankly, one that I wonder why I don't hear more often. I know that information about unprotected sex with undetectable men is out there... and there is a lot of back and forth about what the most accurate information is.

So, I'm not sure how much you want to read about this, but there are a number of studies that have recently come out that have to do with your question. Here is a link to several articles about them on LifeLube.

But the short of it is: In January of 2009, researchers in Switzerland published an article saying that "an HIV-infected person on antiretroviral therapy (ART) with completely supressed viraemia (effective ART) is not sexually infectious, i.e. cannot transmit HIV through sexual contact." Importantly, some important additional factors must be present, also: that the viral load must have been undetectable for over 6 months, the person must be completely adherent to ART, and both partners must be free of other STDs.

Since that statement, a number of other studies have come out challenging the Swiss statement.

1. Some argue that while viral level may be undetectable in blood, it may be found in higher amounts in semen.
2. Others stress the STDs issue, expressing concern that many men may not know they have an infection (such as rectal herpes with or without symptoms or HPV, the virus that causes genital and anal warts).
3. Furthermore, criticism came from the fact that the studies that the Swiss researchers looked at were done only on heterosexual couples from sub-Saharan Africa – not on men who have sex with men.

It is true that if someone is on HAART and has a non-detectable viral load, it will DECREASE the chances of HIV infection, but it will not eliminate any chance. And, in a real life situation, it is very difficult (if not impossible) to know if the person you are deciding to have sex with has been undetectable for a full 6 months, or if they have never missed a dose of their meds. It is even a challenge to be sure if they have had a recent STD test that was either negative or that they had gotten treatment after. In other words, we're still not sure. The U.S. government has not signed onto the Swiss statement in any way.

We still advocate that if you know someone is HIV positive and you are not, then it's best to use condoms correctly and consistently. It still remains the best way we have to prevent HIV transmission.

If you are not going to use condoms, try to use other safer sex strategies like using lots of lube to reduce tearing and friction, make sure you and your partner have been tested for STDs and treated for any that may have been there, and try not to have your partner cum inside of your ass or mouth.

Let me know if there is more information that you would like to have on this topic! I'd be happy to pass it along.


Be Well,
Peter Pointers
Friend Peter on Facebook

Let's all start sucking around

via Fridae, by Jan Wijngaarden

Fridae’s Men’s Sexual Health columnist Jan Wijngaarden wonders why oral sex has not been as widely recommended as a 'safer option' given that it has been found to be of much lower risk compared to anal sex.

A while ago, a friend of mine, who is around 55 years old and from Europe, sadly looked back on his life during a birthday dinner. He said that none of his (gay) friends from when he was in his twenties and thirties was alive to celebrate his birthday with him. They had all died - most of them, by far, died of AIDS.

I was intrigued. Why did he survive? Was he immune, or what? Or was he the only one who used condoms? When we were alone, after the dinner was finished, I decided to ask him.

He said: "Condoms? Nobody used them at that time. It was true; I had syphilis, gonorrhea and chlamydia several times, but those could be treated easily. That was not it, for sure."

So, what then? He answered: "It is the fact that I HATE anal sex which must have saved my life!"

It is an interesting conclusion, with a lot of truth in it. Anal intercourse is the sexual behaviour which is - by far - most likely to transmit HIV among gay men (and - much less well known - maybe among some heterosexuals, too).

Read the rest.

Release (UK) - "Nice People Take Drugs"

Release, the campaigning organisation that specialises in drugs and drugs law, is running an advertising campaign on London buses during June. With the slogan 'Nice People Take Drugs', Release is looking to open up the drugs debate and engage the public in a more sophisticated and honest drugs dialogue.

Explaining why Release was moved to run this campaign, executive director Sebastian Saville said, "the constant association by politicians and the media of drugs with words like evil and shame simply does not reflect most people's experience of drugs. The public is tired of the artificial representation of drugs in society, which is not truthful about the fact that all sorts of people use drugs. If we are to have a fair and effective drug policy, it must be premised on this reality first and foremost."

In this election week, politicians have learnt an important lesson about what is and what is not, tolerated by the public. Outcry over the parliamentary expenses scandal far outstrips any reaction the public has had to previous revelations of drug use by MPs. Their reluctance to engage with the issue of drugs is based on misguided assumptions about the public's perception of them.

The slogan 'Nice People Take Drugs' was especially chosen to illustrate the extent to which drugs are present in many aspects of society and across every generation, culture and class.

Despite this, policy-makers maintain a narrow understanding of drug use and the people who use them. This has resulted in some of the biggest and most expensive policy failures of modern times.

More details about this campaign can be found here.

Harm reduction and a focus on the holistic - Boston's MALE Center goes beyond ...

MALE Center equips men to avoid HIV infection
via Bay Windows by St. John Barned-Smith

Excerpt:

"The whole premise behind the MALE Center was to help reengage the community around HIV prevention, around [the sexual] health of the community," said Shankle. "We moved the focus from just doing HIV prevention, but talking about a whole approach to gay and bisexual men’s health. So we’re looking at things like substance abuse, like how people engage in the community, homelessness, the fact that unemployment - these are all things that lead people to make decisions that may not be the best decisions related to their sexual health."

Read the whole thing.

Control

What’s up! My name is Brandon and I am 26 years old.

I currently live in the Chicago neighborhood of Edgewater (north side), but I am a transplant of Boystown.

I moved to Edgewater to get away from the craziness of Boystown. I got too involved in enjoying all the bars, the hot men and the drugs. I found myself having sex without any regard to anything else. One day, I had an epiphany and I decided that I did not want to live that type of life and so I decided to separate myself by moving.

After my move to another part of town and in an effort to make positive change, I made attempts to use condoms every time I had sex. I kept on trying but there was something evil that got in my way that prevented me from using condoms and it was my challenging addiction to drugs. I am not saying this is an excuse for my actions, but I must admit the drugs made it more difficult. It’s hard to use condoms every time you have sex when you are sober let alone while you are high.

Eventually I was able to use condoms most of the time with most of my guys. I slowed down on my drug use which made me aware of what I was doing. It became easier to use condoms because I was able to take back control.


Want to share your story with LifeLube? tell us how you are healthy. Contact us!

"Most men don’t use condoms at one time or another..."

You don't need to be a hot, speedo-clad Aussie to take advantage of these sexual risk reduction strategies - via Australia's very cool "Cruising" site - which offer clear, non-judgmental info for sexually active gay men beyond "use a condom every time." The site also features good, practical stuff about saunas (bathhouses), backrooms, sex clubs and crusing online, netiquette, cyber sex - and more.

Check it out.

What I do makes a difference

Most men have heard a lot, even from a young age, about HIV and how condoms are the most effective way to stop HIV being passed on. In Australia, HIV remains heavily concentrated amongst men who have sex with men with more than 85% of current HIV infections occurring amongst them. Almost every HIV infection amongst men who have sex with men in Australia has taken place during times when men have had anal sex without condoms.

Most men don’t use condoms at one time or another. Sometimes these decisions are made wisely with an informed sense of the risk being taken and efforts made to reduce the risk of getting or passing on HIV. Other times, these decisions are made in a less-than-informed way, with not a lot of effort being made to reduce risk. Sometimes we’re not really sure how risky or safe what we’re doing really is or we just don’t want to think about HIV at the time. So it’s not until later that we start thinking about the risks we may have exposed ourselves to.

What follows here is not an attempt to advise you to not use condoms. It is given in the knowledge that while condoms and lube are always the easiest and most effective way to stop HIV transmission in casual sex, sometimes men don’t use condoms. At these times, there are other things we can do to reduce the chances of HIV being passed on. Most of these strategies will reduce risk but not eliminate it altogether.


Want to top?

Some men of different HIV statuses fuck without condoms by having the negative guy “top” (that is, be in the dominant or insertive position in anal sex) and the positive guy “bottom” (that is, be in the submissive or receptive position). Sometimes this is called “strategic positioning”. This idea is based on the assumption that the chances of the negative man getting HIV are reduced if he is the one that cums inside the positive man, rather than the positive man cumming in him. It’s also based on the idea that “tops” (men who fuck, rather than get fucked) are less likely to get HIV. While this is true and the chances of getting or passing on HIV are generally greater if a positive man tops a negative man, tops can still get HIV.

Some men have still caught HIV even though they’ve used this strategy. Around 1 in 5 men who recently contracted HIV were tops. This strategy reduces the chances of HIV being passed on, but it does not eliminate the chances altogether. It also means that sometimes men have to take on positions in anal sex that they wouldn’t normally or that they don’t particularly want to do, simply because of the HIV statuses of the two men. It also means that it’s important that both men know what HIV status they are.

I’m pulling out!

Some men reduce the chances of HIV being passed on by pulling out before cumming when they fuck. While this might reduce the chances of HIV being passed on, it doesn’t eliminate the chances altogether. Pre-cum (the clear fluid that comes out of your dick prior to cumming) can contain HIV and little breaks and tears can occur in the lining of the arse when fucking, making HIV more likely to be passed on. HIV can also enter the head of the dick from another man’s arse.

Counting down…

Some men use the results of viral load tests to make decisions about anal sex. Viral load is a test taken by HIV positive men to measure the amount of HIV in their blood. These tests help HIV positive people and their doctors to make decisions about treatment. There van be other factors besides treatments that affect a viral load test result. Other sexually transmitted infections and other infections like the ’flu can increase a person’s viral load.

Commonly, people with HIV who are well check their viral load every three months. It is possible for a person’s viral load to go up and down quickly depending on what else is happening to their health. So, the results of a viral load test taken weeks or even days ago may be very different to what that person’s viral load is now. The lowest viral load results available are called “undetectable”. This doesn’t mean that there is no viral load (only HIV negative people have a zero viral load) – it only means that the viral load is below the level detectable by current tests. Also, viral load tests are measurements of the amount of virus in blood and no test is readily available to measure the viral load in cum. Lots of HIV positive men are interested in knowing whether a low or undetectable viral load result (for their blood) applies to their cum as well. Many experts say that generally, viral load results can be applied to levels in cum, however there is evidence that suggests there can be quite different levels of virus in blood and cum at the same time. Other sexually transmitted infections for example, can rapidly increase the amount of HIV in cum.

Some men make decisions about the chances of HIV being passed on, on the basis of viral load results thinking that an undetectable test means that there is no chance of passing on HIV. This is not true. HIV treatments cannot make an HIV positive man become HIV negative again. Once a man becomes HIV positive it will always be possible for him to pass HIV on to someone else, no matter how effective HIV treatment is for him or how low or undetectable his viral load is. Remember also that a viral load count only indicates what your viral load was at the time of your last test, not what it might be at the moment.


I don’t know anyone with HIV

Some HIV negative men don’t use condoms because they think there aren’t HIV positive men around the places they go to have sex, like beats or sex clubs and saunas. HIV positive people live in all areas of Victoria and Australia – inner city, suburban, regional and rural areas. A lot of people still think that HIV is an inner city problem and that no one in their suburb or town has HIV. Even if we’re travelling and are in a place we aren’t normally, it’s important not to think that there are no HIV positive men around. Wherever you are, it’s important to not guess that a guy you’re cruising or having sex with has the same HIV status as you.

I didn’t think he was positive

Some HIV positive men don’t use condoms in some sex clubs where other HIV positive men tend to gather. If condoms aren’t introduced into the scene it’s easy to think that the other guy is already HIV positive as well. You can never be sure whether another guy has the same HIV status as you.

A lot of the time we think that if a guy has a different HIV status to us, he’ll say so. But a lot of HIV negative men think it’s more important that HIV positive men tell their HIV status. A lot of HIV positive men get rejected by HIV negative men when they say they’re positive. And lots of HIV negative men won’t have sex with a guy they know is positive. You can’t rely on HIV positive men to say they’re positive when they know they’re likely to be rejected. So don’t assume that you’re going to be told when fucking a guy who has a different HIV status to you. Also some men don’t know their HIV status so they couldn’t tell you whether they were HIV positive or negative. A lot of guys who don’t know their own HIV status assume that they’re negative when they might not be.

A lot of men still think they can tell whether a man is HIV positive or negative by looking at him. Men of all ages and all walks of life are getting HIV. There is not one single “type” of man that is HIV positive. HIV positive men look as different from each other as HIV negative men do. And a lot of HIV positive men don’t look “sick”. Sometimes whether a guy introduces a condom or not is what we use the most to indicate his HIV status. But men interpret wanting to use condoms in different ways.

Some men think that wanting to use a condom means a man is HIV negative; others think it means he’s HIV positive. There is evidence that men read condom use in this way differently in different cities and towns across Australia. There’s no way to tell whether a man is HIV positive or negative from the way he looks, how old he is or whether he wants to use a condom or not.

I must be immune

Some HIV negative men have had sex without condoms with men whose HIV status they don’t know and not got HIV. Others have had sex without condoms with men who they’ve even known were HIV positive and still not been infected with HIV. Sometimes HIV negative men and HIV positive men have knowingly fucked together and the HIV negative man has stayed HIV negative. Some of these HIV negative men even think they are immune to HIV. No one is immune to HIV. HIV only needs one opportunity to pass from one person to another, so the more opportunities you give, the more likely it is to happen. In other words, the more chances you take with your HIV status the higher the chances of you getting HIV. Just because something has happened to you once or twice or even many times before, doesn’t mean the same thing will happen each time in the future. So the more you fuck without condoms and the more men you fuck with, the more likely it is you will get and/or pass on HIV.


Read more on the Cruising site.

We believe anything Jay Black says...

REALLY.

This great ad is from our pals at Tweaker.org

For Chicago-specific info on crystal meth, click here.

Remember when an 8-ball was more than enough?

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Hell yes!

This ad via Tweaker.org - one of our favorite sites for great crystal meth info.

For local Chicago resources on crystal meth, click LifeLube.

Q: What is meth mouth?

Why does crystal meth use have a potential for ruining someone’s teeth?

A. "Meth mouth" is caused by a number of things. Meth use constricts the vessels that supply blood to oral tissues. Since teeth and gums need blood to stay healthy, reduced blood supply causes tissues to shrink, which can eventually lead to blood vessels dying.

Also, the saliva in your mouth is a natural way to keep teeth healthy by reducing acid and bacteria that may hurt your teeth and gums. Meth makes the mouth very dry. A dry mouth makes the acid and bacteria more likely to damage the teeth.

Crystal users tend to grind their teeth or bite or chew on the inside of their mouths and cheeks. That hurts the skin and gums even more. Finally, meth users may eat sweets, candy and soda more, causing cavities, and may not brush or clean their teeth regularly.

The true frequency of meth mouth is unknown and we know many meth users with normal, healthy mouths and teeth.

For harm reduction approaches to meth use check out LifeLube.org/crystal, Tweaker.org or CrystalNeon.org.

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For local Chicago resources on crystal meth, click LifeLube.

Methadone Man - que rico

Yesterday in the Global Village at the International AIDS Conference, we couldn't help but notice Methadone Man (above left.)

He handing out cards, with his partner Buprenorphine Babe, that asked for us to "help drug users stop injection, reduce HIV risk, and stay on AIDS treatment."

Check out www.wheresthemethadone.org

and

www.wheresthebupe.org

We just love anything that makes this work fun and sexy...

HIV Transmission under HAART - Lancet Study and the "Swiss Statement"

HIV-Transmission under HAART - Lancet study rather supports "Swiss Statement" than challenging it!

von Pietro Vernazza letzte Aktualisierung 25. Juli 2008

In tomorrow's issue of the Lancet, Australian authors present a mathematical model to calculate the HIV-transmission risk under a HIV therapy. At the first sight it seems as if the calculations question the Swiss statement on HIV infectivity under HAART. However, an exact consideration of the paper rather strengthens the Swiss statement, as the authors of the editorial suggest.

The "Swiss Statement" was an information to Swiss physicians that the Swiss Commission on AIDS-related issues presented issued in January 2008. It said that physicians could inform their patients that the sexual transmission risk to the partner is negligibly low if three conditions were met:

• HIV-infected patient is under a physician controlled antiretroviral therapy with excellent adherence
• Blood viral load has constistently been undetectable (<40cp/ml)>
• no sexually transmitted diseases are present in neither of the partners

The statement also made clear, that it is only the HIV negative partner who can decide for himself whether he/she wants to stop using condoms with the treated partner.

The authors of the Lancet article from the 26.7.08 (David P Wilson, Matthew G Law, Adnrew E Grulich, David A Cooper, John M Kaldor) analyse potential consequences on new HIV infections if the Swiss statement would be followed. In their mathematical model the authors use the known Rakai partner study as their basis (Quinn et al, NEJM 2000). This work has shown that the risk of transmission is dependent on the virus load in the blood. In this population of approx. 450 HIV-discordant couples the HIV-transmission risk was doubled (x2.45) with every 10-fold rise of viral load in the blood

Simple mathemathical model used
The authors used this factor and computed a linear model in which the transmission risk was extrapolated for very small values of viral load. The transmission risk per sex act was therefore calculated for values of blood viral load around 10 cop/ml. The linear approximation is shown in the figure at right (click on figure for enlarged view). By definition, the transmission risk of such a log-log curve can never be zero. In other words, the authors refuse the existence of a threshhold level, below which no transmission would occur.

Estimation of the transmission risk by anal sex
In the Rakay study, only heterosexual couples were included. To calculate the per contact risk of anal sex among men having sex with men (MSM) for very low viral load values, the authors took the linear model (above) and elevated this curve by the mean difference in transmission risks among heterosexual couples and MSM (factor 20). This "parallel movement" of the risk increases the threshhold problem mentionned above. With this extrapolation, the authors receive highly unplausible values: Based on this calculation, the risk of transmission in one receptive anal contact with a man having only 10 viral copies per ml of blood (i.e. 5 viruses!) would be 1 in 6000. Such a risk estimate is hardly plausible. In the Swiss HIV cohort study (and presumably elsewhere, too) almost 20% of the patients do not use condoms consistently with their steady HIV-negative partner (Panozzo et al).

Reality differs!
In fact, such a high risk of transmission under HAART would be difficult to oversee. After all these years of HAART, we would expect to have documented several occasions of HIV transmision. Many experts as myself have been searching for such unusual cases over many years. As the Swiss Commission clearly stated: the risk is not zero (can never be assertained) but it must be in the range of our normal daily risks and this statement was restricted to situations very specific situations (see conditions above).

Most important risk factor for sexual transmission: Sexually transmitted infections
The mathematical Model presented in the LANCET did not consider one key aspect of the Swiss statement: The most important factor (beside blood viral laod) that increases transmission risk, namely sexually transmitted diseases (STD), namley syphilis, gonorrhea, trichomoniasis and herpes. Such STDs have certainly fueld transmission in the Rakai-Study as well. We know that genital viral concentration can increase 10-fold in the situation. In part, the increased average transmission risk among MSM are a result of the incresed incidence of STDs in this population. The Swiss statement has emphasized the absence of STDs, therefore a caclutlation including the risk in the presence of STDs cannot falsify the Swiss statement.

In summary, it seems obvious, that all the mentioned biases of the mathematical model will increase the risk estimate for HIV transmission under HAART.

Swiss Statement: Distinction, not absolution!
The Swiss Statement was widely misinterpreted by many people who have never read the original paper. The statement is not an "absolution" for HIV-positive indivuduals under fully suppressive HAART. Rather, the statement made a clear distintion of a subgroup of individuals with very limited risk to transmit the virus. Prior to our statement, many physicians have talked in private to their patients and informed them about a the limited risk of transmission under HAART. However, the informations were not openly communicated and to our best knowledge were seldom stressing the importance of the absence of STDs. One goal of the EKAF statement was to stress the importance of STDs and perfect adherence in communications regarding the very low risk of HIV-transmission under HAART. At least in Switzerland, this goal was clearly achieved and the message was well accepted.

The Australian study supports the Swiss statement
In fact, the data presented by Wilson et al. acutally support the Swiss statement as the editorialists (Garnett & Gazzard) conclude. In their commentary, Garnett and Gazzard have calculated per couple transmission risks based on the assumptions included in the Wilson paper (after 100 sexual episodes). Wilson et al. also included an estimate of the effectiveness of condoms. Using these figures, Garnett et Gazzard found that 100% condom use in the absence of HAART was as risky (or even riskier) than having sex without a condom on a fully suppressive HAART (see figure, click on figure to enlarge). In fact, this was exactly what the Swiss statement said: The residual risk of transmission on HAART without a condom was in the same range than having sex without condom in the absence of treatment. Thus, the Australian authors assumptions acutally confirmed the Swiss statement.

Responsible patients are able to decide for themselves
The Swiss statement never assumed a zero risk under fully suppressed HAART but rather stated, that the risk is in the range of other risks in daily life. In fact, the risk of transmission during condom protected sex in the absence of treatment is not zero either, nor is the risk of oral sex (without ejaculation). Nevertheless, oral sex and condom use are widely accepted methods of safer sex.

Other risks of daily life are also illustrative: Among 200'000 Swiss alpinists that spend a weekend in the alps, ten loose their lives every year in an avelange. This risk (1:20'000) is socially accpeted and regular insurances cover it without recourse. The Swiss HIV Experts considered it reasonalbe that an HIV-negative Parnter might be informed by the physician about the neglible risk. It was felt that the partners may decide for themselves how to deal with the final residual risk. This is comparable to the alpinist or to the partner who practices oral sex without condoms. They have all been adequately informed about their limited risk.

Other problems of the mathematical model
For the more experienced reader I would like to mention two other problems of the mathematical model by wilson et al. One is relates to the calculation of a cumulative risk (after 100 or 1000 sexual contacts). Epidemiological studies have told us, that the risk of transmission decreases over the duration of a partnershipt. To some extent, an aquired cell-mediated or mucosal immune defense might be responsible for this decline in transmission probability. Very little viral exposure might stimulate the immune defense rather than lead to full-blown infection. A biological fact that was not considered in the mathematical model, where each sexual contact is associated with the same risk. However, biological considereations would rather suggest that there is a threshhold for sexual transmission below which the development of an HIV specific immune response in the partner is more likely.

These biological observations might also play a role in the difference in transmission risk estimates between heterosexual couples and MSM. The higher estimate of transmission risk in MSM might in part also be a result of a higher proportion of parnterships with a shorter duration. In fact, two studies of female-to-male transmission after a single exposure in Kenia and Thailand found a transmission probability that was at least tenfold higher (3-8%) than in established partnerships and in the same range as for MSM. Thus, the risk estimates for MSM used by Wilson et al. might also be based on wrong assumptions.

Source: Wilson et al, Lancet 26.7.2008, 372:314-20
Editorial: Garnett & Gazzard, Lancet 26.7.2008, 372:271-2

Read other LifeLube posts on the "Swiss Declaration."

Raw, Real & Uncut

Speedometer is a publication - very edgy, zine-y and sexy - put together by members and participants of The Speed Project of the San Francisco AIDS Foundation, which exists to improve the safety and health of guys who use speed.. The news, views and opinions are those of these guys and not of SFAF. As the guys are telling their stories and truths, this Zine contains some sexually explicit material and is therefore only intended for adult gay and bisexual men who use speed.

Speedometer is a harm reduction publication for gay, bisexual and heteroflexible men who snort, smoke, hot rail, booty bump, or inject crystal meth. This zine is not intended for anyone else. So keep it in the family, please!

LifeLube, btw, has links to other great resources on sex and drugs, like this one, here on the MotherShip.


Table of Contents of the March/April 2008 issue

Celebrate not Medicate: part II of “Cutting Back, Slowing Down”
Featured Resources: Family Caregiver Alliance, AIDS Health Project, Magnet Health Center massage/acupuncture and Reiki, STOP AIDS Project PLUS Seminar support and treatment education groups for guys who are newly HIV+ or thinking about starting meds.

Want Help sticking with antiretroviral HIV drug therapy?
Interview with Action Point!
Featured resources: Action Point’s HAART adherence support program.

Like most 13 year olds- I thought I was invincible:
SF Hustler tells all
Featured resources: sex work and sexual health: the St. James Infirmary, City Clinic, and the Sage Project.

The Meth Monster:
The Speed Project’s Advice Columnist
Featured Resources:
Positive Reinforcement Opportunity Project- incentives for gay/big men
to quit speed.



Speed Limit: Substance Use Management
Interview with Albie of the Stonewall Project
Featured Resources: Stonewall Project, Harm Reduction Therapy
Center Worksheet: Good things/less good things management sheet.

Shooter’s Corner
Featured Resources: Clinics in SF that will respectfully care for for
abscesses.

Hot Anal Play and Assfucking with Dr. Carol Queen
Featured Resources: The Center for Sex and Culture, San Francisco Sex
Information, Good Vibrations, Body Electric, fun and informative DVDs
and Books on anal play!

Tweaker.org launches en español

Bienvenido a tweaker.org en español

Hay bastante información para ti en nuestra página. Hay información que quizá parezca cursi o tonta y otra que es de una naturaleza más seria. Esperamos que te sea de utilidad.

La razón por la cual existe esta página, es que muchos hombres gay y bisexuales están siendo infectados con el VIH y otras enfermedades de transmisión sexual mientras se encuentran bajo los efectos de alguna droga como speed (pronunciada "spid"). Es un problema serio aquí en San Francisco, y se está convirtiendo en un problema grave a nivel nacional.

Lo que si, es que esperamos que disfrutes del contenido. Cuídate y cuida a tus compañeros de juego.