The BEST of Lifelube - "When Barebacking is Noble: The Ongoing Controversy around Serosorting" From Friday, April 6, 2007

Before you get to the article, a note on language. At the LGBTI Health Summit in Philly last month, I learned a great new term called "sero-adaptation" which was coined by this very cool, edgy Parisian HIV prevention group called The Warning"

Sero-adaptation includes, but is not limited to, the idea of "sero-sorting." It refers to a selection of harm reduction strategies that do not involve the use of condoms. These strategies may reduce the risk of HIV transmission, but are not a guarantee and require a clear-headed risk analysis, weighing the good, the bad and the ugly and making a decision around the amount of risk you and your partners are comfortable with.

So, what are some examples of sero-adaptation?

Sero-sorting - having condom-free sex with guys who share the same HIV status

Strategic positioning - determining who does what based on HIV status. For instance, the neg guys fucks the poz guy, which is less risky than the other way around.

Dipping - just sticking the dick inside a little bit and for a brief amount of time

Pulling out - kinda like the "rhythm method" of the 50"s, meaning withdrawal before cumming. Lot's of people become parents like this, and this is exactly how I myself tested poz, but it is less risky than actually allowing cum inside.

Lube - using a generous amount of the slippery stuff reduces friciton in one's tender, delicate anus/rectum and therby reduces the risk of HIV being offered a pathway in.

And of course, there are other sexual activities that can be done by people with same or different HIV statuses that do not involve fucking - sucking, rimming, water sports, JO, fisting, massage...

By the way, just for a moment of clarity, none of the above can be taken to offer complete or partial protection from other types of sexual transmitted infections...

--Jim

So here is that article already..

"When Barebacking is Noble..."

By Christopher Murray

[From the current issue of Circuit Noize, with thanks to the Gay Men's Health Listserv for posting...]

Last month, a virtual Vesuvius erupted when the popular New York gossip blog,Gawker , posted a link and then the next day an interview with a twenty-something gay guy in Manhattan who gets off on fucking guys without condoms.Confessions of a Bareback Top, his site, details his unapologetic adventures and is whack off material for some guys and proof of the end of civilization for others. The kink with the blogger, and those who identify with him, is the thrill we get when we break the taboo of safer sex.

The undeniable point of Mr. Bareback Top, is that while many gay men mouth lip service to safer sex practices, when push comes to shoving it in, so to speak, it's a different story. The bareback top loudly proclaims both his negative status and his assertion that it takes two to tango and that even if discussions before and during sex with his partners revolved around intentions to practice safe sex, once they acquiesce during the act, then they are just as responsible for what happens as he is, no matter how much they or others cry victim.

A storm of disapprobation not surprisingly followed the boost in the bareback blogger's profile. Gawker's comments file was crammed with postings suggesting he be put on the next train to Dachau, other gay men's health listserves picked up the drumbeat of dismay and disgust. But this controversy is only the latest concerning the practice of serosorting.

Defined as guys choosing only to have unsafe sex with others of the same HIV-status, serosorting has been ade facto reality in gay men's lives since the AIDS epidemic started, and before, if you count guys choosing not have sex with others they knew to have an STD or saying fuck it , if they knew they both had herpes, or whatever.

Serosorting, however, is a concept that is exclusive to considerations of HIV prevention. It's based on the premise that men need to know their status and that if they do, and then limit their unsafe behavior to only others of the same status, that HIV infections will fall. This assumes of course that people take steps to learn their status, that their status stays the same, that they are honest about their status, and that others are too. It is true, by the way, that people are more likely to have safer sex if they know they are positive. This is part of the innate civic-mindedness and altruism of gay men, we'll come back to that later.

Serosorting has recently been picked up by some advocates and taken out of the realm of decisions that gay men make on their own and promoted as a serious prevention strategy to be encouraged. Last fall, the San Francisco Department of Public Health launched their "disclosure" campaign that links knowing your status and talking about it with potential sexual partners to intentionally choosing partners of the same status. And Robert Brandon Sandor, the organizer ofBrandon's Poz Parties, a longstanding occasional sex club event for poz guys in New York, took up the charge, hosting a forum at the gay center in Manhattan on serosorting a month later. Brandon has run afoul of some local public health advocates for his championing of serosorting, as they claim his promotion of the concept is overly simplistic.

For Brandon, serosorting means, if you are poz, and only fuck without condoms with other poz guys, HIV won't be transmitted and will eventually burn itself out. Critics note that the world is more complicated then this with people not sticking to the system, assuming things about other people's status, and remaining vulnerable to other STDS.

This also lays the burden on poz guys to have unsafe sex – or maybe by extention of the argument sex, period – only with other positive guys, but also for negative guys or guys of unknown status to continue to have sex only with condoms.

It's easy to fall into a moralistic discussion about sexual ethics when considering serosorting. But in fact the issue is really one that has been around forever and complicated forever: assessing risk. A noted HIV researcher once told me about a guy in Los Angeles he spoke to who would have unprotected sex if his partner had clean matching socks on. The reasoning went that if he was a nice, clean enough guy to have nice, clean enough socks, they it's likely he wasn't a skank and therefore HIV-negative. Sounds pretty silly, but it's a risk assessment strategy, albeit a poor one.

We are all responsible for making decisions about how much risk we can tolerate. Just about any sex can lead to the transmission of an STD; bottoming for anyone carries some risk of exposure to HIV, no matter how minimal if we choose to engage in sex, a major part of being alive, then we are taking risk. If we have sex with people we don't know, or with people we do know, but whose status we can't be 100 percent sure of, we are taking a risk.

While serosorting is a strategy that attempts to lower that risk, as Bareback Top makes clear, sometimes, for whatever reason, we are likely to be taking risk with less than complete information. Like we do when we are drunk, or high, or deeply in love, or deeply in lust, or inexperienced, or desperate, or stupid or lonely. How much risk we are willing to take is a combination of our mind's intelligent assessment and our hearts over-riding blindness to circumstance based on our desire in the moment. That leads back to the altruism issue. What alternately upsets and turns people on about Bareback Top is that he puts his needs for sexual satisfaction and thrill above others. He turns other people into objects, his playthings, and gets a kick out of when their intentions to protect themselves and others are undermined by their desire for hot sex and closeness with another human being. 

In his most recent posting, Bareback Top describes fucking a young guy without a condom and his assumption that it's the first time the kid has been fucked, He says that the kid was clearly in pain. But he did what he wanted and took care of his own needs, popping a nut up the guy's tender ass. Did he give the young man HIV? Probably not, presuming he's still correct that he doesn't have HIV. Did he give the kid any other STD, who knows? Did he use another human being for his own pleasure at the cost of his own and the other person's humanity? Sounds like. That occurs with a cost that Bareback Top has yet to become aware of. You pay for such cavalier games with a little piece of your soul.

Most of us have probably used other people at some time or another for our own gratification. That's called exploitation. The lucky among us learn to regret it.

Touring an HIV+ gay sex club, plus the porn stars that got away...

via My Fabulous Disease, by Mark S. King

The idea that HIV positive people still want sex is as old as The Denver Principles, the 1983 manifesto drawn up by gay men with AIDS that demanded “as full and satisfying a sexual and emotional life as anyone else.” The document also stated that people with HIV/AIDS have an ethical responsibility to share their status with others.

Fast forward to today, and HIV positive gay men are as open as ever about their status and their sexual preferences (setting aside, if we can for the moment, the increased stigma and discrimination facing HIV positive people of all stripes who disclose their status these days). And those sexual choices may not include HIV negative people at all, thank you very much.

Last year I taped a tour of a sex club that hosts a monthly “Poz4Play” party, and sat down to interview Bill, the party’s disarmingly unflappable host. In this video blog (the video, above, is PG rated but the language is explicit), I revisit the tour and get an update from Bill about the strong reaction to the original video, which includes a frank conversation on barebacking, the risk of other STD’s, and serosorting.

UK Gay Men’s Sex Survey: new data on age, strategic positioning, condom failure and HIV testing

via Aidsmap, by Roger Pebody

Sexual behaviours that are most likely to result in acquiring HIV are most common in teenagers, while those behaviours most likely to pass on HIV are most common among men in their thirties. These are some of the results of the 2008 United Kingdom Gay Men’s Sex Survey, released last month.

The survey also suggests that more men than ever have tested for HIV (including one in ten at a GP's surgery) but that less than half had done so in the previous year. There is also some evidence of ‘strategic positioning’ during oral sex and information about behaviours which lead to condoms splitting or coming off.

At the same time, researchers have issued preliminary data from a similar survey conducted across Europe in 2010. With over 180,000 men completing the questionnaire, it is the largest sexual health survey ever conducted with gay and bisexual men.

Read the rest. 

Can Magnetic "Gut Breeders" Be Role Models Too?

via Bay Area Reporter, by Seth Hemmelgarn

Porn company's 'role models' draw concerns of AIDS advocates
   

The pornography company Treasure Island Media is promoting a couple that includes an HIV-negative and an HIV-positive partner having unprotected sex as "role models." They are believed to be the first sero-discordant barebacking couple to be advertised as porn stars.

According to a Treasure Island statement, the acting couple's James Roscoe is HIV-positive, while Brad McGuire is HIV-negative. In a scene featuring Roscoe and McGuire on a Treasure Island website, Roscoe is the receptive anal sex partner or bottom.

"The two are a real-life, long-term, promiscuous, bareback couple," stated the company in a press release.

In the statement, which was dated October 27, Paul Morris, the studio's owner, spoke of demolishing "the HIV-positive closet" and said, "We know exactly what we're doing and we will not allow reactionary individuals and organizations to dictate our behavior. James and Brad are fitting role models for young gay men. They are living their lives with honesty and integrity."

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.

Discussion: Laying It Bare: Gay Men and Unprotected Sex in the Age of HIV/AIDS

TheBody.com recently hosted a panel discussion - via teleconference - on unprotected sex among gay men.Absolutely fascinating, engaging and illuminating - a must for any and all interested in gay men's health.

Click here for the audio and a transcript.

The call was moderated by fogcityjohn and included Walt Odets, Rashad Burgess and Jeffrey Parsons.

- Select quotes -

Walt Odets: It's a natural behavior, and it's of emotional significance. And I think gay men naturally engage in it. We have liked to feel that it was somehow dispensable -- and it's really not, emotionally. So, again, we haven't helped men to think about what they are doing. It's a very narrow range in which HIV is transmitted. Anal sex has the emotional import for gay men that vaginal intercourse has for heterosexuals. And it can't be dismissed. And we can't expect that that's going to done all the time, under any circumstances, with a condom. It's compelling. It's emotionally compelling. 

Rashad Burgess: We, as Americans, [need to] recognize the value of gay men, in all of our lives, in the many facets of our lives -- whether it be the business owners, whether it be folks' uncles, or family members, other types of family members, the partners that gay men have. Because it is a community that, it's imperative, understands that their lives -- and as a gay man, that our lives, and my life -- is worth saving. 

Jeffrey Parsons: We do sometimes forget about the group of gay men who are out there -- and it's a large group -- who are very happy, very satisfied. They're not depressed. They're not lonely. They're not engaged in risk behaviors. They're not seroconverting. They're actually doing very well. And I think -- and I can certainly say this as a researcher -- that too often we don't get to focus on that group. We don't get to actually talk to them and research them and find out: What are they doing to stay safe, and to stay healthy, and to stay well adjusted?

Read, listen to the whole thing here.

Serosorting and sex clubs - Mark King's video blog takes us there

"Ever taken a guided tour of a gay men's sex club? Brace yourself," says Mark King. In his latest video blog entry, Mark gets a personal look at what these clubs are all about -- and dives into the controversial topic of whether it's OK for someone with HIV to have unprotected sex, as long as it's with someone else who's HIV positive.




When I was sleeping around, I gladly shared my HIV status because I preferred other poz partners. It meant less anxiety and probably unprotected sex, which I preferred. While my sex partner count has been reduced to 1 these days, it turns out my former sexual strategy has a name: serosorting. Seeking out partners who share your HIV status.

In one of life's ironies, I remember alarmists in the 80s suggesting that HIV-positive people be sent to an island or otherwise segregated so as not to infect others. Today, many gay men are essentially doing just that, by limiting sex to other poz men.

It's risk reduction in an epidemiological sense, but does it simply allow for risky sex that might promote other STDs? And what of the more psychological effect, that is, limiting our bodies (and our hearts) to only those "similarly afflicted"?

I'll tell you where I stand. Any practice that a) promotes HIV disclosure to partners, and b) reduces the chance of infecting an HIV-negative person, is fine by me. Yes, people lie. But as a general practice I believe it is solid risk reduction.

Sign up for Mark's blog.


Source - The Body.com

How many guys are "sero-adapting" in San Francisco?

via U.S. Centers for Disease Control and Prevention Medical News

Prevalence of Seroadaptive Behaviors of Men Who Have Sex With Men, San Francisco, 2004

The researchers set out to define and measure the prevalence of HIV seroadaptive behaviors among men who have sex with men (MSM). Time-location sampling was used to recruit a community-based, cross-sectional sample of 1,211 HIV-negative and 251 HIV-positive MSM in San Francisco in 2004.

To define seroadaptive behaviors, all episodes of anal intercourse were enumerated and characterized by partner type, partner HIV serostatus, sexual position, and condom use for up to five partners in the preceding six months.

The results showed that 37.6 percent of HIV-negative MSM engaged in some form of seroadaptive behavior: pure serosorting (24.7 percent), seropositioning (5.9 percent), condom serosorting (3.9 percent), and negotiated safety (3.1 percent). Some form of seroadaptation was noted for 43.4 percent of HIV-positive men -- including pure serosorting (19.5 percent), seropositioning (14.3 percent), and condom serosorting (9.6 percent). Consistent use of condoms was reported by 37.1 percent of HIV-negative men and 20.7 percent of HIV-positive men.

"In aggregate, seroadaptive behaviors appear to be the most common HIV prevention strategy adopted by MSM in San Francisco as of 2004," the authors concluded. "Surveillance and epidemiological studies need to precisely measure seroadaptive behaviors in order to gauge and track the true level of HIV risk in populations. Rigorous prevention research is needed to assess the efficacy of seroadaptive behaviors on individuals' risk and on the epidemic."

Check out other LifeLube posts on this topic:

sero-adaptation 

sero-sorting 

seroguessing 

The End of Condoms? Not so much.

by Daniel Reeders, via Trevorade

It's Friday night, the rain has eased, I've just got back from an enjoyable session at a sauna (that's Aussie for bathhouse) and cracked the top off a Beez Neez -- a Western Australian malt beer brewed with honey. It's been a rough week but right now, life is pretty good.

And then I notice an article about PrEP in The Daily Beast. Danger, Will Robinson, mainstream media coverage of HIV prevention! And sure enough, it's a shocker.

I'm mellowed-out enough to admit there are flashes of insight in the piece. It has all the right pieces of the puzzle, but author David Kaufman has jammed them together trying to make an altogether less optimistic picture of PrEP than their proper placement depicts.

And that's a shame, because there's enough genuine uncertainty to write a balanced piece without leaving any gay boys itching to rush out and score themselves some tenofovir.

A big part of the problem is Kaufman's deathly purple prose. AIDS, he writes, is "caught in a 30-year swirl of sex and morality" -- and he's stirring away furiously. In his article, PrEP is a "necessary evil" but "downright dangerous", "game changers", elation and alarm, and cringing PrEP proponents -- holy asslicking assonance, Batman!

HIV prevention is a big field, and there's an ongoing dialogue about PrEP -- as well as the whole complex of related issues like safe sex, versus serosorting, versus barebacking, versus social network interventions, versus combination prevention.

Read the rest.

Risky Business Podcast is LIVE - WHAT IS YOUR OPINION OF BAREBACKING?

via Feast of Fun

On today’s special edition of Feast of Fun, we’re teaming up with Lifelube and Project Crysp in conjunction with the 2009 National LGBTI Health Summit to bring you Risky Business- a raw discussion with a live audience at the Center on Halsted on the sex and intimacy we crave and the risk we’re willing to take.

How do adult films with bareback sex affect our sexual desires and practices?

Are videos depicting sex without condoms a hot but safe way for viewers to find pleasure or is it a dangerous normalization of risk?

We have a panel of experts here to break down the ins-and-outs of condomless sex.

Tony Valenzuela, Writer and Activist whose work focuses on the politics of gay sex, subcultures and assets based perspectives. He’s known as AIDS activism’s most misunderstood man.

Mufasa Ali, Minister and Activist, as well as co-founder of ONYX, a leather group for men of color.

Dr. Braden Berkey, Clinical psychologist whose practice focuses on gay men, and the director of the Center on Halsted’s Sexual Orientation and Gender Institute.

Chuck Renslow, the founder of International Mr. Leather Conference and Convention, was in the audience to talk about why he recently banned bareback porn at IML and the future of the ban.

This is a frank talk about the kind of sex men have in real life and how they “seroadapt” or reduce sexual harm.

For many people, this is just the start of the conversation surrounding sex without condoms, it is not the final word. If you have any questions or insight, please leave a comment and keep the conversation going. Please be respectful and refrain from personal attacks, inflammatory remarks or general hysteria.

Listen to the podcast.

Check out photos from the forum.

Stay Negative

Just found out you’re HIV-negative?


Where you go from here
is up to you.

LifeLube recommended!
via GMFA the gay men’s health charity
Part of the Pan London HIV Prevention Partnership


Your next HIV test could also be negative, or it could be positive.

But you can be in control of that. You can stay negative.

Even though you have a negative test result now, this might not be the case in the future if you put yourself at risk.

That’s why it’s important to develop strategies to help keep you HIV-negative. We’ve written this book to help you.

The information in this booklet was accurate on 1 April 2009
Click here to download the booklet.

Alternatives to condom use can help reduce HIV transmission among gay men

via Fridae - empowering gay Asia - by Jan Wijngaarden

The HIV epidemic among gay men in Asia is continuing to grow. 30.7 percent of Thai men who have sex with men are now infected with HIV in Bangkok; in Cambodia, Vietnam and Indonesia between 5-10 percent of men who have sex with men have HIV. In a cross-sectional study among MSM in Taipei in 2004, the HIV prevalence was 8.5 percent; in Singapore in 2007, 4.2 percent; and in Hong Kong in 2006-7, 4.1 percent. In most places our transgender sisters are even harder hit.

And that while transmission of HIV is quite hard, with a relatively low per-contact-transmission chance – HIV is much less efficient than other viruses, such as the ones causing flu or measles. Preventing HIV is relatively simple – covering our favorite organ with a 0.06 mm thick coating whenever we have anal sex...

Yes indeed, I am talking about condoms. So why are – even in places were significant numbers of men are infected with HIV – significant numbers of men still not using condoms? Are they not thinking clearly or what?

Well – perhaps so. A recent study from Sydney, Australia that appeared in the AIDS journal earlier this year (Jin F, Crawford J, Prestage GP et al, 2009) found that even when men do not use condoms, they still employ certain strategies to reduce their risk for HIV infection (or for transmitting HIV to their partners, if they are already HIV positive). Three of these strategies were found to reduce the chance of getting HIV significantly, compared to men who did not use any strategy (and no condoms).

These strategies are not as effective and not as safe as always using condoms, but nevertheless, they are protective.

What were these strategies?

Read the rest.

CDC Meeting Summary: “Consultation on Serosorting Practices among Men who Have Sex with Men”

Here is a link to the full (short and sweet) summary.

[NOTE: Jim Pickett of LifeLube attended this CDC consultation, held Dec 2 - 3, 2008. He is delighted to finally see this summary published, and will be active in pushing this important conversation forward.]

Select highlights:

- "Serosorting is most often defined as a person choosing a sexual partner known to be of the same HIV serostatus, often to engage in unprotected sex, in order to reduce the risk of acquiring or transmitting HIV."

- "The consultants perceived seroadaptation to be a broader and more inclusive term than serosorting and, more consistent with the broader goal of improving the sexual health of gay and bisexual men in the United States. Discussions also focused on possible ways to frame prevention messages, including breadth and content of the messages as well as specific messages for partnerships in which both members are infected with HIV, partnerships in which both partners are not infected with HIV, and partnerships in which the members are serodiscordant or serostatus is unknown."

- "Regarding superinfection, the consultant noted that few cases have been reported in the literature and that the risk appears highest soon after seroconversion and may decline over the course of infection. Some data discussed by the consultants also indicate limited clinical consequences of superinfection. However, the consultants noted the lack of research among African American and Latino men and on superinfection in general."

- "The consultation highlighted the need to clearly define seroadaptation practices, and particularly serosorting, among MSM, and to understand the differing risks based on a variety of contextual factors. Several areas for future research were recommended. The information obtained in this consultation will inform potential future CDC activities, the development of prevention messages or guidance documents, and the creation of future funding announcements. As follow-up to this consultation, CDC will develop a fact sheet on serosorting among MSM that will include definitions of various seroadaptation practices, the state of the science with regard to behavioral patterns and their potential HIV risk under different situations and with different types of partners, and recommendations for future research. The fact sheet will be released later this year."

Read the whole thing.

It's more than just condoms

Prevention for HIV serodiscordant couples: it's more than just condoms

via Aidsmap, by Michael Carter

Promoting 100% condom use may not be the most appropriate HIV prevention strategy for serodiscordant couples, according to research presented to the Fifteenth Conference of the British HIV Association. However, researchers found that there was little awareness or use of other methods of HIV prevention, such as post-exposure prophylaxis (PEP) or the impact of viral load on infectiousness.

Investigators recruited 38 serodiscordant couples (where one partner is HIV-positive, the other HIV-negative) to a prospective study lasting three years. Most (30) of the couples were gay men. To be included in the study the couples had to have been in their relationship for at least two years and to have engaged in at least 20 separate episodes of unprotected anal or vaginal sex in the previous twelve months.

The couples were interviewed about their understanding of issues such as PEP, viral load and infectiousness, and the reasons why they engaged in unprotected sex. The investigators hypothesised that there were likely to be three factors underlying unprotected sex in relationships: failure to understand the mechanisms of HIV transmission; emotional reasons; and a low concern about the consequences of HIV transmission.

Read the rest.

Increase in serodiscordant casual sex among Sydney gay men at a time when HIV diagnoses have not increased

via Aidsmap

Between 2003 and 2006, there was an increase in the numbers of HIV-negative gay men in Sydney who reported having unprotected anal intercourse with casual HIV-positive partners, report researchers in the online edition of AIDS and Behavior. However the researchers do not believe that these men form "a core group of high risk men".

Iryna Zablotska and her colleagues from the University of New South Wales analysed data from two cohort studies among Sydney gay and bisexual men: the Positive Health cohort of 760 HIV-positive men, and the Health in Men cohort of 1427 HIV-negative men. Both studies asked identical questions about sexual behaviour in annual surveys from 2003 to 2006, including questions on sex with partners of a different HIV status (rather than, as in some other studies, sex which could have been with a partner of a different HIV status).

Among the HIV-negative men, whilst the number having sex with casual partners decreased from survey to survey, there were small but statistically significant increases in the numbers having serodiscordant sex. Those having sex with casual partners they believed to be HIV positive rose from 11% to 13%, and the number specifically having unprotected anal intercourse with those men increased from 3% to 4%.

The number of HIV-positive men reporting serodiscordant casual partners did rise, but there was no statistically significant rise in unprotected anal intercourse with them.

The study examined a number of behaviours that have been previously found to be associated with sexual risk-taking, and confirmed that serodiscordant unprotected anal intercourse with casual partners was more common among men with higher numbers of sexual partners, men who met partners online or in sex clubs, Viagra users, those who injected drugs, men who used 'party' drugs regularly and those having ‘esoteric’ sexual practices (fisting, sex toys, water sports, bondage etc).

However the researchers note that men who had risky sex did not do so consistently. Over 85% of the men who reported having serodiscordant unprotected anal intercourse only reported it at one of their annual interviews, and they typically reported that behaviour with just one or two partners in the previous six months.

Read the rest on Aidsmap.

Risk reduction strategies are safer for Sydney gay men than other unprotected sex practices - but less safe than consistent condom use

via Aidsmap.

Gay men in Sydney who only have unprotected anal intercourse as part of a risk reduction strategy such as serosorting or negotiated safety have a considerably lower risk of acquiring HIV than men who have unprotected sex in other ways, report Australian researchers in the January 14^th issue of AIDS.

Men who have unprotected anal intercourse only as the insertive partner, and those who ensure that their partner withdraws before ejaculation, also had a lower risk of acquiring HIV than men who don't employ any form of risk reduction strategy when they have unprotected anal intercourse.

Taken together, men using any of these practices were three times more likely to acquire HIV than men who had no unprotected anal intercourse (UAI). However men who practiced UAI without any of these safeguards were almost eleven times more likely than men having no UAI to acquire HIV.

Moreover, withdrawal before ejaculation was the riskiest practice studied. It was associated with a five fold increase in the risk of infection (compared to no UAI).

These strategies have been used by gay men for many years and some scientists consider them to be biologically plausible, but until now there has been limited evidence on their effectiveness in the real world. One important study came in 2007 when Fengyi Jin reported that a third of Australian gay seroconverters had tried to employ a risk reduction strategy.

Read the rest.

Study examines repeated exposure to HIV in treatment-suppressed HIV patients

A new study looking at unprotected intercourse within gay couples when each partner has established HIV-infection found a correlation between anti-HIV immune response and sexual activity.

Study results showed that individuals who had regular unprotected receptive anal intercourse with partners with significant levels of HIV in their blood showed a stronger anti-HIV immune response. In addition, the magnitude of anti-HIV specific immune response correlated with their exposure to HIV through sex.

Published in the October 24th, 2008 issue of PLoS Pathogens, "Immunity to HIV-1 Is Influenced by Continued Natural Exposure to Exogenous Virus," is authored by a research team from UCSF and the Gladstone Institute for Virology and Immunology.

The researchers found no evidence of systemic superinfection (re-infection with another strain of HIV) in the receptive partners, whose virus had been successfully suppressed through antiretroviral therapy for at least five months. In a comparison group of HIV-infected couples in which both partners' viruses had been suppressed by therapy, researchers did not find the same strength of immune responses correlations or the same correlations with sexual exposure.

"We found HIV-specific immune responses in the treatment-suppressed partners that correlated with the level and route of exposure. The individuals with no detectable virus who were on antiretroviral
therapy and who were exposed to HIV through receptive intercourse with a partner with detectable virus, had the stronger anti-HIV immune responses in comparison to individuals exposed to partners whose virus was also suppressed by antiretroviral therapy, where no effect was seen," said study lead author, Christian B. Willberg, PhD, post- doctoral fellow in the UCSF Division of Experimental Medicine.

Notwithstanding the intriguing HIV specific findings, the findings also reveal an important general mechanism occurring in infectious diseases.

"We found that immune responses to chronic viral infections are influenced not only by the chronic infection existing in an individual or host, but also by exposures to exogenous virus from outside the individual or host," said study co-senior author, Douglas F. Nixon, MD, PhD, professor of medicine in the UCSF Division of Experimental Medicine.

The investigators were unable to determine from these findings whether there is any benefit from this type of repeated exposure to HIV—i.e., a type of therapeutic vaccination for HIV-infected patients with suppressed virus. Some HIV patients on antiretroviral regimens lose many of their HIV-specific immune responses over time due to the successful suppression of viral replication by therapy.

"Indeed, our hypothesis had been that in the context of these waning anti-HIV responses among the suppressed partners and the expected level of exposure from repeated unprotected receptive intercourse, we would find evidence of superinfection. While we did not find systemic super-infection, we cannot exclude limited or localized superinfections in the gut. And, antiretroviral therapy may have been the factor that prevented superinfection in these patients," said study co-senior author Robert M. Grant, MD, MPH, senior investigator at the Gladstone Institute of Virology and Immunology and associate professor of medicine at UCSF.

The study involved 49 HIV-infected gay men from the San Francisco Positive Partners Program study—a cohort of couples in which both partners are HIV-positive that began enrolling participants in 2000. Viral suppression in this study meant viral loads less than 50 copies. Among those participants whose virus had not been suppressed, the lowest viral load was 9,420 copies.

The team that designed this study benefited from its unique multidisciplinary composition. Immunologists working with social researchers were able to design a study that managed to distinguish between different levels of viral suppression and different patterns of sexual contacts and correlate the immunological aspects with the behavioral variables.

"We call the interaction between these two scientific communities together: 'social immunology'. It may be true that patterns of social activities shape immune responses generally, as we observed for people with HIV having contact with other HIV infected persons. Obviously more study is needed and we would like to see whether social immunology will continue to offer important insights," said Grant.

"While we have not found a case of superinfection in our cohort of chronically infected HIV couples, a handful of cases of superinfection verified by linkage to a known partner's virus have been reported in chronically infected HIV patients. It is also important to stress, these findings do not address the negative consequences of acquiring other sexually transmitted diseases through engaging in unprotected sex or the potentially positive consequences that unprotected sex may have in partnerships where both individuals are HIV-positive," said study co-author, J. Jeff McConnell, MA, director of the Positive Partners study at the Gladstone Institute for Virology and Immunology.

Read the paper here.

'It's like the treasure': beliefs associated with semen among young HIV-positive and HIV-negative gay men

Published in: Culture, Health & Sexuality, Volume 10,
Issue 7 October 2008 , pages 667 - 679

Authors:
Arn J. Schilder a; Treena R. Orchard ab; Christopher S. Buchner c; Mary Lou Miller a; Kim A. Fernandes a; Robert S. Hogg ad; Steffanie A. Strathdee ade

Affiliations:
a British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
b Department of Women's Studies, Faculty of Health Sciences, University of Western Ontario, Canada
c Vancouver Coastal Health Authority, Vancouver, Canada
d Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
e Division of International Health and Cross-Cultural Medicine, University of California San Diego School of Medicine, San Diego, USA

Abstract
This paper examines cultural and social meanings associated with semen, along with related issues of unprotected receptive anal intercourse, HIV seroconversion, treatment optimism and viraemia. The findings are derived from qualitative interviews conducted with 12 HIV-positive young gay men and 12 HIV-negative counterparts who participated in a prospective cohort study in Vancouver, Canada. Focussing on the narratives of young gay men, the analysis reveals a diverse range of knowledge, values and functions of semen, especially in relation to its exchange. Beliefs about semen appeared to differ by HIV serostatus and were linked with intimacy, identity and pleasure, particularly among the HIV-positive men. Against dominant representations of semen in relation to issues of loss, anxiety and infertility, this unique study sheds much needed light on its role within the cultural construction of sexuality among gay men. As such, these narratives are of direct importance to primary and secondary HIV prevention, including condom promotion and the development of rectal microbicides.

[want to know more about rectal microbicides? visit IRMA]

"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.

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."