ASHM2002plenary

The Complexity of HIV Risk in Australian Gay Men : 

The Complexity of HIV Risk in Australian Gay Men Susan Kippax National Centre in HIV Social Research

Factors Associated with Increases in HIV-Incidence : 

Factors Associated with Increases in HIV-Incidence Increases in sexually transmissible infections Treatment-related issues Increases in unprotected anal intercourse

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UAI-C and place of residenceMale Out (2000): 

UAI-C and place of residence Male Out (2000) The proportion of men who engaged in UAI-C: 22.6% in capital cities 27.7% in major regional centres 33% in smaller city/town and rural/remote areas The smaller the settlement the higher the proportion of men reporting UAI-C in the previous 6 months (pandlt;.001)

Factors hypothesised as related to increasing rates of UAI : 

Factors hypothesised as related to increasing rates of UAI Optimism in light of success of new treatments Invisibility of AIDS/ Complacency AIDS fatigue Changing Medical knowledge Adoption of risk-reduction strategies

Moral Panic or Head in the Sand : 

Moral Panic or Head in the Sand Belief that ‘AIDS fatigue’ or ‘complacency’ or ‘optimism’ in the context of successful treatments’ means ‘relapse’ and the end to ‘safe sex’ Belief that risk reduction strategies currently in play make unprotected anal intercourse safe.

The aim of this paper is:: 

The aim of this paper is: To disrupt / destabilise the binary between ‘mastery’ and ‘gay men have it all under control’, on the one hand, and relapse/complacency and ‘it’s out of control’, on the other by Describing the complexity of HIV risk and risk-reduction strategies – noting their dangers and weaknesses as well as their strengths

Context of Regular Relationships: 

Context of Regular Relationships Sero-concordant relationships Sero-discordant relationships Sero-status of partner and/or self unknown

Regular Anal Intercourse: SGCPS: 

Regular Anal Intercourse: SGCPS pandlt;.001

Agreements between Men in Regular Relationships: 

Agreements between Men in Regular Relationships No unprotected anal intercourse (38.8%) Negotiated safety (33.6%) Unsafe agreement (10.6%) No agreement (17.0%)

Risk in relation to Agreement : 

Risk in relation to Agreement Type of agreement % Engaging in Risk No unprotected 8.9 Negotiated safety 6.6 No agreement 27.1 Unsafe agreement 70.9

Consistent and inconsistent condom use with regular partners: 

Consistent and inconsistent condom use with regular partners

Inconsistent condom use related to: 

Inconsistent condom use related to Type of agreements with partner Length of relationship

Consistent and inconsistent condom use and length of relationship: n=220: 

Consistent and inconsistent condom use and length of relationship: n=220

Consistent and inconsistent condom use by serostatus of regular partner (HIM): 

Consistent and inconsistent condom use by serostatus of regular partner (HIM)

Men in serodiscordant relationships who sometimes engage in UAI with ejaculation with a regular (serodiscordant) partner: 

Men in serodiscordant relationships who sometimes engage in UAI with ejaculation with a regular (serodiscordant) partner *Periodic surveys February 1996 to February 2000 (N = 13,267) 2 (2) = 64.65, pandlt;0.000 Serostatus

Touchwood Study: 

Touchwood Study An HIV-positive man explains ‘no condoms’ (with regular partner): 'I’ve been undetectable now for six months and I’ve been pretty happy about that … My partner understands the risks he’s taking [by not wearing a condom], … he’s being very careful and constantly gets tested.' Being asked to elaborate, he confirms that ‘his partner’s ‘being careful’ means being ‘a top’ or ‘insertive’.

Seroconversion Study: 

Seroconversion Study … It was not actually mutually talked about but we both knew that he was positive, whenever we had sex, there was penetration but there was never any semen passed or… You don’t even think during the hour and a half of sex and love... Nothing going to stop you from doing it. Not when you’re programmed… because I loved him so much, it didn’t matter. It was just … it over-rode everything else…

Touchwood Study: 

Touchwood Study As an HIV positive man explains ‘no condoms’: 'I’m not good at stats and figures, but there’s a much higher chance of him becoming infected if I come inside him as opposed to the other way round. I also wonder about viral load levels, you know…'

Risk Reduction Strategies Regular Partners: 

Risk Reduction Strategies Regular Partners Condoms – no unprotected sex inside/outside relationship Negotiated safety Positive-positive sex Strategic Positioning Withdrawal Reliance on undetectable viral load

Men in Casual Sexual Encounters: 

Men in Casual Sexual Encounters Sero-concordant Sero-discordant Serostatus of partner and/or self unknown

Casual Anal Intercourse: SGCPS: 

Casual Anal Intercourse: SGCPS pandlt;.001

Inconsistent Condom Use : 

Inconsistent Condom Use Longitudinal data (SMASH) indicates that of 659 men who completed 3 annual interviews (1994-1997): 127 (19%) men reported ANY UAI-C during one six-moth period prior to interview 45 (6.8%) men reported ANY UAI-C during 2 periods 20 (3.0%) men reported ANY UAI-C during 3 periods

Inconsistent Use - HIM: 

Inconsistent Use - HIM For men who have some unprotected sex and some protected sex with casual partners, the data indicate that in a six month period such men use condoms with around 80% of their casual partners. That is, among inconsistent condom users, approximately 20% of their casual sexual encounters are unsafe and condoms are not used.

Patterns of sex with casual partners: 1996-2001Sydney Gay Community Periodic Surveys: 

Patterns of sex with casual partners: 1996-2001 Sydney Gay Community Periodic Surveys

Men who sometimes engage in UAI with ejaculation with casual partner(s): 

Men who sometimes engage in UAI with ejaculation with casual partner(s) *Periodic surveys February 1996 to February 2000 (N = 13,267) 2 (2) = 87.42, pandlt;0.000 Serostatus

Risk Reduction StrategiesCasual Partners : 

Risk Reduction Strategies Casual Partners Condoms – no unprotected sex Positive-positive sex Withdrawal Strategic Positioning Reliance on undetectable viral load Assumed negative-negative sex

Conclusion: 

Conclusion The majority of men – but not all men – engage in strategies and tactics to avoid harm to themselves and their partners Research is needed to detail these strategies and evaluate their relative danger and safety

Conclusion (2) : 

Conclusion (2) It is not the case that gay men have got it all right – note the increase in Victoria and the absence of a fall in HIV in the rest of Australia And it is not the case that ‘safe’ sex has been abandoned Educators need to engage with the complexity of risk and risk reduction strategies and where possible make the strategies safer

Acknowledgements : 

Acknowledgements Participants Researchers from NCHSR Researchers from NCHECR Researchers from ARCSHS AFAO and its constituent bodies NAPWA and its constituent bodies Funding – C’wealth and State Health Departments