Bareback Sex: What you Need to Know.

Some guys have ‘bareback sex’ (anal sex without a condom). At ACT, we encourage men to practice safer sex by using latex or polyethylene condoms and water or silicone-based lubricant for anal sex. This is the best way of avoiding HIV infection, HIV transmission, or infection with other sexually transmitted infections (STIs).

However, we also understand that there are other ways guys can reduce their risks. While these ways are not as effective as condom use, we respect the decisions men make for themselves. Our hope is that guys can make fully informed and conscientious decisions based on accurate information, if they choose to bareback.

All adults have the right to choose the type of sex they want to have. People have the right to decide what level of risk they are willing to accept for themselves.

In partnership with the Ontario Gay Men’s Sexual Health Alliance, ACT created a comprehensive resource on gay men’s sexual health. To learn more about other ways to reduce risk when barebacking visit: www.thesexyouwant.ca

Things to Consider if you are Thinking about Bareback Sex:

■Make sure your partner is actually agreeing to bareback sex: he shouldn’t be drunk or high, or in any other type of altered state that may prevent him from making a decision he wouldn’t normally make for himself. Just because a partner didn't ask to use a condom, doesn't necessarily mean he wants to have bareback sex: perhaps he's making an assumption about your HIV status, or he doesn't feel he can ask to use a condom. Think about this.

■If you are HIV positive it’s good to be aware of the legal obligations surrounding HIV disclosure (i.e. telling your HIV status). For more information about this check out this page.

■Use lots of water and silicone based lube when fucking. Apply more lube as you fuck. Water and silicone based lube will minimize the risk of irritation to the mucosal lining of your anus which allows a route of entry for HIV and other STIs. Lube also makes the initial penetration feel good! Avoid using saliva for lube. Try silicone lube. It has a different thickness and texture than water based, is safe with condoms, and may be hotter for you.

■Spread your barebacking adventures over time to allow any potential damage to your ass to heal.

■Be aware of pain levels. Fucking may cause discomfort or sensitivity, but it shouldn’t be painful. There doesn’t have to be blood for there to be damage.

■Early withdrawal does not reduce the risk for HIV transmission, as pre-cum can also contain HIV. Early withdrawal also does not prevent the transmission of other STIs (like syphilis).

■Don’t fuck if you have open sores on your dick.

■Don’t get fucked if you have sores around your ass.

■Before getting fucked, relax your asshole as much as possible: try anal massage, get finger-fucked or rimmed (lots of foreplay!). Repeated deep breathing helps your hole open up and makes it feel good.

■It's best not to put anything (like a dildo or butt plug) that has been in another person's asshole, in your ass.

■Douching (rinsing inside the ass) makes sense. Fecal matter (shit) doesn’t make good lube! Here are some tips we’ve collected that will make your experience more pleasurable:

 o Use warm water only. Douching removes the natural protective fluids in the mucosal membranes of the ass.

 o It’s best to wait at least 60 minutes following douching before insertion to allow time for your ass fluids to regenerate.

 o If you douche often, it helps to replace the good bacteria (microflora or probiotics) in your gut. This restores balance and aids digestion and absorption. You can get probiotics from yogurt or in capsule or powder from your local health food store. We don’t recommend packaged enemas you buy at the pharmacy. Not only will this solution irritate your mucosa, it will make you shit more than you need to. If you are concerned about your bowel movements, a diet rich in fibre and plenty of water can increase your overall ‘fuck-a-bility’ in a much healthier way than regular douching.

■Urinate (piss) immediately after fucking. This can help to clean out the urethra (piss slit) and may help to flush out any bacteria.

■If you are a trans guy and are getting fucked in your front hole without a condom, be aware that you may be able to become pregnant.

■If you are HIV negative, get regularly tested for STIs and HIV. If you are HIV positive, you should be aware that STIs are infections that can have a fast and negative impact on your health and your HIV viral load, so you should also consider getting regularly tested for STIs and Hepatitis C, as many STIs often have no noticeable symptoms. Talk to your doctor, local HIV/STI information line, sexual health clinic or AIDS service organization for more information on STIs and how they impact HIV.

Some questions you may have about bareback sex.

1. How risky is barebacking for HIV transmission?

 Let’s break down the possibilities.

■If you and your partner are both HIV negative, then there’s obviously no risk for HIV transmission. However, you may not really know the HIV status of your partner, or you may be assuming that his HIV status is the same as yours. In addition, you might think that you are HIV negative because you got tested: but when were you last tested for HIV? Six months ago? A year ago? Longer? Have you had unprotected anal sex with others since your test, and as a result become infected with HIV? You might have HIV and not know it: studies have shown that almost 20% of gay and bi men who think they are HIV negative actually have HIV.

■If you are HIV negative while your partner is HIV positive, unprotected anal sex is high risk for HIV transmission. The Canadian AIDS Society’s HIV Transmission Guidelines define "high-risk" practices as those presenting the real potential for HIV transmission because they involve an exchange of body fluids such as semen, vaginal fluid, blood or breast milk. In addition, a significant number of scientific studies have repeatedly associated those practices with HIV infection.

2. How safe is barebacking for other sexually transmitted infections (STIs)?

There are several STIs that you are at risk of getting if you have bareback sex. These include chlamydia, gonorrhea, Hepatitis B and C, genital warts, herpes and syphilis. Having an STI can weaken your immune system, which is a concern if you are living with HIV. Having an STI also increases the risk of HIV transmission. We've seen a dramatic increase in syphilis among gay and bisexual men in Toronto and other parts of Ontario. Syphilis can be easily spread through bareback (condomless) anal sex.

 3. Is it true the ‘top’ is at less risk for getting HIV than the ‘bottom’?

Yes, you are less likely to be infected as the top than the bottom, but the risk isn’t eliminated. According to a study in Australia, around 1 in 5 men who recently contracted HIV were tops. In a research study published in 2007, among a sample size of 102 gay and bi men who were recently diagnosed HIV-positive, 10 of them were infected despite being the top.

4. I have weighed the pros and cons of barebacking, and I’ve decided to do it. Is there anything wrong with that?

Bareback sex is not morally “wrong”. There are a many things really hot about it; however it does have greater risks. These may or may not be worth it to you. We believe knowledge is power. If you chose to bareback, we encourage you to be as informed as possible. Use the information here and in the suggested resources to be as informed as possible and reduce the risks to you and others.

5. I’m HIV positive and I choose to bareback. Why don’t other guys take responsibility for protecting themselves if they want to?

Well, some men assume that if their partner doesn't tell them they are HIV positive then they must be HIV negative. If you are HIV positive, and you don't tell your partner, and he assumes you are HIV negative, you are putting him at risk for HIV infection. Everyone should take responsibility for protecting themselves and their sex partners. If you are HIV positive, you should be aware that you could be charged for failing to disclose (tell your sex partner) your HIV positive status. Find out more about this issue here. 

There are many reasons why guys will consent to bareback sex without knowing the HIV status of their sexual partner:

■You might think that bareback sex is hotter than sex with a condom and so it's worth the risks;

■You might assume something that a guy said in his online profile indicates he is into barebacking (e.g. if he says he likes it "wild" or is into "pig play")'

■You might be HIV positive and assume that your partner is also HIV positive;

■You might be HIV negative and assume that your partner is also HIV negative;

■You might assume that your partner actually knows his HIV status;

■You might have an allergy to latex;

■He might be so hot that you feel like you don't care if you use condoms;

■You may be uncomfortable or afraid to mention condom use for fear of being rejected;

■You may be anxious about using condoms for fear of losing your erection;

■You may be really turned on during sex and decide, at the moment, that it’s worth the risk;

■You may be drunk or high;

■You may have been rubbing your dick against his hole, and slipped it in for a bit and decided to just keep going;

■You or he may not be fully aware of the risks.

6. I’m HIV negative and I choose to bareback. Wouldn’t someone who is HIV positive tell me before having sex?

Some guys might think they are HIV negative (because their last HIV test was 'negative'), but may have done something since that last test to cause them to become infected with HIV. They assume they are HIV negative, but in fact they aren't. Studies have shown that most new HIV transmission happens between guys who both think they are HIV negative, but one of them has been recently infected with HIV and doesn't yet know it. Studies have shown that when someone is newly infected with HIV, they have very high amounts of HIV circulating in their blood, semen, rectal and vaginal secretions, making HIV transmission likely.

Also, not all men may disclose that they have HIV before having sex with you. There are many reasons for this. They might assume that since you didn’t ask to use a condom, you are also HIV positive. It takes a lot of guts to tell someone you have HIV. Often, HIV positive men are rejected once they reveal their HIV status, but if they don’t say anything, they won’t get rejected. In a casual sex encounter, what would you do?

7. I’m HIV positive and I only bareback because I feel I will be rejected if I tell my potential partners of my status.

This is a valid concern. We all know that discrimination happens against people who are HIV positive - even within the gay community. Remind your partner that people who are HIV negative should also be using condoms, as someone could be infected and not know it - people have often had risky sex since their last HIV test.

8. I’m HIV negative and I’m worried that if I ask to use a condom, my partner might believe I am HIV positive.

That could happen. But what if your partner is HIV positive and assumes that you are also HIV positive since you did not ask to use a condom? You could tell your partner that you’re HIV negative and you would like to use a condom. If he then says ‘if you know you’re HIV negative, why not forget the condom’, you can tell him that there are other STIs to think about. You can also tell him that research studies show that up to 20% of gay or bi guys who think they are HIV negative, are in fact HIV positive but don't know it: they may have been tested quite some time ago, and got HIV since their last test. They think they are HIV negative, but in fact they aren't.

9. My partner and I are both HIV positive. Why shouldn’t we bareback?

It’s your choice to have condomless sex together. We’re not saying you should or shouldn’t do it. You should talk to your partner (if you have sex with other people) about the kinds of sex you have with others. STIs, like syphilis, are still a risk to you, and can compromise your ability to fight HIV. STIs increase your viral load (a measure of the amount of HIV in your blood), and certain STIs can progress much more rapidly in people living with HIV. If you are HIV-positive and have bareback sex, it's important to get tested regularly for STIs and Hepatitis C.

10. I feel guilty whenever I bareback. Why do I sometimes slip up and have unprotected sex?

We’re all human. Nobody is perfect. Try to better understand the situations in which you get involved in unprotected sex. Where are you usually? How are you typically feeling? What reasoning do you use to make it more acceptable for you to have unprotected anal sex? Does your partner pressure you?

Just because you might occasionally 'slip up' and have unprotected sex doesn't mean you are necessarily a 'barebacker'. Some guys feel that sex without a condom is more care-free, more pleasurable and exciting. Others are worried about rejection, or about losing their erection. If you really want to be using condoms for anal sex (and there are many good reasons to do this!), there are ways you can experience intense pleasure and intimacy. And, you can learn to wear a condom and keep your dick hard.

11. I bareback because it’s an intimate feeling; I feel closer to my partner.

Some believe having unprotected anal sex is the ultimate, most intimate, sex act. There’s nothing wrong with believing that. But what about other sexual acts that might give you the same, or nearly the same level of intimacy with your partner? There are many different ways to feel intimacy with a partner and anal sex without a condom is only one of them. Try exploring other aspects of your sex life.

12. I am HIV positive but I take anti-HIV medications and my viral load is undetectable. Doesn't this mean that barebacking is OK because I can't transmit the virus?

While anti-HIV medications can dramatically reduce the amount of virus in your blood (and other body fluids), therefore reducing the likelihood of an HIV positive person passing on HIV to an HIV negative sex partner, there remains the possibility of HIV transmission.

Viral load is the amount of virus in a specific sample amount of blood. When a viral load is so low that it can’t be measured with common testing procedures, it is called ‘undetectable’. Some people call this ‘zero viral load’, but the virus is still present - it just means the number of copies of HIV is too low for routine tests to detect. Although it's quite rare, research studies have shown that some people with an undetectable viral load in their blood may have a viral load in their cum (or rectal secretions, or vaginal secretions) that is high enough to pass HIV onto their partners. Most of the time, guys with undetectable blood viral loads who are taking their anti- HIV medications as prescribed, and get regularly tested for STIs (and treated for STIs if need be!), also have undetectable viral loads in cum and rectal secretions. Having an undetectable viral load clearly reduces the likelihood of HIV transmission, but we can't rule out the possibility that HIV transmission still can occur. Condoms can provide that additional protection.

Photo credit © Doodkoalex | Dreamstime.com

From The Associated Press via CTV News 

WASHINGTON —  U.S. drug regulators on Tuesday affirmed landmark study results showing that a popular HIV-fighting pill can also help healthy people avoid contracting the virus that causes AIDS in the first place. While the pill appears safe and effective for prevention, scientists stressed that it only works when taken on a daily basis.

The Food and Drug Administration will hold a meeting Thursday to discuss whether Truvada should be approved for people who are at risks of contracting HIV through sexual intercourse. The agency's positive review posted Tuesday suggests the daily pill will become the first drug approved to prevent HIV infection in high-risk patients.

FDA reviewers conclude that taking Truvada pre-emptively could spare patients "infection with a serious and life-threatening illness that requires lifelong treatment."

Despite the positive results, reviewers said that patients must be diligent about taking the pill every day. Adherence to the medication was less than perfect in clinical trials, and reviewers said that patients in the real world may forget to take their medication even more than those in clinical studies.

First announced in 2010, Truvada's preventive ability was hailed as a breakthrough in the 30-year campaign against the AIDS epidemic. A three-year study found that daily doses cut the risk of infection in healthy gay and bisexual men by 44 per cent, when accompanied by condoms and counselling. Another study found that Truvada reduced infection by 75 per cent in heterosexual couples in which one partner was HIV infected and the other was not.The FDA's panel of advisers will take separate votes on whether Truvada should be approved for:

• gay and bisexual men
• men or women in relationships with HIV-positive partners
• other people at risk of acquiring HIV through sexual activity

The FDA is not required to follow the advice of its panels, though it usually does.

An estimated 1.2 million Americans have HIV, which overwhelmingly affects men who have sex with other men, according to the Centers for Disease Control and Prevention. HIV attacks the immune system and, unless treated with antiviral drugs, develops into AIDS, a fatal condition in which the body cannot fight off foreign infections.

Because Truvada is already on the market to manage HIV, some doctors currently prescribe it as a preventive measure. FDA approval would allow the U.S. drugmaker Gilead Sciences to formally market its drug for the new use.

But support for FDA approval is not unanimous. Some researchers stress that condoms remain the best weapon against AIDS, and a prevention pill is not the chemical equivalent.

"We know that if the person doesn't take the medication every day they will not be protected," said Dr. Rodney Wright, director of HIV programs at Montefiore Medical Center in New York. "So the concern is that there may not be adequate adherence to provide protection in the general population."

Wright, who is also chairman of the AIDS Health Foundation, added that some upcoming medications may be more effective at preventing infection than Truvada.

Researchers also worry about Truvada's mixed success rate in preventing infection among women. Last year a study in women was stopped early after researchers found that women taking the drug were more likely to become infected than those taking placebo. Researchers speculated that women may need a higher dose of the drug to prevent infection. They also said the disappointing results may have resulted from women not taking the pills consistently.

Still, many HIV patient advocacy groups say the drug should be a prescribing option to prevent HIV, alongside condoms, counselling and other measures.

"If we're going to reduce the more than 50,000 new HIV infections in this country each year, we need to increase the available options for people," said Ronald Johnson, vice-president of AIDS United. He added that more studies are needed to determine the drug's effectiveness in women and other patient subgroups.

"The current state of the data warrants going forward, but we believe additional clinical trials should also go forward to broaden the use of Truvada."

Last month, AIDS United and more than a dozen other advocacy groups sent a letter to the FDA, urging approval of Truvada.

California-based Gilead Sciences Inc. has marketed Truvada since 2004. The drug is a combination of two older HIV drugs, Emtriva and Viread. Doctors usually prescribe the medications as part of a drug cocktail that makes it harder for the virus to reproduce. Patients with low viral levels are far less likely to develop AIDS. Side effects with Truvada include diarrhea, dizziness, nausea and vomiting. More serious problems can include liver toxicity, kidney problems and bone thinning. 

This article is based on a report by Greta Bauer, Nick Redman and Kaitlin Bradley for the Trans PULSE team. E-Bulletins, presentations and articles available at www.transpulseproject.ca To contact Trans PULSE: This email address is being protected from spambots. You need JavaScript enabled to view it. or 1-877-547-8573

The Trans Pulse study says about two-thirds of trans guys are gay or bi men who have sex with men, and are attracted to or sexually involved with either trans or non-trans men. Trans guys already exist within gay men’s communities, gay bathhouses, and gay men’s bedrooms. Yet, their sexual health concerns are rarely made visible. No  assumptions can safely be made about how an “average” GB-MSM trans guy may act, what he may do in bed (or not do in bed), or what other psycho-social stressors he may or may not have to deal with.

The report concludes “Sexual health and HIV-related prevention and testing programs and materials need to incorporate trans guys’ issues and needs, and to reflect the potential for gay or queer bodies to be trans bodies.”

Trans guys include those who identify as transgender, transsexual, or have a history of transitioning medically or socially to male, or to another identity such as Two-spirit or genderqueer. A broad definition of “trans” was used in the study; participants were not limited to particular identities, and were not required to have begun or completed a social or medical gender transition. A total of 433 participants were recruited over a 12-month period,

Trans PULSE is a Canadian Institutes of Health Research-funded, community-based, research project to understand and improve the health of trans people in Ontario.

The survey included items on health-related measures, including social determinants of health, psycho-social measures, health care experiences, and sexual health. Participants were trans people age 16 and over who lived, worked, or received health care in Ontario.

The research team gathered data which indicated  diversity in the sexual orientation of trans guys and this data is shown in Table 1 (right) Trans guys identified across a full range of sexual orientation identities, with only about one third identifying as straight. As a group, trans guys had cis (cisgender, or non-trans) partners and trans partners who identified as men, women, and genderqueer.

This diversity clearly challenges assumptions that trans guys transition to be straight men, as even many of those who were currently partnered with a woman did not identify as straight, and there were many who were attracted only to women (sometimes only to cis women) who still identified as queer.

63.3% of trans men fit into the GB-MSM category, the focus of this report, which defined GB-MSM trans guys as those who had a sexual minority identity (e.g. gay, bisexual, pansexual, queer) and were not exclusively attracted to women, or those that had sex with a cis or trans in the past year, regardless of how they identified.

Relationships, Sex, and HIV Risk of GB-MSM trans men

Table 2 (right)  provides details on the relationships, sexual activity, and HIV-related risk for GB-MSM trans guys.

While not every trans guy used all of his body parts for sexual activity, trans guys engaged in all types of activity, including receptive genital sex. These sexual behaviours do not correspond to HIV-related risk, however, as not all involved “flesh genitals”, but may have involved prosthetics, toys, or fingers, for example, and even where flesh genitals were involved, condoms or other barriers may have been used. Proportions engaging in high-risk activities were much lower than those representing any engagement in activities. 

The primary contributor to HIV risk was unprotected receptive genital sex, an activity some may assume trans men are unlikely to engage in. Most HIV-related sexual high risk related to having cisgender male partners, as exposure to ejaculate is required to qualify as high risk. For this reason, overall HIV-related risk among trans guys was entirely borne by the sub-group of trans guys who are GB-MSM. About one-third of GB-MSM trans guys had a cisgender man as a partner in the past year, and 1 in 10 had engaged in high-risk activity; roughly three-quarters engaged in low/moderate risk activities.

While a fair amount of research exists on trans women who engage in sex work, participation by trans men is infrequently acknowledged. Researchers  found that 15.8% of GB-MSM trans guys had engaged in sex work or exchanged sex for money or goods. While proportions engaging in sex work were similar to trans women, it’s not known if trans guys are similar with regard to the frequency of sex work activities, or the length of time spent in the trade.

While it is not clear how or if it relates to HIV risk, results indicate a high proportion of GB-MSM trans guys had never been tested for HIV, while 1 in 5 had been tested in the past year.

Psycho-social Factors that may Impact Sexual Health

Table 3 (right) presents data on several psycho-social factors that may impact sexual risk taking.

GB-MSM trans guys were no different from other groups of trans people in the study with regard to sexual satisfaction. Sexual body image worries were assessed using a scale developed by Trans PULSE to capture trans-specific concerns such as not being seen as one’s gender when naked. Low relates to never or infrequently having this range of worries, while high related to often having such worries. For about 1 in 5 GB-MSM trans guys, these worries were very frequent, while for another 2 in 5 they were common.

Depressive symptoms are common among trans guys. Researchers found that trans guys had a decreased risk of depression if they experienced greater sexual satisfaction, and an increased risk if they experienced high levels of transphobia or were in a period of planning but not having yet begun a medical transition.

The majority of GB-MSM trans guys in fact  scored as “depressed”. However, the measurement scale used has not been validated for trans people, and given the extreme stresses trans people can be subject too, it’s considered unlikely that for most such trans guys, that this indicates what would be considered as clinical depression. However, this does indicate a high burden of depressive symptoms.

An estimated 16.9% of Ontario’s GB-MSM trans guys have experienced physical or sexual assault that they attribute to being trans. Many trans guys also reported experiencing assault, but were unsure as to whether it was a transphobic attack. An additional 36.1% experienced harassment or threats, but not assault. This indicates an extremely high level of violence that trans guys are subjected to, in addition to other types of violence they may have experienced in their lives.

Illustration © Dawn Hudson | Dreamstime.com

A topic that you might expect to enter into HIV education more frequently than it does is risk management. How do people make decisions around managing risk? It’s a topic that I know very little about, and I certainly hear very little about it in this field.

While we put a fair amount of effort towards understanding social and cultural nuances that affect sexual decision making, a part of me wonders if we could be drawing on the body of knowledge that exists around how people interpret and manage risks in their daily lives. This occurred to me today, during an early morning conversation about HIV transmission. I say “early morning” because, at quarter past 8, as I was taking the first few sips of my coffee, I found myself explaining to a friend, visiting from out of town, what particular sex acts are at higher risk for HIV transmission and why.  (Innocent questions about my job quickly transition into talking about vaginal lining or anal mucus… hence my previous post on how the job never ends).

 My friend asked an interesting question – do different at-risk groups pay more or less attention to the nuances of different levels of risk? Specifically, he wondered about sero-discordant couples. My response was that partners who make a decision to engage in a sero-discordant sexual relationship would likely be interested in learning about the different levels of risk; a more relevant issue is that many people tend to take a completely “hands-off” approach when it comes to risk management around HIV infection, attempting to avoid dealing with sexual risk completely.

I do, unfortunately, often encounter HIV negative people who seem to believe that having sex only with only HIV negative people is the best solution to protecting themselves from HIV. Of course this avoidance of risk is an illusion; they fail to recognize that they may be having sex with HIV positive people without knowing it (because not everybody knows their status, nor will they necessarily always disclose it) and this false impression may lead people to increase their level of risk by failing to use condoms, for example.

But this led me to a question. Why do people make such severe judgements about risk when it comes to sex and not when it comes to many other aspects of our lives?  Everyday many of us get in the car and drive to work, even though there is a significant risk that we get into a car accident.  In fact, the risk of an accident likely trumps the risk of acquiring HIV by unprotected sex. The number of car accidents per year far exceed HIV infections, yet people get into their cars every day, buckle their seatbelt as a matter of harm reduction, and go ahead with their day without thinking, calculating, or questioning these risks, let alone judging others who also put themselves at risk by being on the road.  But many of these HIV negative car drivers would not carry this same approach to sero-discordant sex, even though it could be argued that a car accident could potentially have worse consequences than HIV acquisition and that missing out on a great love or even great sex would be a tremendous loss.

So what are the psychological or sociological factors that make people behave so illogically when it comes to decisions around risk taking?  As we work to address stigma, disclosure, condom use and other issues, it may be information worth knowing.

Who says senior years mean an end to sex?.  Studies have shown shown that more than 80% of 50-90 year olds are sexually active.  But for the same age group, sexually transmitted infection rates have doubled in the past decade in Canada, the U.S. and the U.K., says a recent study.

According to a CTV News story, there has also been a significant increase in the number of older adults accessing HIV care, up 82 per cent since 2001. While much of that increase is due to HIV patients living longer because of new treatments, new HIV diagnoses in adults over 50 doubled between 2000 and 2009 in the U.K.

Says CTV News  "The statistics also show increases in incidents of syphilis, chlamydia and gonorrhoea in adults in the 45-to-64 age bracket. “Over the last 10 to 15 years, we were seeing in this (over 50) group that . . . (sexually transmitted) infections were really rising . . . across the board," one of the study's authors, Rachel von Simson, told CTV News. "In some cases, they now form a larger group of infections than those aged 15 to 29.”  Statistics show in Canada that in adults over the age of 45, they are seeing more cases of syphilis in them than in adults aged 15 to 29. They theorize that the increase in the use of erectile dysfunction drugs has allowed men to stay sexually active longer, increasing the amount of time a man can put himself and his partners at risk.  Von Simson says doctors should look at older patients the same way they do younger patients, and examine the possibility that they may have an STI.”

"Doctors don't really particularly expect to see (older) patients at risk, so they might not be picking up infections like HIV early on when they need treating and that might mean a greater spread," von Simson said. "(Doctors) are very afraid they may offend older adults by speaking about it."

All of which makes the US-based website Safer Sex for Seniors so much sense.  It’s chatty site lacks pizzaz but nevertheless sports a nifty video that has been raising  eyebrows all over the net.  And it seems decidedly straight – true, ther is a nod to bisexuality here  and even transgendered people here but nothing at all about gay sex.  Still, what’s here is solid enough, even though its message “There’s Only One Way to Safety – Use Condoms” lacks the nuanced approach we’ve come to expect of our safer sex menus that nowadays tend to stress individual decision making rather than edicts.

But I’m being picky.  Any website that features seniors working their way through the Kama Sutra can’t be all bad.  You be the judge.

This article by Roger Pebody first  appeared on aidsmap. 

The First Study

Pre-exposure prophylaxis (PrEP) would be an acceptable HIV prevention strategy for large numbers of gay, bisexual and other men who have sex with men in major UK cities, according to two studies presented to the British HIV Association (BHIVA) conference in Birmingham this week.

The conference also heard details of a small pilot PrEP study, likely to start recruiting later this year.

A cross-sectional survey of 842 HIV-negative gay and bisexual men, recruited at bars, clubs and saunas in London, suggested that half the respondents would be interested in taking PrEP.

Respondents were given information about pre-exposure prophylaxis and asked: “If PrEP were available, how likely is it that you would take a pill (oral dose) on a daily basis to prevent HIV infection?”.

Half said yes, with 16% saying they were likely to take PrEP and 34% saying they were very likely to. Men interested in PrEP were slightly more likely to be under the age of 35 (AOR adjusted odds ratio 1.58), have attended a sexual health clinic in the past year (AOR 1.59) and to have previously taken post-exposure prophylaxis (PEP) (AOR 1.96). After statistical adjustment, various measures of risky sex were no longer associated with interest in PrEP.

In this survey, 17 men (2.1% of those answering the question) said that they had previously taken antiretroviral drugs to reduce their risk of HIV infection.

Secondly, clinicians at the Manchester Centre for Sexual Health surveyed HIV-negative men attending their service who reported unprotected receptive anal intercourse. Of the 121 men who responded, 36% said they would be “very willing” to take PrEP while only 14% said they would not take the treatment. Daily dosing was perceived as a better option by four fifths of respondents – just one fifth would prefer taking a dose before sexual activity.

These data confirm and reinforce findings from a study reported in November 2011, which found that half the gay men surveyed would consider taking PrEP. Once again, daily dosing was preferred to taking a dose before sex. In the qualitative data, men commented that sex is often spontaneous and that they felt daily dosing would facilitate adherence.

However these data are all based on giving men a few key facts about PrEP and presenting it as a hypothetical option. In real-life circumstances, where men think more seriously about PrEP as an option and hear friends’ experience of taking it, actual uptake and sustainability may be very different.

While the Manchester respondents largely assured the researchers that they would take all their doses of PrEP and wouldn’t have more risky sex, real-life experience needs to be tested in research.

To this end, the Medical Research Council are seeking funding for a 5000-participant, two-year study which would randomise HIV-negative gay men who report unprotected anal intercourse to either take PrEP (Truvada) and attend motivational interviewing (intervention group) or to be put on a one-year waiting list for PrEP and to have motivational interviewing in the meantime (control group).

For the researchers, it is crucial that this is an open label but randomised study, in which participants know whether they are receiving the actual drug. This unusual research design would, they argue, tell us more about the real-world effectiveness of PrEP than a blinded study as it would take into account the possible impact of participants taking more sexual risks because they felt that PrEP afforded some protection. (Researchers call this ‘risk compensation’ or ‘behavioural disinhibition’).

Rather than test efficacy in artificial conditions, the study would therefore test effectiveness in more realistic UK conditions.

So far, however, the potential funders of this costly study have not been persuaded by this argument and it is unclear whether the study will be able to go ahead.

What will, however, start recruiting later this year is a pilot version of the same study, aiming to include 500 men who attend one of around twelve sexual health clinics.

As well as allowing the researchers to have a dry run of the main trial and identify teething problems with its strategy, it should also provide valuable information on the number of men who actually follow through on a clinician’s offer of PrEP. Data on the characteristics of men who seek PrEP, drop-out rates and risk compensation will also be collected.

The researchers intend to take some of these data back to the main study’s potential funders, in order to support a revised application.

Acceptability of taking HIV treatment for prevention purposes

As well as asking people hypothetical questions about PrEP, researchers have also been asking people waiting for an HIV test result hypothetical questions about treatment as prevention.

Individuals from high-risk groups attending the Jefferiss Wing at St Mary’s Hospital for HIV testing were given an explanatory paragraph about treatment, infectiousness and safer sex. They were then asked: “If you were diagnosed with HIV would you consider taking treatment to reduce the risk of passing on infection (even if you did not need to take treatment for your own health)?”.

Four out of five respondents said ‘yes’. Encouragingly, gay men who reported unprotected anal intercourse in the past three months were more likely than others to be interested in the idea. Less encouragingly, people who had had a sexually transmitted infection or who had previously taken PEP were slightly less likely to say that they would take treatment for prevention.

The researchers suggested that the latter factor may be associated with PEP users’ experience of side-effects. It contrasts with the findings of the London PrEP attitudes study described above which found people who had previously taken PEP more likely to be interested in PrEP.

References

Aghaizu A et al. Who would use PrEP? Predictors of use among MSM in London. 18th Annual Conference of the British HIV Association, Birmingham, abstract O23, 2012. See abstract here.  

Thng C et al. Acceptability of HIV pre-exposure prophylaxis (PrEP) and associated risk compensation in men who have sex with men (MSM) accessing GU services. 18th Annual Conference of the British HIV Association, Birmingham, abstract P233, 2012. See abstract here.

Jones C et al. Treatment as prevention: the views of high risk patients attending an outpatient GUM clinic. 18th Annual Conference of the British HIV Association, Birmingham, abstract P234, 2012. See abstract here.

This article is copyright © NAM Publications, 2012. All rights reserved