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 14th 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.
In an editorial accompanying the Australian report, Frits van Griensven of the Thailand Ministry of Public Health and U.S. Centers for Disease Control asked if non-condom risk-reduction behaviors can help contain the spread of HIV infection among MSM.
“In a world where condom use during anal intercourse has been the cornerstone of HIV prevention among MSM, it is remarkable that all these risk-reduction behaviors include anal intercourse without condom use, he wrote. “This inevitably raises the question why the sexual behavior identified as the primary driver of the HIV epidemic in MSM has become the central component of HIV risk-reduction behaviors employed by MSM.”
“The answer lies in how institutional and individual HIV-prevention strategies have evolved over the past 25 years,” he continued. In the early years of the epidemic, HIV prevention for MSM was based on the principle of “risk-elimination,” such as avoidance of any unprotected anal intercourse. “Because anal intercourse appeared to be too difficult to change,” he wrote, condom use soon became the norm in HIV prevention among MSM, and widespread changes in sexual behavior led to a dramatic decrease in HIV transmission among gay/bisexual men in the Western world.
HIV prevention based on risk elimination “probably worked well until the mid-1990s,” van Griensven continued, at which point men started to develop “safe-sex fatigue” and began looking for alternative prevention strategies. Around the same time, younger generations of gay/bisexual men came of age who “had not personally experienced the devastating effects of AIDS in the MSM community,” and the advent of HAART led many men “to no longer view HIV infection as a death sentence but as a manageable chronic disease.”
With these developments, “Risk for HIV infection was no longer seen as constant across partners, but varied according to certain conditions, such as partner characteristics (e.g. serostatus) or sexual position in anal sex (e.g. insertive versus receptive intercourse),” he wrote. But, he noted, until now there have been no solid data on such risk-reduction strategies from prospective studies.
In summary, he wrote, based on the Australian data, “we can say that with the exception of withdrawal and possibly serosorting, risk-reduction behaviors in this population of MSM were equally to somewhat less effective in preventing HIV infection than was no unprotected anal intercourse.”
“Serosorting and negotiated safety require honest communication between partners who are accurately informed about their HIV status, whereas the effect of strategic positioning is supported by epidemiologic data indicating the decreased risk of insertive anal intercourse compared to receptive anal intercourse,” he continued. “The risk of withdrawal during unprotected receptive anal intercourse has not been well documented, but this practice seems unreliable because of possible exposure to body fluids and cells, including those from untimely withdrawal and pre-ejaculate.”
Looking at the conditions under which non-condom risk-reduction behaviors can be effective, van Griensven wrote, “First of all it is crucial that MSM have updated and accurate information about their HIV serostatus…Second, HIV seropositive MSM need to be willing to disclose their HIV serostatus…Third, strategic positioning needs to be common, with HIV seronegative men taking the insertive and HIV seropositive men taking the receptive role in anal and oral sex.”
He suggested that these risk-reduction behaviors may well have helped reduce HIV infection in
“These conditions will certainly be different for many other groups of MSM, such as non-urban MSM, urban MSM of lower socio-economic status, and MSM outside of the Western world,” he cautioned. Thus, “we need to be careful in generalizing the results” of the Australian study to HIV prevention programs elsewhere.
F Jin, J Crawford, P Garrett, and others. Unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS 23(2): 243-252. January 14, 2009. (Abstract).
SF Morin, SB Shade, WT Steward, and others (Healthy Living Project Team). A Behavioral Intervention Reduces HIV Transmission Risk by Promoting Sustained Serosorting Practices Among HIV-Infected Men Who Have Sex With Men. Journal of Acquired Immune Deficiency Syndromes 49(5): 544-551. December 2008. (Abstract).
F van Griensven. Non-condom use risk-reduction behaviours: can they help to contain the spread of HIV infection among men who have sex with men? AIDS 23(2): 253-255. January 14, 2009.