The “HIV’s a pain” theory of prevention: can it work?


So gay guys go on having unprotected sex after they are diagnosed with HIV, a new descriptive study of gay poz guys at a clinic in Boston tells us. Nothing new there, although it’s sobering to be reminded that one in two of the men who know they have HIV choose to bareback with someone who may be negative.

The most important finding from the Boston study is that the more recently diagnosed a guy is, the more likely he is to be exposing other people. We can’t tell from the paper if that’s something new. It may be that there’s a blast of screwing around soon after diagnosis, possibly as a reaction to it, then a calming down. The post-diagnosis binge is one of the possible explanations given by NAM’s ever-sensible Gus Cairns, posting over at rectal microbicide site IRMA.

The thing that most determines whether a poz guy will pass on HIV during unprotected sex is his viral load. We know that’s likely to be highest for the few months after he first gets infected. So if we do get better at detecting HIV early and we don’t do anything about bringing viraemia down instantly, the “post-diagnosis sex binge”, if real, would be a worry we’d have to add to the known dangers of the “slutty phase” that affects undiagnosed men as well.

Gus gives us another potential explanation:

3. The historical explanation. It can’t be about young gay men not having experienced AIDS, because it was recent diagnosis that was the risk factor, not age. But it could be about prevention fatigue that affects all ages, and lack of relevant, effective and up to date messages. The result would be that the recently diagnosed have higher risk behaviours (and have caught HIV) because they haven’t internalised prevention messages in the way that the longer-term diagnosed seem to. Does risk behaviour decline over time in the longer-term diagnosed for one reason or another (more ease of disclosure, self-education, awareness of criminalisation, catching one too many STIs, etc) or will men diagnosed today continue to be higher-risk than men diagnosed years ago?

If it’s a binge thing, behaviour will get safer over time. If it’s an “I’ve zoned out HIV messages” thing, it won’t. But there might be something else going on: The “HIV isn’t so painless after all” thing.

One of the reasons that HIV prevention messages are failing is that much of the public health world still treats HIV as though it’s AIDS, as though it is self-evident why you would want to prevent it. But now that AIDS has virtually disappeared, what’s the big deal about HIV? Why bother to protect yourself, or to avoid passing it on?

Guys who were diagnosed longer ago are more likely to have realised that HIV (like diabetes and arthritis) is actually more than a one-pill-a-day shrug-off. The ups and downs of treatment — having to call off a date because you’ve blown up like a tomato, worried that your boss will see you popping pills, having to cancel a day’s skiing because you’ve got to go for your viral load monitoring, — it can be a real pain. A pain that, on reflection, you might go out of your way to avoid passing on. That may be one reason why people who were diagnosed longer ago are less likely to expose their partners to HIV.

But treatment is improving all the time; as prevalence goes on rising and the ick factor falls, HIV becomes less and less of a pain. It seems likely to me, then, that barebacking will continue to rise. That makes people in public health crazy, of course. We have to think about resistance, a reappearance of AIDS, costs to the health system. But frankly, the guys who think HIV is no big deal at the individual level are not entirely wrong these days, at least in rich, socially tolerant countries with good health systems.

Ken Mayer and his colleagues in Boston end their paper by saying that we need “Innovative programmes that facilitate education and skills building around safer sex when MSM are relatively recently diagnosed”. But frankly, we’re never going to figure out how we should prevent HIV in a post-AIDS world if we can’t make a convincing case to the individuals most at risk that we should prevent HIV.

For more nerdy observations on the Mayer and co. paper, read more.
As far as I can tell, the paper looks at syphilis, gonorrhea and chlamydia in HIV-positive gay men who come to a gay-friendly clinic for health care. It seems that guys are deemed to have had an STI if they test positive in a baseline study screening or if their clinic records say they had any one of those infections in their urethra, rectum or throat in the year before the start of the study or. But the arse or mouth appear to come only from clinic records. If that’s correct, then pharyngeal and rectal infections may be substantially underestimated. Rectal STIs include infectiousness in Bottoms, which is worrisome for negative guys practicing “strategic positioning” — only ever being the Top when they’re barebacking with a guy who is poz and who’s status they don’t know.

The study does have some measures of viral load at baseline; guys with detectable viral load (>75 copies/ml) were 68% more likely than guys with undetectable viral load to have barebacked with someone who might be negative. Since viral load is THE key in transmission, that’s not good. The effect disappears, though, if you sling it in to a model with a lot of things that are related to viral load, including meds and years since diagnosis. But it would be hard to wave too many flags about that anyway — viral load is apparently measured only at baseline, while the unprotected sex we don’t want to see in conjunction with it can be up to six months previously, and STIs (which also lead to spikes in viral load) up to a year previously. As though that’s not enough confusion about time periods, drug use is measured up to three months previously.

Just to be clear, the thing that the Boston gay community (and/or the public health authorities) need to be most worried about in terms of ongoing spread of HIV among guys in care, are, in this order:

• Poz guys with detectable viral load being the top in bareback sex with guys they don’t know are poz

• Poz guys with urethral STIs being the top in bareback sex with guys they don’t know are poz

Drug use: ah yes. I was surprised by two things. The first is that “binge drinking” (defined as five or more drinks in one day any time over the last three months — oh dear, oh dear) is so low — at 19%. The other is that crystal meth use is so high — 23% worship at the shrine of Tina. If there is one mistress that makes you behave worse than most, it is surely Tina.
On the other type of drug, there’s a bit of a surprise too while 66.1% of the nearly 400 guys in this study are on ARVs, only 54.4% had an undetectable viral load. That means that over 11% of these men are on meds and don’t have an undetectable viral load in a single baseline measure. Pause for thought for those who’s prevention strategy relies on thinking “Oh well, if he’s poz he’s probably on meds so he’s not infectious”.

One more deeply curious finding. Men who had any unprotected anal sex with someone that they didn’t know was HIV-infected over the last six months were over four times more likely to have had an STI in the last 12 months (odds ratio 4.42, 95% CI 1.88 – 10.36). But when they looked separately at insertive and receptive anal sex, they found lower chances of infection for both. In receptive anal sex, which you might expect to be associated with greater risk of STIs generally, guys were under four times as likely to have had as STI as those who never took it up the butt without a condom, and despite the fact that it’s by definition a subset of the previous measure, the confidence interval is narrower (OR 3.86, 95% CI 1.78 to 8.28). In insertive anal sex, which you’d expect to be perhaps less likely to associated with STIs, it was lower still: guys were just over twice as likely OR 2.11, 95% CI 1.04 to 4.30). I’m on a flight right now without my trusty stats textbooks, but in my mind, those you can’t have smaller sub-sets of the same measure giving you tighter confidence intervals.

Maybe they are not sub-sets. The “risk behaviour” measure is unprotected anal sex with anyone who is not known to the poz guy to be infected with HIV. In the results section of the paper, the other two measures are described as “unprotected serodiscordant insertive anal sex” and “unprotected serodiscordant receptive anal sex”. In other words, it’s possible that it excludes the “don’t know his status” partners, although the truth of it is that the only status you every really know for any length of time is poz. As the paper says in its introduction, poz guys have higher rates of all these infections, especially syphilis, so if there were a way of restricting the analysis to those who only had truly negative partners, you’d perhaps get those lower rates. But you’d still likely have wider confidence intervals.
In my day job, I teach a course in scientific writing; it includes a fair bit of paper critique work. If I were to add this paper to the course, what else would you expect students to pick out?

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This post was published on 05/04/10 in Men, women and others, Science.

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  1. Comment by Jim Pickett, 05/04/10, 06:58:

    None of this analysis takes into account the large amount of infections that:

    A. happen during acute infection (when people don’t know their status) and

    B. that 68% of new infections (see Patrick Sullivan’s paper from late 2009) happen in the context of RELATIONSHIPS, and not on binging and screwing around.

    Sure, those relationships are defined in all kinds of ways – but they are considered relationships by the men – and that is what matters.

    Where are the prevention campaigns that take relationships into account? We spend TONS of time talking about all these “naughty” boys doing “naughty” things – and completely ignore the context in which most infections occur.

    It’s a very sad state of affairs. And speaks volumes about the ways in which our homophobic society continues to pathologize and disrespect gay men’s lives.

    Sure this is anecdotal – but MANY of the gay men who are POZ seroconverted in relationships – and I am one of them.

    Until we address these realities, and help gay men take better care of themselves in all kinds of relationships – from dates, fuck buddies and friends with benefits to open and monogamous relationships.

    We have known for eons that the number one risk factor for women’s acquisition of HIV is marriage. Somehow no one ever thought something similar could be going on among gay men…

    Why is that?

  2. Comment by Jim Pickett, 05/04/10, 07:00:

    One thing I missed above:

    Sure this is anecdotal – but MANY of the gay men I KNOW who are POZ seroconverted in relationships – and I am one of them.

  3. Comment by olen, 05/04/10, 07:59:

    I am so happy to see that someone in public health/epidemiology actually getting it. Your exploration of rationality cutting clear through the bog of epidemiological statistics, or rather, effectively complementing it. The horrible data and nasty statistics are not the reality lived by developed-world MSM, to whom HIV APPEARS no longer a threat. Continual traumatization from fear-based public health propaganda hastens the subconscious dismissal of statistical fact in favor of the lived experience, while at the same time fueling self-destructive drives towards intentional seroconversion. I am personally working to challenge HIV stigma, as it’s a HUGE problem, and will continue this discussion in an email! 🙂

  4. Comment by Paddy, 06/04/10, 09:59:

    @ Jim Pickett,

    I read your post with interest. How would you recommend that campaigns could better prevent transmission in the context of male-male fuck buddies, fwb, etc?

  5. Comment by Gus Cairns, 09/04/10, 08:27:

    Hi Elizabeth,

    First, thanks for quoting me and calling me sensible (my bf and family would probably not agree).

    I’d like to add in the other two possible reasons I’d suggested for the study’s findings. NB having talked to Ken Mayer, it’s clear now that age and time since diagnosis are so closely correlated in this study it’s impossible to say if what we’re seeing is a “foolish youth” explanation or a “post-diagnosis shock” one.

    For what it’s worth, I favour explanation 2.

    1. The sociopsychological explanation: HIV diagnosis in heterosexuals is marked by shock, shame, withdrawal and social isolation, so they tend to reduce the amount of sex they have. Gay men’s reaction to diagnosis may be very different, if only because they have the opportunity to be different: they may still be shocked but react to it by throwing caution to the winds or drugging and boozing, or they may rationalise diagnosis as relief that they ‘don’t have to worry’ any more. Good qualitative research might unpack some of this.

    The solution would involve really good post-diagnosis education and sociopsychological support.

    2. The biographical explanation: What we’re actually seeing is HIV infection as a passive marker of a period of high risk sex and drug use that a lot of gay men go through once or several times in life, maybe associated with coming out or relationship breakup. Eventually for one reason or another they sober up or get steady relationships or something – a sort of behavioural regression to the mean. Meanwhile some have inevitably caught HIV. We could find this out with a longitudinal cohort study of initially HIV-negative men.

    In this case the solution would be nothing to do with HIV and everything to do with reducing social isolation, stigma and self-stigma in gay men.

  6. Comment by Drew, 15/04/10, 06:22:

    I expect this line of reasoning will be passed-over as a revenant of Freudian thinking; but as a Behaviour Analyst I see some cogency to it:
    MSM recently diagnosed may have a period of compulsive sex due to the “sex proves you are alive”-effect. It may not be any of these elegant suppositions but rather that old & robust: ” Dead people don’t have sex ” concept. Yes, this implies sticky bits like the unconcious mind hypothesis- but is there not a pro intuitive edge to it? A (virally induced) mid-life crisis where the sex act so central to the debate/research is merely a facet of a larger process of wrestling with mortality?

  7. Comment by Yani, 16/04/10, 06:28:

    I think there is some scope here for looking at concepts of Swarm Intelligence (SI). When messages aren’t working then either they aren’t being repeated enough or they have been made too soft to ‘spare people’s feelings’. AA don’t spare people’s feelings, quite the opposite. “Look at what you have done to the people you love!” Certainly here in Australia we need campaigns that really upset people with deliberate intent to reactivate SI. They need to cycle between disturbing and compassion most likely following the seasons. I say that as a negative person with many positive friends and way too many dead friends. HIV and suicide being the biggest killers. Hard messages but in the context that it is life that is to be encouraged.

  8. Comment by Tony, 29/04/10, 04:45:

    The number of times I have slipped up since becoming poz is very small. The reason it’s happened is that I’m human. I try and analyze the factors that came into play (was I drunk, where was I (venue, time of day/night, psychological headspace), was it someone I know well or not, did we talk much or not and about what) and do everything I can to prevent a recurrence.

    I know I’m just as fallible as anyone else, but call it stigma or whatever but the 60 seconds where I get carried away and BB someone before snapping out of it and putting on a rubber or switching to a different activity sure make me feel like I’m a horrible human being. Which feels like a barrier to me doing better in the future, but it doesn’t stop me from trying.

    And the name and email I posted above are a lie, because even though I have an undetectable VL and almost always consistently play very safe, those few short instances of making a mistake could put me in jail for a longtime and/or change my life irrevocably.

    Honestly, I don’t think any of these ads really make a difference, and I think the “Life with HIV sucks” ones in particular are useless and damaging.

  9. Comment by Haris, 30/05/10, 02:22:

    I just finished watching your TED talk, as well as reading your blog post. I am ecstatic that there is finally a multidimensional dialogue about prevention of HIV. Scare tactics, condom use, HIV testing buses simply do not work.

    Young gay men are already feeling too invincible, and defiant after coming out of closet, and in combination with drugs such as meth, condoms are the farthest thing on their mind.

    We have to design a system, where we can tap into this defiance and invincibility to use it as a prevention method.

    For my undergraduate thesis, i have designed a campaign for “safer sex” encouraging “bottom power” i would love to get any and all feedback on it. http://www.harissilic.com/hiv-prevention/

    Thank you in advance.

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