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.
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?
First, there was what the researchers call strategic positioning. This means that if an HIV positive person has sex without condoms with a partner who is negative, or who is not sure what he is, that only the HIV positive partner is the receptive partner in anal intercourse. This is because the receptive partner is up to ten times more likely to get HIV from an infected insertive partner than the other way around.
Second, there was negotiated safety - this means that HIV negative men have one steady partner with whom they practice unsafe sex, while they promise each other that when having sex with others, they will always be safe - if an 'accident' happens, they must tell their steady partner.
In the Sydney study, both these strategies reduced HIV infection risk to a similar degree as consistent condom use.
A third strategy is called sero-sorting. This means that HIV negative men only have (condom-less) sex with HIV negative men, and HIV positive men only with HIV positive men. This led to an intermediate risk of HIV infection - higher than when consistently using condoms or when employing one of the two above mentioned strategies, but lower than having unprotected sex indiscriminately, without exchanging information about one's presumed serostatus.
Sero-sorting is usually not recommended, as some HIV negative men may in fact be positive, but the virus may have entered their body so recently that it does not show up in HIV tests yet. The period where a person is infected already but the virus can not yet be detected is called the 'window period'. It is also possible that a presumably HIV negative person had his last test quite a while (and quite a few partners) ago - he may in fact have become infected already, but is still relying on his last (negative) test result.
Even so, sero-sorting also reduced the chance of transmission in the study; it was simply better than having unprotected sex with partners of whom the serostatus was not known or discussed, but not as good as the other two strategies or as consistent condom use.
A fourth strategy - withdrawal from the rectum before ejaculation - was found not effective.
What do these findings mean? This study was done in Australia - we do not know if Asians also use these strategies, and whether they use them as successfully. For one thing, Asian men have far fewer HIV tests than the men in the Australian study, making these strategies - which depend on knowing your HIV status - difficult to use.
What I think is an important lesson from this study is that gay men who do not use condoms are not necessarily irrational - there is a certain intelligent design in the way they take risks. And this study has now shown that three of these designs do indeed decrease the risk of HIV transmission.
I believe that in our work to help prevent HIV infections we should give men OPTIONS. We can start by making HIV prevention less 'simple' than we have hitherto done. It is not just a matter of 'using condoms' or 'not using condoms' - a choice between 'life' or 'death'. We should instead conceptualise our sexual behaviour as a 'ladder of risks'; at the bottom of the ladder is 'No sex / solo sex', and at the top is 'having unprotected receptive anal intercourse without condom with a person of whom you know he is HIV positive'. But in between these extremes there are numerous nuances and shades of risk - men should be made aware of these, so that if they can not totally eradicate their risk of infection (by consistently using condoms and lubricants) they can at least reduce their risk to a certain degree.
We, the 'HIV prevention mafia', should therefore not talk only about condoms, but also about other ways in which men can reduce risk of transmission while having sex.
Simplifying the HIV prevention too much may actually cost lives, as men who fail (for whatever reason) to use condoms may become fatalistic, desperate and more reckless in their sexual behaviours.
Men who have sex with men have the right to know about all HIV prevention strategies at their disposal - not only those that follow from the 'ABC' formula of Abstinence, Be Faithful and Condoms, which has been promoted in African and Asian countries, aimed mainly at the heterosexual population.
Gay men need to develop their own set of options. Since abstinence and being faithful seem to be viable strategies for only few gay men, 'CNSS' could be the answer (Condoms, Negotiated safety, Strategic positioning, Serosorting and Condoms). This might be a good start - but there may be more strategies out there, like reducing anal sex in favor of mutual masturbation and oral sex, or (rather than abstinence, using webcams and phones for (very safe!) cyber/phone sex.
Let me know what strategies you use to reduce your risk of getting or passing on HIV!
Jan is the moderator of MSM-Asia, an information network on men who have sex with men, HIV and human rights, with nearly 600 members from across the region. If you want to become a member of MSM-Asia, or for information requests or comments, pls contact him at jwdlvw@gmail.com.
April 30, 2009
Postscript from the writer
In view of the myriad of thoughts and discussions that has surfaced after the publication of this article, the writer hopes to clarify a few points to address the concerns and worries that he may appear to be advocating against using condoms as a prevention strategy.
1. Condoms, properly used and in combination with water-based
lubricants, are still the best prevention strategy we know. The additional advantage is that they also prevent other sexually transmitted diseases, as someone noted in the comments.
2. However, it is a fact that condom use remains low among particular
groups of MSM, despite a decade of efforts to persuade them to use
condoms consistently. The article does NOT say that this is a
good thing. But it tries to highlight that even if you do not use condoms,
you can reduce your risk for HIV by adhering to certain strategies.
In other words, it is meant as an ADDITION to condoms as a prevention strategy, not as a REPLACEMENT.
3. Very importantly, it should be noted that the three non-condom
related risk reduction strategies mentioned in the article all require
regular testing for HIV. This is missing in many Asian countries,
making these strategies less viable (for now) and less suitable to be
adopted by Fridae readers.
Note from Fridae editors
We continue to take the position that 100% condom use is still the most effective prevention strategy. But just like condom use is to abstinence, so are these risk reduction strategies to condom use.
As ongoing clinical research sheds more light on this topic, we decided to open up the dialogue on other risk reduction strategies, especially as we have observed that there are still some who persist in not using condoms.
In doing so, we are seeking to acknowledge the realities of the behavioural patterns in the MSM community, and to respond with a shift from a one-message-fits-all approach to one that is more nuanced and addresses different target groups within MSM.
This topic is only going to get more complex as the clinical evidence for PrEP, rectal microbicides, etc, as viable prevention strategies become available.
It is heartening to see our readers' interest in these developments and thank everyone for participating in this discussion.