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.
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Despite the marketing hype, there is yet to be made a condom that allows the same sexual pleasure as bareback sex. Until they do, all the condom-mafia (I love that name) are doing is telling thousands who practice bare-back that they are bad people thus alienating the very ones they seek to help. Jan's approach of a "ladder of risks' and discussing options is surely the best way forward on this issue.
Well done Jan!
While these may reduce the risk of HIV transmission, what about the risk of other less fatal STD's like hepatitis B, VD's and such? It takes regular testing to keep all your health status updated, which is not commonly done in Asia. So I would still protect myself even if I knew my partner is HIV negative because I wouldn't know if he has other diseases. What's your opinion on this?
Also condomless sex amongst men at any rate is not in the least advisable...for obvious reasons of contracting other STD's because of the nature of the intercourse besides HIV
An estimated 40% of people who get HIV get it from someone who has recently contracted HIV and who would test *negative* on a standard HIV test. Why? Because during the first 3 months after infection, the virus is completely out of control - with 10x as many copies of the virus as after the 3 months (when the body produces antibodies to start fighting back).
If you have sex with someone in this stage, he will
A. legitimately believe he's clean (so "sero-sorting" won't help)
B. be so crawling with hiv that even he pulls out or you top him, the risk of infection is incredibly high
For those who think topping bareback is fairly safe, guess what bodily fluid contains the highest concentration of the virus? Blood? Semen? Nope. Anal mucous. Think about that as you slide unprotected up his ass. Would you stick your cock in a pool of HIV-infected blood?
Just because we are clearly having difficulty convincing boys to suit up, doesn't mean we should give up on the ONLY working method we have of preventing the spread of HIV! It means we need to find the root causes of why they are not using them and attack that. False beliefs about alternative methods is one of those.
Wanna know why HIV rates among MSM in Bangkok went from 16% to 30% in just 3 years? Because they took the condom dispensers out of the saunas (for complex political reasons). That was all it took. Lobbying to get rid of terrible laws like that could save tens of thousands of lives in one city alone. HIV awareness messaging through all gay channels (like fridae normally does) is another method. This article pushes HIV-spreading myths and should be removed from this site.
However, I think that you failed to mention an important part of sero-sorting that needs to be acknowledged for the sake of protecting those already infected with HIV. Sure, finding out that your partner is HIV-negative and engaging in somewhat risky behaviour may lower the risk of contracting HIV, but does it work the same way for two HIV positive individuals to engage in such acts? Don't they run the risk of contracting another strain of HIV?
I think it's great that you are providing MSM with risk-assessed options, but I also think you need to take all people involved in these acts into account and provide further details so as not to exclude them from the article!
Great job, otherwise, and I look forward to reading more from you :-)
It is important to acknowledge the reality of sex and the need and desires of all humans to be intimately connected.
I recall a paper on Barebacking written by a VICAIDS researcher in Australia, Bruce Parnell, titled "Because it's warm, it's moist and it's intensely human". The paper was written in 1993 and the truths it holds are only just now begining to be acknowledged; the "Safe Sex Mafia" have a lot to answer for.
It is my life you're talking about. Shades of risk, I pass.
33longchamp
I think that says it all.
I understand the rationale behind the approach, but anyone who's had to see a friend waste away and die from this dreadful disease is more likely to ensure they always use a condom I guess. Much simpler approach, too.
This sentence, in particular, is unfortunate:
"These strategies are not as effective and not as safe as always using condoms, but nevertheless, they were protective."
You are correct. However, I think you have vastly underestimated the number of people whose minds will emphasise, "nevertheless, they were protective" over "these strategies are not as effective". And what a choice of words: protective. That word has quite a positive connotation. Actually you mean the "risk" of contracting HIV was lower. The methods you mention are not in any way "protective".
Combined with the fact that you note (correctly) that HIV is not the easiest virus to contract, and we have an article that really doesn't give much incentive to use condoms. We'll just practice your simple methods and we'll have "significant" protection.
I am not questioning any of the "facts" you quote, but I am questioning your approach in dealing with this topic. This is not something that I would expect from a serious sexual health expert.
Believe it or not, there are many people out there who are looking for ways to avoid using condoms. You have unwittingly provided some.
As for the rest of you who think that this is an adult treatment of an issue, you should also be ashamed. An adult treatment of this issue would have forcefully stated from the start that 1) This article cites only ONE study, and as such cannot be conclusive; 2) Even if more than one study were cited, that there is NO substitute for condom use (besides abstinence, although we know that nobody will practice that).
Second, the published strategies might not have considered the Asian contexts. There are still communities with poor knowledge of HIV. And I've encountered gay men who know nuts about HIV and people who get confused by tonnes of information published on the Internet.
The above statement "these strategies are not as effective and not as safe as always using condoms, but nevertheless, they are protective" can be confusing. What can readers interpret from a comparison of "effective and safe" vs. "protective"? Aren't condoms protective? Perhaps we can all write with greater clarity.
For eg:
"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."
I had to read these 2 long sentences about 3 times before I understood what it actually meant.
Then I gave up reading the rest of the article. I'm sure I'm not the only one.
Personally I think that's even more dangerous, especially since the rest of the article probably has some important messages. But unfortunately the writer has lost me as his reader, due partly to the content, partly to writing style.
Perhaps some work needs to be done by the editor & proof-readers?
Or perhaps future articles could be written in briefer form, with key sub-headings & shorter sentences & paragraphs, or even bullet points?
Easier that way for readers to take in the key messages.
It is unbelievable that after more than 20 years that the virus appeared, cases are multiplying. Above all in so called 'well developed' countries (ie: United Kingdon). It is a joke. And this is partially cause we take things lightly and some people don't give a shit about the other.
Xavier
To even SUGGESU, however inadvertanTly, that the "alternative" methods can help reduce the risk, compared with using condoms is UTTERLY irresponsible.
I wonder how many new infections will be caused by the misreading of this ill thought out and badly-written heading????
The position is 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.
In light that there are some who PERSIST in not using condoms, we firmly believe there needs to be a dialog on other risk reduction strategies. Given that there is now clinical research on this topic, we decided to open up the dialog. I know it is a can of worms, but it is not baseless or misleading. If we are to respond to what is happening out in the community, and acknowledge the realities of the behavioral patterns, then we need to 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 come online. I don't think keeping the message simple is going to be so straightforward.
These ARE the realities of MSM sexual behavior, and we need to be able to address them head on.
Also, the writer states that:
"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."
I think that this claim is unjustifiable. Condoms are readily available and reasonably priced in most countries. Why do people "fail to use" them? By saying that people "fail to use" condoms is a very convenient strategy to justify this entire article, but shouldn't we be more concerned with addressing the individual reasons for "failure"? In transactional sex or prostitution, shouldn't awareness be the priority? In HIV+ people, we should be working to change their mindset. I am not saying the writer is giving up on condom usage, but the priority of his "alternatives" or "solutions" to the "failure" of using condoms should be rethinked.
I think wording is crucial for such a controversial stand. For e.g. the writer mentioned "These strategies are not as effective and not as safe as always using condoms, but nevertheless, they are protective."
I suggest rewriting this sentence as:
"These strategies are protective, but will never be as effective or as safe as using condoms. "
By a different choice of words and syntax, a clearer and more positive message has been sent across.
I think merit has to be given to this article, though, for its pragmatism and realistic perspective. A two-pronged approach of idealism and realism , if well-balanced, can definitely be more effective than one employed singly.
"To late to apologise", although you do not and you should for the pitiful way the whole affair was handled from the start.
It is the responsibility of a writer to foresee the impact of his writings on young people -the majority of Fridae's users- and, equally that of Fridae's editors to
the possible Pandora's box it may open by publishing any articles; both are at fault in this instance.
hopefully, a lesson has been learned.
33longchamp
People responsible for this webpage, find a responsible author for this topic. Otherwise you will along with Jan W. partly be to blame for the explosion of infection rates we will see. I wrote to about 20 of these young guys asking them why they take this risk, not one of them answered...
I hope they follow very strictly your new miracle doctor's advice and always ask the guys "that use them as they please" if they are really, really, seriously, no bullshit, honestly HIV negative. Sorry, Jan, your postscript does not cut it. Take that article down!
Condoms block a broad range of STDs, not just HIV. All STDs wear down the immune system.
A call for complexity instead of simplicity? Outrageous. Three simple rules will effectively reduce your risk:
1. wear a condom for any penetrative sex.
2. use only water-based lube with condoms
3. ejaculate outside the body, even when using a condom
To top your sex partners without a condom is selfish and stupid.
Although with good intentions (it still promotes the use of condoms), it just is absolutely misleading because it is badly written.
We cannot assume that the general public fully understand the danger of practicing such alternatives.
How widespread is the phenomenon?... of the strategy of "Let's get tested TOGETHER BEFORE we have sex, for A vARIETY of STDs."
What evidence is there of any failure of the strategy?... of "Let's get tested 2GETHER B4 we have sex, for A VARIETY of STDs."
http://NotB4WeKnow.blogspot.com
As the response below shows, there are some men who find consistent condom use reasonable and doable, and they simply don't understand why everyone else can't be like them. On the other hand, there are just some men who have higher appetites for risk and pleasure, and they don't necessarily mind the possibility that a chance encounter might change their lives forever; and it's in that small subgroup where serosorting, strategic positioning and viral load counting really make a difference -- because they have a lot of risk to reduce.
But there's a group in the middle who use condoms mainly because everyone else does, and their motivation for condom use isn't all that strong; what they really want is not to have to think about HIV at all. For those guys, validating serosorting as harm reduction simply gives scientific approval to their general prejudice against positive men, and if it weakens their condom usage, it's not harm reduction at all. They don't need to hear about harm reduction: they need to learn about newly-infected "HIV-negative" men whose viral load is sky high. All of these strategies depend on gay men having pretty accurate knowledge of their serostatus and, as Jan points out, in Asia they generally don't yet.
PS. Don't waste any time/energy debating TheZak, he does this on every site that discusses harm reduction strategies.
I was also disappointed that the writer failed, unlike some of the posts here, to mention why certain countries may have higher percentages of infected MSMs and how this could be remedied.
I agree with idasein (post #6) and chinchy (post #12) when stating:
(idasein) 'Wanna know why HIV rates among MSM in Bangkok went from 16% to 30% in just 3 years? Because they took the condom dispensers out of the saunas (for complex political reasons). That was all it took. Lobbying to get rid of terrible laws like that could save tens of thousands of lives in one city alone. HIV awareness messaging through all gay channels (like fridae normally does) is another method'
(chinchy) 'the published strategies might not have considered the Asian contexts. There are still communities with poor knowledge of HIV. And I've encountered gay men who know nuts about HIV and people who get confused by tonnes of information published on the Internet.'
However, I do believe the article did spark needed discussion on the topic of why and how some MSM have unprotected anal sex without getting too judgmental to hopefully come to some understandings and ways of protecting ourselves and our fellow MSMs as much as we can without 'dulling' our enjoyment of sex. Telling people what to do 'no ifs, ands or buts' doesn't usually get even the most well-intended messages across.
Since you mentioned oral sex in the last part of your article, can you please write next about how safe/ how risky oral sex is in catching HIV based on the latest studies?
Cheers.
I think the problem rests with the title of the article - a better choice than "alternatives" might be for example, "Supplemental strategies to help prevent HIV infection".
The article is helpful because it actually gives some fresh valuable information and an assessment of HIV in Asia. It's also important because it offers a range of behaviors for men when condoms are unavailable, or God forbid, if they should fail.
I think there is too much emphasis on fucking in gay culture. It seems just so, well, heterosexual. Top and bottom is all so man/woman str8 to me... A lot of Asian men AREN'T into fucking and often do it just to please their partners. (Of course there are many who are really into being a bottom).
I'm not saying, be like me, and give up something you (well I, in my case) never really liked completely.
What I'm saying is that if you don't know your partner's status well; one of the MOST effective strategies - other than ALWAYS using a condom PROPERLY for anal sex - is to have another kind of low risk sex, which even unprotected like oral, is far less risk.
Also, I remember 20 years ago when we all assumed that any of our partners could be infected at any time - and that drug treatments weren't not great or very toxic (still toxic actually). Why isn't that happening now? Especially in the fast lane lifestyle of casual bathhouse sex.
In the early 90's HIV rates were starting to decline and level off in North America because of this assumption - even among steady partners.
It's kind of a weird effect of longer term coupledom and improved HIV treatment that people now don't assume the risk in such a real sense. [yet heterosexuals - as relationships increasingly break down or change these days - are increasing their awareness of HIV] I think we should get back to that assumption in the gay community.
Anybody can be infected at any time, with all kinds of stuff other than HIV. Even you. From last weekend. Use protection, learn to play in other safer ways than anal and ENJOY it. Have regular STD tests as well. If you can't face the "big one" yet, at least do the other STIs and get them treated if you have them. Your immune system will thank you :) And ultimately, try to get yourself tested for HIV at some point - and right away if you have had an exposure. The meds are less toxic and regimens easier to take if you catch the HIV earlier rather than after symptoms or AIDS appears. [Some people can go straight from no symptoms to full blown AIDS in as little as 2 years; others can go 20 years with nothing - you never know with HIV unless your immune system is being monitored].
Your article did not mention this but, the presence of an STI greatly increases HIV transmission and/or reinfection, also immune suppression. Safer sex, condom use reduce many STIs like herpes and often syphilis (but not always). Regular testing and treatment (if needed) of non-HIV STIs is a great strategy to reduce HIV transmission.
Finally, I think fucking without a condom is just plain dangerous and there is no real risk reduction. Barebacking with a positive or unknown person is pretty much like the "withdrawal method" for avoiding pregnancy - A method to eventually get yourself in trouble.
In my view ,condom manufacture should be looked into , to increase their sencitivity and ease of opening the packet .
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