Washington Blade - December 9, 2005

"No glove, no love" may be the mantra of many gay and bisexual men who refuse to have sex without condoms.

But this "Nancy Reagan" mentality to "Just Say No" to unprotected sex is unrealistic and should be tempered with increased education about less risky sexual activities, according to some HIV prevention educators.

Malik Williams, an African-American gay HIV educator at AID Atlanta, wants gay and bisexual men to know the risks associated with certain activities and employ that knowledge during sex.

"I think in reality, people don't like using condoms, and we don't talk about this a lot," Williams said. "Within that context, I want to help men make choices to keep them healthy - we support you where you are." Williams said, for example, that if someone has unprotected anal sex - which carries the highest risk of contracting HIV -five times a week and then chooses to replace one sexual encounter each week with oral sex, which carries a low risk of contracting HIV, he has greatly reduced the risk of contracting HIV once that week.

"And I think that's a success story," he said.

"We want people to make changes they are willing and able to take. If I say wear a condom all the time, they probably aren't going to do that. We are talking about what people are willing to do and to have all the information they can," Williams said.

On Dec. 1, World AIDS Day, Williams wrote on his blog brothalove.typepad.com that he's "worried that too many of us have swallowed the absolutism pill whole: use a condom every time in every sexual situation if you want don't want to die." "If it was that easy, though, the epidemic would be over," Williams wrote.

Instead, he said, gay men need to look at the overall picture of sexual identity and how that impacts behavior.

"Somewhere in there are answers to slowing and maybe even ending the spread of HIV in our communities. Anything short of that starts to sound like the Nancy Reagan approach to drug prevention," Williams said.

Fighting 'condom fatigue' Longtime gay activist and author Wayne Besen, however, believes condoms save lives and putting out any other message can be fatal.

"Promiscuity doesn't cause AIDS, being gay doesn't cause AIDS - not using condoms causes AIDS," Besen said.

"The most important thing we can do is to be very repetitive about this. It's not sexy, it's not pretty, it's not innovative - but it works," he said.

Complaints from some gay men of "condom fatigue" are a poor excuse for engaging in unprotected sex, Besen said.

While abstinence is the only way to avoid contracting HIV, and condom use is more than 90 percent effective in preventing its spread, researchers at the Centers for Disease Control & Prevention are discussing the risk associated with acute HIV, or HIV in the very early stages.

"Right after a person is infected, the virus is very high [in the blood] for about six weeks to two months. The risk of transmitting HIV during this time is about 12 times higher than if you've had the virus longer," said Bernard Branson, associate director for laboratory diagnostics in the HIV division at CDC.

As a general rule, Branson said, the CDC estimates the risk of acquiring HIV is about 20 times higher when a condom is not used.

Dr. Jeff Klausner, director of the San Francisco Public Health Department's STD Prevention Section, said studies in Africa show that while HIV is relatively difficult to transmit, epidemics can be propogated by people who are newly infected.

Rapid HIV tests and proposed over-the-counter HIV testing kits can help reduce the spread of HIV because once you know your partner's status, steps can be taken to either have sex with or without a condom, Branson said.

The possibility of infection declines with decreasing viral load, Klausner said.

The viral load test, introduced in 1996, measures the HIV in a given amount of blood.

Although the test measures the amount of HIV in the blood, more than 95 percent of the HIV is in the lymph system. But the total amount of HIV in the body is accurately represented by the amount of HIV in the blood, according to "The Guide to Living With HIV Infection" by Dr. John G. Bartlett and Ann K. Finkbeiner, posted on website thebody.org.

A person with a high viral load, such as 100,000 or 1 million, is more likely to transmit HIV than a person with a low viral load, like 1,000 or 10,000.

Low viral load = low risk While a person may have recently tested as having an undetected viral load, there are still "blips" that can occur in which the viral load is higher and transmission of HIV is more likely, so determining a specific numerical risk is difficult, Branson said.

"Theoretically there is lower risk with a low viral load, but it is not a guarantee," he said.

As a person taking HIV medications becomes more resistant to the drugs, the viral loads increase. An undetectable viral load also does not translate to an absence of HIV in the semen, although this doesn't occur very often, Klausner said.

The more complicated question comes for HIV-positive people on drug cocktails.

There is currently no specific data on what the risks are in having sex with an HIV partner who is on the cocktail, though most researchers believe the risk is decreased, Klausner said.

There is no scientific data on how bleeding gums might impact the risk of HIV transmission, Klausner and Branson said. Crystal meth could increase the risk of HIV since it may lead to high-risk behavior and it also weakens the immune system, Klausner said.

Assigning risks Public health messages need to emphasize the main risk of contracting HIV is from unprotected receptive anal sex among gay and bisexual men, Klausner said.

"If men who had sex with men only had unprotected oral sex, but protected anal sex, there'd be no HIV epidemic in men who have sex with men," Klausner said.

A significant harm reduction measure that can be taken even during unprotected anal sex is to limit exposure to semen, Klausner said.

"Get regular STD check-ups, try to find a partner of the same HIV serostatus but recognize that many negative persons don't know their true infection status," he said.

"Like it or not, condoms remain one of the most effective ways that sexually active people can protect themselves. While the style of the message may need to be updated for the 21st Century, the bottom line remains the same - condoms save lives," Klausner said.

A 2002 CDC study reported an interesting set of data, Branson said.

"Having sex with a person who has recently tested negatively for HIV is safer than using a condom with a partner whose status you do not know," he said.

Consistent condom use versus finding out your partner's status is another alternative to HIV prevention education, Branson said.

Assigning numbers to certain sexual activities is not a foolproof method for protection, according to Noel Alicea, spokesperson for the Gay Men's Health Crisis in New York.

"We know, for example, that certain activities pose a greater risk than others, but they are not a clear determinant for transmission. Receptive anal sex is much riskier than insertive oral sex, but it's hard to assign a specific number or percentage of risk. Viral load makes this all the more complicated," he said.