Bay Area gay and bisexual men hold a wide spectrum of views about condom-free sex and serosorting as an HIV prevention strategy, according to a well-attended community discussion last week.
The September 12 forum - the second in the San Francisco AIDS Foundation and Stop AIDS Project's Real Talk series - featured a panel of HIV-positive and HIV-negative men moderated by local personality Sister Roma. But the debate was well under way on Facebook in the days leading up to the event.
Introducing the panel to about 100 people at the LGBT Community Center, SFAF CEO Neil Giuliano recognized that sex without condoms and sex-related harm reduction can be uncomfortable, bringing up issues around stigma, rejection, ethics, and honesty.
"A condom is still the most effective tool to prevent HIV and other sexually transmitted infections, but the fact is sometimes condoms go unused and we need to discuss that reality," Giuliano told the Bay Area Reporter.
What happens in the real world?
An unscientific phone text poll conducted during the forum revealed that 97 percent of participants said they had "ever fucked without a condom," while only 3 percent had not. Another lopsided majority, 85 percent, answered "no" to the question, "Do you think condom use is the norm in San Francisco?"
In response to a question about how important it is to have sex with someone of the same HIV status, nearly 40 percent said it was unimportant or of little importance, about 50 percent said it was important, and 12 percent chose very important.
Getting down to specifics, panel members talked about their different risk-reduction approaches.
Douglas McLaughlin, a bartender and participant in Stop AIDS' Bridgeman group for men in their 30s and 40s, said that he tells prospective partners up front that he is HIV-positive, and if they don't want to deal with it he moves on to the next guy. The onus should not always be on positive people to negotiate safer sex, he said. "If you're HIV-negative, you have to take personal responsibility to say you want to use a condom."
Ramon Martinez, a clinical psychologist, is HIV-positive and in a "magnetic" relationship with a partner who remains negative after eight years. He always uses a condom, both with his partner and in outside relationships. "I personally hate condoms, but they're necessary in this day and age," he said.
Derek Brocklehurst, a nurse and study coordinator at Quest, is HIV-negative and sometimes has sex without condoms with negative and positive partners. He employs a variety of risk-reduction strategies including frequent HIV testing, in-depth pre-sex conversations about risk, and using Truvada for pre-exposure prophylaxis (PrEP) - a drug that just received U.S. Food and Drug Administration approval in July.
"My most important message is not to demonize people who choose to have condom-less sex, but to encourage other safer sex strategies," Brocklehurst told the B.A.R. "Meet them where they're at and listen to their needs and desires."
Looking at the big picture, SFAF development director Jen Hecht presented findings from a 2008 survey showing that about 40 percent of HIV-negative men and just over 50 percent of HIV-positive men in San Francisco said they practiced some form of "seroadaptive strategy," ranging from "pure serosorting" (only having sex with same-status partners) to "seropositioning" (negotiating top and bottom roles based on serostatus).
Is serosorting effective?
Two recent analyses found that serosorting was safer than unprotected sex without considering HIV status, reducing risk by 26 percent and 64 percent. Serosorting was less effective than condom use, however, raising transmission risk by 73 percent in one study and by three-fold in another. Furthermore, a study reported this year found that serosorting was less effective among black gay men, who have a high and rising rate of new infections.
The weakness of serosorting and other seroadaptive strategies is incomplete or incorrect information.
"Serosorting by HIV-positive men to protect others is totally different from serosorting by HIV-negative men thinking it will keep them safe," forum attendee Carl Barnes told the B.A.R. "HIV-positive serosorting works because if someone identifies as HIV-positive, it means they know they're HIV-positive, and if two HIV-positive men bareback, they can't spread HIV. But HIV-negative men who are sexually active cannot know they're HIV-negative."
The Centers for Disease Control and Prevention estimates that one in five people with HIV are not aware they are infected. Some have never been tested, but even people who get tested regularly may have been infected recently, before they produce enough antibodies to show up on a standard screening test. HIV viral load can be very high during this early stage and experts think a large proportion of new infections are transmitted by people with acute HIV.
An HIV RNA test can detect the virus within days, long before an antibody test is accurate (several weeks to a few months). Some people with acute HIV experience symptoms such as fever, fatigue, and headache, but this is often attributed to a routine illness like the flu.
Clinicians could offer HIV RNA tests when people at risk for HIV infections present with symptoms suggesting acute infection. But for this to make a difference, "we would need to get every person in the community to see a doctor and get RNA testing every time they get a sniffle," said Henry Raymond from the San Francisco Department of Public Health. "How would we fund this? It would be unsustainable."
In other cases, people may not reveal that they are HIV-positive due to fear of the consequences.
"For a practice like serosorting to be effective, we need to strive for a world in which disclosure of HIV-positive status does not come at a risk of violence and rejection," said Cyd Nova, harm reduction services coordinator at the St. James Infirmary. "We need to get to a place where those conversations are safe for people to have."
What about ART?
In 2008 the Swiss Federal Commission for HIV/AIDS stated that an HIV-positive person on antiretroviral therapy with completely suppressed viral load for at least six months and no other STIs "is not sexually infectious." More recently, the HPTN 052 trial showed that early antiretroviral treatment reduces the likelihood of HIV transmission within serodiscordant couples by 96 percent.
But these findings are based on data from heterosexual couples, and in HPTN 052 participants received a comprehensive prevention package in the setting of a clinical trial. Whether the same will hold true for gay men in the real world remains to be seen.
Several studies have found that men with fully suppressed blood viral load can still have HIV in their semen. Data presented last week at the Interscience Conference on Antimicrobial Agents and Chemotherapy showed that nearly 8 percent of gay/bisexual men on antiretroviral therapy with undetectable blood viral load intermittently shed HIV in their semen - more than twice as often as heterosexual men.
When making estimates about infection risk, "community viral load" can also be important. A study by Moupali Das from DPH found that 44 percent of HIV-positive people in San Francisco have suppressed virus. Nationwide, the CDC puts the proportion at 25 percent.
The effectiveness of antiretroviral therapy leads to the counterintuitive conclusion that an HIV-positive person on treatment may actually be less likely to transmit the virus than a random person who thinks he is HIV-negative.
"If you have multiple partners (or your partner has multiple partners) and you (or he) only has sex with people who believe they are negative, you are more likely to have sex with someone highly infectious than if you only have sex with people who you know are taking HIV medications regularly and have had undetectable viral load for at least six months," longtime community advocate Stephen LeBlanc told the B.A.R.
Nevertheless, the overall sentiment at the forum suggested that serosorting is likely to remain a popular prevention strategy.
"[Gay men] who are serosorting know they're doing harm reduction and that it's not completely safe," said Jackson Bowman. "People in the community are saying we're not going to use condoms every time. The current message endangers those men by not providing them with tools and information that they can use to reduce their risk."
Stop AIDS, which is a program of SFAF, is holding a follow-up discussion to provide additional opportunity to explore these issues. It will take place Wednesday, September 26 at 7 p.m. at 2128 15th Street. More information is available at http://www.stopaids.org/bridgemen.