The Bay Area Reporter - August 24, 2000
Terry Beswick

And still other men, notes the DPH/UCSF publication, have only recently started to have sex that runs a higher risk of transmitting HIV to themselves or their partner.

"This group makes situational decisions about risk behavior," says the document [see http://hivinsite.ucsf.edu/ari/HIVEstimatesReport8900.pdf]. "These decisions are based on their knowledge and understanding of HIV transmission, the perceived risk of the behavior in question, and the stated or presumed HIV status of their partner."

Included in the report is a new "11-point action plan," which the authors describe as an "opening salvo" to begin a dialogue on a new approach to HIV prevention in San Francisco.

But rather than attacking the whole concept of gay men practicing anal intercourse without condoms (barebacking), the plan takes a new approach of "harm reduction," in effect abandoning the philosophy that has driven HIV prevention efforts from the beginning of the epidemic: the old, well-worn "use a condom every time."

Citing "basic learning theory," Steven Tierney, director of HIV prevention at DPH, explained earlier this month to the city's HIV Prevention Planning Council, "If people hear 'use a condom every time,' and then they don't do that à they will begin to tune that out."

"It's a whole combination of stuff: whether it feels better, or there's a greater sense of connectedness, whether it's your boyfriend or trick number eight at the bathhouse," said Michael Scarce, explaining why more gay men are turning back to barebacking in the 20th year of the HIV epidemic in San Francisco.

Scarce, a doctoral student in medical sociology at the UCSF, and author of the recent Smearing the Queer: Medical Bias in the Health Care of Gay Men, wrote a widely disseminated and highly controversial article about barebacking published in POZ magazine in February 1999. Accompanying the article was a sidebar called "Safer Barebacking Considerations," a list of eight ways gay men who had decided to bareback could reduce their risk of infection with HIV or other STDs [www.thebody.com/poz/features/2_99/bareback.html].

"Folks went ballistic when they saw that because it represents all the questions that they get on a daily basis, and that we continue to dance around," Scarce told the Bay Area Reporter, explaining that prevention organizations around the country had not come to terms with the idea of barebacking in the gay community -- much less using "harm reduction" techniques to help people to do it more safely.

"In the past, most folks in public health have thought of harm reduction as a method of reducing risk," Scarce said. "Harm reduction is thought of more broadly in Europe, which has been so much more progressive, not just with needle exchange, but in doing away with harmful laws that stigmatize [needle users]."

Less enticing?

Could removing the taboo stigma from barebacking also make it less enticing?

In the context of HIV prevention, Scarce noted, harm reduction embodies "a willingness to trade a potential increase in unsafe behavior for a potential decrease in harm associated with it," a definition still resisted by publicly funded prevention groups.

"They're still responsible for serving the entire community," Scarce stated, however, "and that includes barebackers."

From the beginning of the HIV epidemic, gay and bisexual men, who comprise the vast majority of HIV cases in San Francisco, have often been forced to make life-and-death decisions based on intuition and limited data from medical research.

Some of the techniques and suggestions listed below, which offer some ideas on harm reduction for barebackers, are culled from numerous interviews with men who bareback, as well as with researchers and front-line prevention workers.

As Scarce put it in a preface to his POZ piece last year, "This is not a set of HIV prevention guidelines. Intended only for gay men who have already decided not to use condoms for anal sex, some advocates believe these strategies may help reduce the harm associated with barebacking. Here, harm should be interpreted more broadly than HIV infection; these tips may also help reduce the risk of other STDs. And bear in mind that much of this info is anecdotal and debated by researchers."

* Know what you will do. Everything in life is a trade-off, right? Everyone is balancing potential risk with known pleasure, whether you are into hang-gliding, cigarette smoking, walking in San Francisco, or barebacking. Learn what you can about the risks associated with different sexual practices, and decide how important each act is to your sexual fulfillment. Decide in advance what sexual acts you will participate in. Write them down.

* Know what you will not do. Even the biggest barebacking fans in your neighborhood who say sex is not sex without anal-penile intercourse (i.e. fucking) and that they will never use a condom will actually, when pressed, admit that there have been times when they have drawn the line. "If you're negative, stay negative," offered HIV-positive barebacker Niq Shelbi, a local titleholder in the leather community.

* Decide what precautions you will take. If barebacking made it onto your "must do" list of sexual pleasures, then think about ways you can reduce your risk of infection or re-infection with HIV, as well as other sexually transmitted diseases. Decide what precautions you will take all the time, and which you will take under certain circumstances. Write them down on a list. Add them to your AOL profile.

* Be consistent. Generally speaking, sex partners will be respectful of decisions you have made, although men are notoriously incapable of controlling their urge to persuade their partner (and themselves) into going further than they would choose in a less heated moment. But whatever you do, make it a conscious decision. "Consistency is a very good thing," said Keith Folger, director of the Positive Force program with the Stop AIDS Project. "If I develop a point of view, until the evidence changes, I should stick to it."

* Negotiate safety. Being firm is cool, but if the point is negotiable, being flexible is also considered an asset. "The moment" is not necessarily the best time to review your list of sexual favorites for possible cuts and revisions based on even the most intoxicating of seductive cues, but if he's got something on his list that is a "maybe" on yours, then find a cooler moment to have a little offline chat. Ask him the key questions that will help you decide whether he qualifies to pass "Go."

* Know your HIV serostatus. If you don't have a pretty good idea of what your own HIV status is -- positive or negative -- then you're on your own. And so are all your partners, as you aren't leaving them much room to fairly negotiate anything. But if you've already decided to bareback -- either once in a while or every time, especially if you are versatile or a top -- when your bottoms ask for your status, it's nice to be able to answer with your best manly, confident voice.

* Take the test regularly. "While most gay men in San Francisco have been tested, the test may have been taken two or three years ago," noted DPH's Tierney. Generally speaking, even if you got your negative test results yesterday, the results don't mean a heck of a lot if you've been passing your weekends lately getting ploughed bareback by a dozen guys of unknown status. If you may have been infected with HIV during the "window" period of the last six months, you may not yet test positive for the antibodies, even though you are infectious. In fact, you may be highly infectious during the "peak" post-infection period of viral replication -- more so than someone who has been infected for years. Some guys take the test every six months to a year. If you're big on barebacking, consider taking the test even more frequently, perhaps every three to six months.

* Beware the false security factor. Some research has suggested that people who take the HIV antibody test frequently may be more likely to engage in barebacking, and therefore more likely to be infected. Some guys who have tested negative repeatedly say they figure they must be "immune" to HIV, though most likely they are somehow mitigating their risk, or simply beating the odds. It's just a blood test, not a vaccine. And for HIV-negative guys: don't bother with the expensive "viral load" tests to give you extra assurance that you're not infected with HIV. Lots of positive guys test below detectable levels on viral load tests, but they're still positive on the antibody test, and still harbor HIV in their organs and tissue.

* Ask for his status. This is not Bill Clinton's military, it's San Francisco in the year 2000. Current estimates are that about one in five men in the city are gay or bisexual (happy news), and an increasing number of them, perhaps 30 percent, are HIV-positive (partially happy news: HIV-positive guys are not dying at the rates they used to). While it's true that, if you're into group scenes, it may not be cool to stand on a chair and take a poll, it is still almost always socially acceptable -- especially if they're thinking of topping you bareback -- to ask mano-a-mano, "So, I'm negative, how about you?" Most positive guys would much rather that you ask beforehand, rather than watch you throw a self-righteous little fit afterwards. And if there's some quasi-militaristic "don't ask" house rule announced, then you've no choice but to assume: they're all positive, and are just not in a chatty mood. Steven Gibson, program director at the Stop AIDS Project, described the classic false "assumption" scenario: Two guys are on the verge of anal intercourse, with the top being HIV-positive and the bottom being HIV-negative. Neither asks for the other's status, nor volunteers his own status. "The negative guy thinks the top must be negative, too, or he'd put on a condom," said Gibson. "And because the bottom doesn't get out a condom, the positive top figures the bottom must be positive."

* Ask how recently he took the test. Your chances may be significantly improved if your prospective partner states that he has recently tested negative for the virus that can cause AIDS.

* Face it: some guys lie. This may come as a shock to uninitiated readers, but gay men lie, too. And what's more, there have been several well documented cases of positive guys flat-out lying about their status. It happens -- and perhaps with greater frequency than scientists will ever be able to measure (they lie to the surveyors, too). But why do they lie, other than to satisfy their carnal desires? For one thing, it's fairly well understood that the recent, renewed interest in "natural," skin-on-skin barebacking among HIV-negative guys is largely attributable to a sense that HIV infection is no longer a fatal illness. ("People who become infected now," DPH Health Director Dr. Mitch Katz stated at a recent press conference, "can now expect to live a normal life span.") Therefore, HIV-positive tops may not think it's as big a deal to bareback with HIV-negative guys as it used to be. Others may rationalize, if their viral load is very low, that somehow this gives them the right to decide the unknowing bottom's acceptable level of risk on their behalf. But, whatever the complex reasoning behind it, as Survive AIDS recently noted, "Living with HIV and AIDS is not glamorous, it's more about toxicities and diarrhea."

Again, this is not Clinton's military. If you are asked, then either tell, or take a pass on barebacking with your inquiring partner. The "harm reduction" model is predicated on honesty, and falls apart if guys are going to be lying about their HIV status as casually as many guys tell "fish stories" in their AOL profiles. (Note: people who knowingly put their partners at substantial risk of infection may be subject to criminal as well as civil penalties).

* Your partner is not responsible for you. The vast majority of HIV-positive men don't lie, if asked for their status by someone who has a reasonable right to know. However, a word to the wise: like it or not, many HIV-positive guys hold that their responsibility is limited to their own health. Period. "The only responsibility I have is to myself. And I'll do what I'm morally comfortable with. I'm not responsible for your health. You're responsible for your health. I'm responsible for my health," said "Mr. X" in the May 2000 Positive Living newsletter from AIDS Project Los Angeles [www.thebody.com/apla/may00/barebacker.html]. "If we did an across-the-board rule that nobody with HIV is going to use a condom, then we'd all be operating on the same assumption, and you'd see rates drop because people would learn that they could protect themselves, that it's not the responsibility of the person who is positive to protect the person who is negative. It's the responsibility of the person that's negative to protect himself."

* Get tested for STDs frequently. If you're going to bareback, it is critical that you check yourself frequently for other sexually transmitted diseases. There are more diseases out there besides HIV. While it is true that some sexually transmitted diseases can be treated with a quick course of antibiotics, sometimes people can be infected with syphilis, gonorrhea, chlamydia, and others, without displaying symptoms for years, and can unknowingly pass these on to others. Moreover, infection with another STD can leave your body vulnerable to infection with HIV. In San Francisco, free STD screenings are available at City Clinic. Call (415) 487-5500.

* Ask if he is STD-free. Ask your partner whether he has tested for STDs recently, and visually inspect your partner for signs of sexually transmitted diseases, including discharge from the penis, or sores, warts, bumps, or blisters on or near the genitals, rectum, or mouth.

* Get regular Pap smears. Some doctors recommend this simple test for exposure to human papilloma virus (HPV) every six months for HIV-positive men. HPV infection, which causes anal or genital warts, is very common, and has been associated with rising rates of anal cancer in gay men. Early detection is critical to effective treatment. "If you're going to be fucking bare, you're going to have a few kinds of HPV," noted Scarce, "so you're going to be at increased risk of anal cancer."

* Get vaccinated. Barebacking can expose you to hepatitis. Vaccines against hepatitis A and B are available in San Francisco at City Clinic.

* Have fun, but not too much fun. This one's a no-brainer, but nevertheless easy to overlook, especially when you're popular: limiting the number of partners will reduce the odds of infection or re-infection with HIV or other STDs. Scarce also noted that "rationing" the frequency of partners "allows time for healing of tears or trauma in the rectum, urethra and outer skin of the penis" -- potential points of entry for HIV into the bloodstream. Last year, a UCSF/DPH study [American Journal of Epidemiology, August 1999] of over 2,000 gay men in the early 1990s found that the average risk of being infected from any one episode of unprotected receptive anal sex with a known HIV-positive partner was roughly one in 120, compared to one in 370 if the barebacking top was of unknown status. Average risk of infection from one episode of receptive anal sex with a condom with known HIV-positive partner: one in 1,000, according to the report.

* If you're HIV-negative (and versatile), think "top." Ask around, and you will see that the mythology in gay San Francisco -- as in most other major cities -- is that there are more bottoms than tops. The truth is that most guys are probably versatile -- able and willing to assume either the insertive top or receptive bottom position -- to one degree or another. To the degree that it is practical, being on top may reduce your chances of being infected, all other factors being equal, and some negative guys who are versatile bareback only as tops, or restrict their bareback bottoming to guys they know who are also HIV-negative. One DPH/UCSF study found that being the insertive unprotected partner in anal sex may be five times less risky than being the receptive unprotected partner when the partner's status is not known. Moreover, the DPH's new emphasis on "condoms for HIV-positive tops with HIV-negative bottoms," and conversely, "condoms for HIV-negative bottoms with HIV-positive tops" clearly de-emphasizes condoms for HIV-negative tops with bottoms of any status. DPH's Katz recently asserted that if we could stop all HIV-positive tops and HIV-negative bottoms from having unprotected anal intercourse, "95 percent of the epidemic would go away."

* If you're HIV-positive, consider HAART, or highly active antiretroviral therapy, that has not only dramatically cut into the death rate from AIDS nationwide, but has probably cut into the infection rate at the same time by reducing levels of virus in semen. "If we could get every HIV-positive man into treatment, we could reduce infections by driving down viral load," asserted Katz at the recent City Hall unveiling of his action plan.

* Ask what his viral load count is. If you're going to bareback with an HIV-positive guy, ask if he knows his viral load count. Is it below detectable levels or is it in the hundreds of thousands? If it is very low, this will not eliminate your risk of infection or re-infection, and you should not interpret this as a green light to toss caution to the wind, but it may reduce the likelihood of infection.

* Ask if he has tested for treatment-resistant strains. The dangers of barebacking between guys that are HIV-positive are more than theoretical. First, there is the danger of infections with diseases other than HIV. Second, there is anecdotal evidence to suggest that infection with a "super virus" -- a strain of HIV that has become resistant to currently available therapies -- could render these therapies useless for the newly infected partner.

* To douche or not to douche? Within the barebacking subculture, douching is considered de rigueur for anyone thinking about getting topped, especially if they're going to a barebacking party. In his 1999 POZ article, Scarce wrote, "Douching or using enemas with harsh detergents can strip away protective cells in the rectum. If you use an enema before sex, try warm water. Be careful not to create tears inside or around the anus. Some believe lubes, especially oil- and silicon-based, can trap germs against the skin, increasing likelihood of infection. Douching with a spermicidal foam or homemade vinegar-and-water solution after sex may render some infectious agents inactive, but little research has been conducted in this area. If you are having sex with multiple partners over a short time, don't douche until after the last one. Try to urinate right after sex: Urine's acidity can help clean out the urethra." Still, "no one can tell me whether it's safe or not to douche before I get fucked 20 years into the epidemic," Scarce recently told the B.A.R.

* Withdrawal before ejaculation. What little research has been done on risk factors for HIV infection associated with various sexual behaviors between men has not differentiated between whether HIV infection is more likely for bottoms if their top man cums inside, or not. Although this is perhaps the most common "harm reduction" technique practiced by gay men, researchers seem to assume that it's all the same. And indeed, for some barebacking men, the act of ejaculation while fucking, or taking a man's cum inside them, is a central goal of the whole sexual experience. "The thought that [my] being fucked is going to lead to a lovely load of sperm is terribly exciting," said Shelbi. Men who choose to bareback should be aware that there is almost always precum, or pre-ejaculate, from the penis well before actual ejaculation, and that this semen potentially could be infected with HIV. Nevertheless, common sense dictates that the lesser the volume of possibly HIV-infected semen in the rectum, the lesser the volume of HIV.

* Gently, boys, gently. "There are boys who will rough up their asses before they go out," said Scarce, referring to so-called "bug-chasers," guys who have decided they want to get infected for reasons beyond the scope of this article. With unprotected anal intercourse, HIV is most easily transmitted when semen infected with the virus comes in contact with the blood of the receptive partner or bottom, through the delicate lining of the rectal tissue. This tissue is relatively easy to tear, compared to the vagina or oral cavity. The size of the top's penis, and the vigor and duration of his thrusts, are factors to consider for bottoming barebackers. Rougher sex can be more dangerous for HIV infection. Fisting and inserting large dildos and other toys can also weaken and tear the rectal tissue, and if preceded or followed by raw anal-penile intercourse, toys and fisting can make it easier for HIV to enter the receptive partner's bloodstream.

* Post-exposure prophylaxis. If you think you may have just been exposed to HIV, there is a chance that a course of aggressive anti-HIV therapy could be of some benefit to you, and possibly could help protect you from infection. Contact your doctor immediately. For more information, go to http://epi-center.ucsf.edu/PEP/PEPDPHSEX.html.

* Pre-exposure prophylaxis? Noting that the concept was "really common in the 1970s" among gay men who would take antibiotics used to treat STDs, and then throw caution to the wind, Scarce spoke of people practicing pre-exposure prophylaxis for HIV, "borrowing meds from their friends and having an "unsafe sex holiday." Don't try this at home.

* Plan your travels. "If I get fucked bare in Kansas, statistically speaking, it's not as dangerous as here," offered Scarce. Barebacking for HIV-negative guys is all about playing the odds. In San Francisco, estimates of the proportion of HIV-positive men vary. At the height of the epidemic, about half of the gay and bisexual men in San Francisco were HIV-positive. Many of these men have since died of AIDS-related conditions. Current estimates are around 30 percent, meaning that of every gay or bisexual man you pass on the street or hop into bed with, about one of every three is likely to be HIV-positive. These proportions are likely to be true across all adult age groups.

* Circumcision. There have been a number of highly controversial studies suggesting that men who are uncircumcised may be more susceptible to HIV infection. Watch for more data on this; the jury is still out.

* Use a lot of lube. Lubricants can help to protect the rectum from tears and abrasions that can make it easier for HIV to get into the bottom's bloodstream. Water-based lubes laced with nonoxynol-9, a spermicide, may afford some limited additional protection against HIV and other STDs. However, some people are allergic to N-9, and there have been a few studies suggesting that the chemical itself may irritate and create tiny holes in the rectal walls.

* Watch the poppers and Viagra. "Dilated blood vessels in the rectum caused by sniffing poppers make it easier for viruses to enter your bloodstream, so if your partner ejaculates inside you, you're wide open for infection. Viagra works similarly and poses similar risks by increasing blood flow to the pelvic region, facilitating erection, and to the rectum," noted Scarce in his POZ article.

* Be aware of mind-altering drugs. Whether your drug of choice is available at the corner liquor store, from your neighborhood pot club, in the alley, or from your pharmacy, know your limits. Many people believe crystal methamphetamine and other "party" drugs are lighting the fire under the gay HIV epidemic in San Francisco. If you know that the last time you had sex, a drug or combination of drugs affected your judgment and put you and or your partner at more risk than either of you were willing to accept, then don't do those drugs again. "Sex is very complicated," said Survive AIDS' Hank Wilson. "I think people are different at 10, 11 p.m., midnight, and when the bar closes."

* Do the research. This is not to suggest that HIV-negative guys should volunteer for a study to see how many times an HIV-negative guy can get barebacked before he becomes an HIV-positive guy, or whether it really is possible for an HIV-positive guy to get infected with a "super virus" that will hasten his demise. Rather, "do the research" means take responsibility for staying abreast of the latest science as well as the latest expert thinking on the sexual risks of infection with HIV or another sexually transmitted disease. Often, the research has simply not been done, in which case, common sense and instinct for self-preservation may have to be your guides. In any case, do not depend on any one source, and especially not the soothing words of a prospective partner.

For referrals, or more information about HIV/AIDS, call the California HIV/AIDS Hotline at (415) 863-2437, or 800-367-AIDS.

Next week, in the final part of "Barebacking, top to bottom," the Bay Area Reporter will take a closer look at the DPH/UCSF "11-point action plan," and community response to the plan.

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Always watch for outdated information. This article first appeared in 2000. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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