Important note: Information in this article was accurate in August 2001. The state of the art may have changed since the publication date. My article on disclosure elsewhere in the last issue mentioned the Seropositive Urban Men's Study, or SUMS. This study in San Francisco and New York City was undertaken in order to try to understand the sexual practices of HIV+ gay and bisexual men, how they understand these practices, and what other things are associated in our minds and behaviors with what we do sexually. The purpose was to help plan a prevention program that would help positive gay men behave safely toward others while also living satisfying, whole, lusty (if desired!) lives. A six-session peer-led structured group program that came out of this formative research is being tested now, to see if indeed it can support positive gay and bisexual men in achieving this goal.
The content of the group sessions includes: building connections with other HIV+ gay and bisexual men; facts and controversies in transmission risk of specific behaviors and STDs and the possibility of re-infection; personal responsibility, assumptions and disclosure of serostatus; communication skills; substance use and effects on sexual behavior and the immune system; and coping with HIV and the impact of mental health on sexual behaviors and health care.
Meanwhile, articles exploring different facets of this in-depth formative research in 1997 and 1998 are wending their way into the scientific literature. This brief report is to preview some of these articles, on issues related to sex and safer sex and attitudes about them. To summarize the participants in the study, 61% were recruited in New York and 39% in San Francisco. Recruitment was in a variety of venues to get a diverse group, including public sex environments (27%), aids service organizations (29%), mainstream gay venues (23%) and friendship referrals (20%). Overall, 29% were African American, 6% Asian or Pacific Islander, 24% Latino, 30% White/non-Hispanic and 11% of mixed or other ethnicity. The average age was 37, and median time since testing positive the first time was 7 years. About one-third were college graduates, one-third had some college or technical school and one-third had a high school diploma or less.
More than 96% of the men in the study reported having at least one male sex partner in the three months before the interviews, with the average participant having five partners in those three months. Thirty-nine percent (39%) had a main partner and 80% had non-main partners (some clearly had both categories of partner). The range in the number of non-main partners was from one to 180, and the median was five. Ten percent (10%) of the men had had a female partner at some point in the previous year. The median number of female partners among those who had any was one, and the range was from one to nine.
Of the main partners, a slight majority (51%) were also HIV+, whereas 41% were negative and 9% were of unknown status. Among those who had non-main partners, 62% had at least one partner of unknown status, 32% had partners they knew were HIV-negative and 43% had positive partners.
Potentially risky sex behaviors varied according to the status of the partners. For example, 9% had had unprotected insertive anal sex (fucking without a condom) with a partner in the previous three months, but 17% had done the same thing with a partner of unknown status and 23% with positive partners. The pattern was similar for unprotected receptive anal sex (getting fucked without a condom): 13% had done so with negative partners, 22% with unknown-status partners and 26% with other positives. For unprotected insertive oral (being sucked by a partner), the pattern was 26% with negatives, 47% with unknowns and 40% with positives.
A key finding, typical of other studies as well, is that a substantial number of positive men have sex with men of unknown status, and that we as a group tend to be less careful with unknown-status partners than with those we know are negative and sometimes even than with fellow positive partners. Part of this difference may simply be that people tend to be less likely to use protection in those very environments where one is least likely to know or ask a partner's status. However, a big part of it is that we tend to make assumptions about serostatus; assumptions that have a way of making us feel good or better about what we want to do anyway! We figure, for instance, that anyone in a bathhouse who does not explicitly ask for a condom to be used must be positive anyway. Why else would anyone have raw sex in an environment where you know there are a lot of positive men? Convenient…but not necessarily true.
Some of the factors that SUMS found to be correlated with behavior carrying a higher risk of HIV transmission are the same factors that predict risky sexual behavior in general, regardless of whether one is positive or negative. These factors include mental health problems (loneliness, depression and anxiety); a tendency to seek sensations and enjoy temptations; childhood sexual abuse; substance use and abuse; frequenting commercial and other public sex venues; and cognitive variables (the ability to adhere to one's personal decisions or boundaries (self-efficacy), perceived social and peer norms, knowledge base). These are very important for positive people, of course, even though they are also very important for high-risk negative people.
Then there are also factors that are specific to HIV+ individuals. Two of these that appear correlated with transmission risk are the degree of responsibility one perceives for protecting one's partners and also whether one blames others for infecting one in the first place.
Most men (more than 75%) in SUMS (and other studies support this) say that they feel a clear responsibility for protecting uninfected sex partners. Those who do not feel this responsibility or feel it less strongly are more likely to engage in unprotected sex. Only 11% of those who perceive responsibility engaged in unprotected insertive anal sex compared with 37% of those who did not feel themselves responsible. For unprotected receptive anal, the difference was 22% versus 45% and for unprotected insertive oral, 63% vs. 78%.
A separate study (a Gary Marks study done at 5P21 in Los Angeles) assessed, among other things, the extent to which the subjects’ own HIV infections had resulted from things they had done themselves or from characteristics of themselves, and also the extent to which they felt their infection was due to the characteristics or behaviors of others. They were also asked whether their infection had resulted from something someone else, or they themselves, had done intentionally. Participants had a much stronger tendency to attribute the causes of their infections to themselves than to other persons, and few considered their infections the result of an intentional act. Also, only a minority reported unprotected anal sex with someone of negative or unknown status: 24% insertive anal, 28% receptive anal, or 37% at least one of the two. Those who thought they had been intentionally infected, and those who attributed blame or responsibility to others even if not intentional, were significantly more likely to engage in sex that was risky to others. This risky behavior is rarely itself intentional; rather the blaming of others operates more subtly to lessen one's motivation to protect one's partners.
Many studies have found a strong association between childhood sexual abuse and risky sexual behaviors as an adult. One reflection of this is that HIV+ people in any given demographic category are much likelier to have been abused sexually as children than HIV-negative people in the same social stratum. SUMS is among the first however to look at how childhood sexual abuse (CSA) affects the sexual behavior of positives in ways that might affect transmission risk toward partners. The findings indicated that CSA does predict unprotected insertive and unprotected receptive anal sex. The psychological "mediators" through which CSA affects current sexual behaviors were explored. In terms of fucking, CSA is associated with higher levels of anxiety and hostility which are in turn associated with more unprotected insertive anal sex. With getting fucked, anxiety and hostility are also the "middle men," as well as having suicidal ideas or past attempts. Potential mediators that were explored but turned out not to be associated with both CSA and risky sex included drug use, frequent alcohol intoxication, depression and sexual compulsivity (these factors do predict higher levels of unprotected sex but are not any more common among CSA survivors than in those without CSA, in this study anyway).
Alcohol and drug use were explored as predictors of unsafe sex not only in terms of participants’ general patterns of use, but particularly the frequency with which they drank alcohol or used drugs just before or during sex. Overall in this study, among those who drank, 80% drank with sex and 17% drank every time or almost every time they had sex. Among users of non-injection drugs, 90% used with sex and 37% did so every time.
Those who drank frequently with sex were almost three times more likely to fuck without a condom someone who is negative or whose status they did not know (44% of those who drank frequently with sex versus 16% of those who drank infrequently with sex). There were no differences for getting fucked without a condom based on frequency of drinking with sex. The story was different for the use of other drugs with sex. Getting fucked without a condom was much more common among frequent users-during-sex (45%) compared to infrequent users (25%). Perhaps this is no surprise given that poppers and crystal meth were the two drugs that drove this phenomenon!
In terms of overall use (not just during sex), a higher percentage of those who acknowledged unprotected insertive or receptive anal sex with negative/unknown partners were drinkers or users than among those who did not practice such sex. The differences were most striking and consistent in terms of poppers.
In sum, all other things being equal, people who used poppers in general and those who used alcohol before or during sex were significantly more likely to fuck someone who could get infected, without a condom. People who used poppers at all and those who used other drugs before or during sex (crystal, ecstasy, cocaine or marijuana) were more likely to get fucked by someone who could get infected, without a condom.
In general these studies show a fairly high degree of perceived responsibility for the safety of our partners, and a fairly high level of practice of safer behaviors, particularly when taking into account the fact that most people appear to take into account the serostatus of their partners when having sex. There is a lot of strength and integrity in our communities and we should honor and enhance that.
There are some worrisome findings here too, though few of them are surprising. Alcohol and drug use before and during sex are strongly associated with more often putting others at risk for HIV. No doubt this is enhanced even more by the part the alcohol and drug use on those partners’ parts play in the decision to risk a new HIV infection. Poppers keep arising in study after study as a risk factor for getting infected and one for possibly infecting others. The other sex drugs play some role in increasing transmission risk, but not as much as alcohol and poppers because they are mostly associated (thanks to phenomena like "crystal dick") with getting fucked without a condom, something only about one-tenth as likely to infect a negative top as fucking a negative bottom. Our communities must deal with epidemic substance abuse as well as widespread levels of use that might not be "abuse," but that correlate with more frequent sex that runs the risk of infecting others.
Childhood sexual abuse has already wreaked its havoc by the time we are adults, but there is evidence that particular mental health problems resulting from such abuse can in fact be treated or otherwise helped, thus not only reducing the chance that those issues in turn lead to new HIV infections but also helping those surviving CSA to live better in general.
Bathhouses, sex clubs and outdoor public sex environments I'll leave to another time, but somehow or other we have to come to grips as a community with the pretty obvious fact that positives who regularly patronize them are much likelier to engage in unprotected sex that puts others at risk for HIV, and negatives who frequent them are much likelier to practice unprotected sex that puts them at risk to get infected. Is it enough just to say caveat emptor (let the buyer beware)? I think not, but certainly am not sure what to do or recommend.
Our new prevention efforts for positives must take into account all these and other factors that together determine or provide the context for our sexual activity. There is no simple solution, no magic bullet, no one-size intervention or technique that fits all of us. There are some clear places to start, though, such as intensified discussions of the issues raised by SUMS and the 5P21 studies.
As an earlier article argued, we have the power to stop the HIV epidemic, and the choice of whether or not to use it.
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