When Condoms Ain't Enuf ... What to Do With a Sex-Phobic Society in a "Post-AIDS" Era?

"I also want to mention that we are increasingly becoming better at incorporating conversations about 'harm reduction' into the realms of substance use (needle exchanges, safe injection sites, pill testing, etc.), but we often fail to adequately translate this model when speaking of communicating risk reduction in sex (strategic positioning, sero-sorting, viral load suppression, etc.). My question back to the group then is, how do we more effectively communicate to young people the abstract concept of 'harm reduction' for sex within the context of a sex phobic society?"

Allen Kwabena Frimpong

Michael Terry Everett

This was a question posed by Jamie Forrest of Vancouver, Canada in the North America, Western Europe, and Caribbean CrowdOutAIDS Open Forum on Facebook. CrowdOutAIDS is UNAIDS new collaborative online youth-led project. He posed this question to the group after people were discussing what they considered to be the main reasons for HIV infection among young people.

Reading the responses on Facebook gave us one of those jolted reactions. The dominant message about sexual health in relation to HIV prevention has been focusing on condom usage. Jamie's question was one that I saw as challenging; given the propaganda that the HIV/AIDS field has been pushing around what it means to have safer sex. My colleague at the Harm Reduction Coalition, Michael T. Everett, was also raising this same question especially among young men who have sex with men (YMSM) of color given that their rates of infection have been steadily increasing while rates of infection among injection drug users has been on the decline.

The question for us became what (besides the exchange of needles) was accounting for the decrease in transmission of HIV among injection drug users, and how could we use what works in harm reduction messaging and education when it comes to drug use (if anything) for other high-risk populations greatly affected by the epidemic through sexual transmission. We considered this in light of the following:

1. We cannot exchange condoms like we do syringes.
2. We know people are not using condoms all the time, and the possibilities of HIV and other STI's has not scared enough people into doing so, and so ...
3. If people have been harboring condom use as the dominant end all be all harm reduction response- well then something is terribly wrong with this picture.

The place to begin the conversation around the idea of prevention of at-risk behaviors like having unprotected sex is a great place to start. We need to engage an intentional conversation concerning the reality that the message of safe-sex, by way of condom usage, may not resonate with people because it is limited and does not allow one to ponder the spectrum of other possible harm reduction practices. The point is: we want people to still live a healthy life without causing further harm to themselves and others. The spectrum of harm reduction practices includes everything from prevention to helping those who are most affected by the collateral consequences of their at-risk behavior. The spectrum does not begin or end with condom usage only.

As a society many people hold the moral belief that people should suffer for the consequences of their own actions. This is why in the United States syringe exchange programs were illegal for so long. We had evidence-based science that told us that it was a viable intervention to decrease the spread of HIV and Hepatitis C among injection drug users, but we watched people suffer despite the evidence.

This moral belief undergirds prevention measures. But, what many of us name "prevention" is a far cry from a spectrum of diverse prevention methods that are responsive to individual's contexts and sexual choices. Many systems fail to acknowledge the reality that not everyone uses condoms and that there are also viable options outside of condom promotion that could still protect people from acquiring HIV. Many young people of color are being infected with HIV at alarming rates because they are not being informed about their full spectrum of options. "Meeting people where they are at" has lost meaning in this context. Our world is not one dimensional and, therefore, our strategies cannot be one size fits all.

We need to re-imagine ways to resist holding the current prevention paradigm at the center of our work. In response, we would like to provide the following questions from a capacity-building perspective as we begin to further this dialogue around harm reduction practices that could be useful in empowering people to protect themselves from HIV.

1. When are we using condoms,when are we not, and Why? What becomes of a generation of people who consume sex together through a smokescreen of condom usage and negotiation messages?
   
   Tangible empowerment recognizes the nature of human beings. Sex should reinforce intimacy, trust, and respect all elements of a "healthy" relationship. What does it mean to be in a healthy relationship? Furthermore, who gets to define what that means, and how does a universal definition impact peoples choices around how they build relationships with people? We have spent years interrupting intimacy among people of color and we have gutted the potential foundation for intimacy among men who have sex with men. In addition to condom use, we must support building concepts of what being in a healthy relationship means as it relates to sexual health. Sex and HIV infection does not happen in isolation, therefore a harm reduction response must focus on building meaningful relationships with partners, and preparing people to engage in sex using condoms, and provide the same enthusiasm to support individuals who do not choose to use condoms.
2. While we are pushing pre-exposure prophylaxis, what about frottage (dry humping), strategic positioning, sero-sorting, viral load suppression, etc. especially for those who are living with HIV as a harm reduction response? Why aren't these things talked about as equally as condoms?
   
   Harm reduction strategies have often identified the spectrum of possibilities to reduce harm. The delusion of prevention has prioritized condom use over options that could potentially be more feasible for high-risk communities. Frottage, strategic positioning, sero-sorting, etc. lack intentional messaging and education that would enhance the level in which sex partners could negotiate safety. Sexual partners would be able to make informed decisions around how they protect themselves around HIV, if they are not at the place of using condoms consistently or even at all. Prevention dollars have been used to support problematic and seemingly oversimplified interventions (i.e: New York City's Department of Health's - It's Never Just HIV campaign) while negating means to identify and emphasize behaviors that decrease risk and increase personal and collective responsibility where people are ready and able to make changes. It is time for providers to reduce our own harm, put aside the delusion of prevention in our judgments, and put our human resources (i.e. facilitation, counseling, program planning and organizational development skills) behind harm reduction strategies that support realistic opportunities to be empowered and self-determined.

Thirty years into the epidemic we attempt to coexist in a sex-phobic society that intentionally and unintentionally endorses guilt, shame, and secrecy around sex thus driving sexual transmission of HIV. We cannot afford the delusion of prevention. It has no place in HIV prevention particularly when so few voices of the most at-risk communities are a part of dictating what works for them.

Translating harm reduction into safer-sex practices is about an awakening of our asset-based practices. We must reframe our approach to prevention and incorporate opportunities to promote the multiplicity of people, an acknowledgment of a continuum of behaviors, and a spectrum of options that enhance quality of life.

Allen Kwabena Frimpong is the online community organizer at CrowdOutAIDS in North America, Western Europe, and the Caribbean and Michael Terry Everett is the Team Leader for Capacity Building Assistance at the Harm Reduction Coalition.