"Raw Sex" -- Are the Rules Changing?
December 5, 2013
Moderated by Naked Sword director mr. Pam and featuring a panel of community members and experts, the forum considered questions such as: Why do gay and bisexual men have condom-free sex? Are community attitudes around condom use changing? How do treatment as prevention and pre-exposure prophylaxis (PrEP) factor into the equation?
Coming from a community that strongly espoused condom use, mr. Pam said she was always harping on the men she works with to use them, but acknowledged that "it's like telling high school students to practice abstinence -- it's not going to happen."
In an anonymous audience text poll, 100% of attendees said they had ever fucked without a condom, 80% said the rules around condomless sex are changing in San Francisco, and only 37% thought condom use is now the norm. Most reported that they'd had sex with someone of a different HIV status, or didn't know whether they had.
Dr. Joanna Eveland of Mission Neighborhood Health Center started out with some definitions and trends in HIV and sexually transmitted infections (STIs) in San Francisco.
Today, "safer sex" goes beyond just condom use and may include strategies such as serosorting (having sex only with people of the same HIV status), choosing sex acts and top or bottom positions based on status ("seropositioning"), and using antiretroviral drugs as prevention. Surveys by the Stop AIDS Project found that in 2008 about 40% of HIV-negative men and half of HIV-positive men reported using any "seroadaptive" strategy.
Based on his experience as an HIV test counselor and community organizer at Magnet, Jared Hemming thinks men are using a broad range of tools. "The rules are definitely changing and people are using different strategies," he said.
"The problem with a condoms-only approach to safe sex is that I certainly want condomless sex," said Chrissy Scardina of Stop AIDS, who is HIV negative and on PrEP. But he added that "getting new technologies and strategies doesn't mean letting go of old strategies that are working, it means diversify."
Gonorrhea, chlamydia, and syphilis rates rose between 2008 and 2012, according to figures from San Francisco City Clinic, suggesting that more people are having unprotected sex. But the rate of new HIV infections has declined or remained stable overall. This may indicate that more men are using safer sex strategies that protect against HIV but not other STIs. There was small uptick in HIV incidence between 2010 and 2011, but it's too soon to tell whether this is the start of an upward trend.
"San Francisco is ahead of the game" when it comes to HIV testing and treatment, Dr. Eveland said. While the Centers for Disease Control and Prevention (CDC) estimates that 20% of people with HIV nationwide do not know they're infected, that drops to around 7% in San Francisco.
During early infection -- before the body makes enough antibodies to show up on a standard screening test -- HIV viral load is often very high, posing the greatest risk of transmission. But suppressing viral load with antiretroviral therapy dramatically lowers the risk. A large study of serodiscordant heterosexual couples in Africa (HTPN 052) showed that when the positive partner was treated, the risk of transmission fell by 96%. If a large proportion of people are on treatment, "community viral load" goes down, as well.
San Francisco was the first city to recommend that everyone who tests positive should consider treatment -- regardless of their CD4 T-cell count -- both for their own health and to reduce the risk of transmission. While only 25% of people with HIV nationwide have been tested, entered care, and achieved viral suppression, according to the CDC, in San Francisco the proportion is closer to half.
Safer Sex Strategies
Asked about what safer sex strategies they use or recommend, panel members discussed a range of options.
"We have come a long way since 'Play Fair' and 'How to Have Sex in an Epidemic' and we have more tools in our toolkit," said Alan Guttirez of Lyric, who is HIV-negative, referring to two pioneering safer sex resources.
"Condom use has been a pendulum," suggested Daniel Ramos, a pharmacy specialist with the AIDS Healthcare Foundation who is HIV-positive and until recently was in a long-term serodiscordant relationship. When HIV came on the scene there was a big push to get people to use condoms, but "people got exhausted being force-fed the message to use them."
"Talk to your partners prior to sex, know what to look for, what things should and should not smell like," he advised. "But you can't really judge a book by its cover, so discussion is important -- but not easy."
Scardina recommended getting tested for STIs every three to six months. Having other STIs increases the risk of both transmitting and acquiring HIV. If you have something, tell your partners. "It's not a pleasant conversation, but it's the right conversation for our community," he said. (Magnet and the SF Department of Public Health offer anonymous services that will contact partners and tell them they've been exposed to STIs; the inSPOT website serves a similar function.)
Regular HIV testing is also important. A recent CDC study showed that the longer gay men went between tests, the more likely they were to be infected without knowing it. "When asking a partner's status, the follow-up should be 'When were you last tested?'" Dr. Eveland said.
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