There has been increasing media and public attention to bareback sex, somewhat obfuscated by a parallel increase in confusion about what bareback sex is. While bareback sex is often used as a synonym for condomless vaginal and anal sex, it more accurately refers to such encounters in which one of the partners knows that he or she is HIV positive. Bareback sex can be applied to an occasional lapse in condom use, or to the exclusive practice of condomless anal/vaginal intercourse. Bareback sex can also refer to "extreme sex" which is high-risk sex involving the exchange of blood, semen, vaginal, and anal secretions when at least one party is HIV positive, and when the risk of infection or other bodily harm (i.e., via S&M) is a central component of the associated sexual gratification. So for clarification, this editorial uses the term extreme bareback sex.
The focus of Sabin Russell's article in the January 29 San Francisco Chronicle headlined "Russian Roulette Sex Parties" with the subhead "Rise in gay fringe group's unsafe practices alarms AIDS experts" refers to extreme bareback sex and deservedly received considerable local and national attention. The two February POZ bareback sex features were about extreme bareback sex, and not the occasional lapse into unsafe sex. The Stephen Gendin POZ feature profiles an openly HIV-positive bareback hustler whom Gendin anoints as the "Bareback Sex Poster Boy," for his lifestyle choice and not for unintentional lapses in condom use.
Michael Scarce's POZ entry titled "A Ride on the Wild Side" is a thoughtful apologia of the extreme bareback sex phenomenon in the gay community, and includes a list of scientifically questionable hygiene tips offered to reduce the risk of infection by those whose raison d'etre is high-risk sex. Unfortunately, Scarce does not address the extreme bareback sex popularity in the heterosexual community, and provides only a glimpse into the division between the old-guard safer sex advocates in the AIDS community and the younger vanguard of sexual libertarians over "Russian Roulette Sex Parties" and public conventions of extreme bareback enthusiasts.
Missing from the extreme bareback sex debates is the response of the medical community to their HIV patients' possible high-risk sexual practices and/or attitudes toward such practices. There is data indicating HIV/AIDS patients on protease inhibitors are more likely to engage in bareback sex. Because of the general reluctance of physicians to take sexual histories, one might assume that many physicians who care for extreme bareback sex practitioners are unaware of their patients' sexual practices and the potential harm of such practices to these patients and their sexual partners.
The medical community has the opportunity to reduce such potential harm through monitoring their HIV patients' sexual practices through regular sexual history/activity updates and, when necessary, counselling such patients to limit and hopefully curb bareback sex. Such monitoring, education, and counseling could reinforce their patients' knowledge of both the promise and limitations of virus-suppressing antiretroviral combinations, and the increased responsibilities of patients to themselves and to their sexual partners mandated by a diagnosis of HIV infection.