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Laying It Bare: Gay Men and Unprotected Sex in the Age of HIV/AIDS

June 23, 2010


Introduction

Why are some gay men still having unprotected anal sex in the age of HIV/AIDS? Whether you're a man who rejects the term "barebacking" as stigmatizing, dismisses the act and any conversation about it as criminally risky, or embraces barebacking as part of your identity, the fact remains that it's happening -- and very few people are talking about it.

According to many studies, anywhere from 12 to 46 percent of men who have anal sex with other men in the U.S. are doing so without condoms -- and meanwhile, for many gay men, HIV prevention messages have become like broken records.

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On the other hand, when you look at nearly 30 years of the HIV/AIDS epidemic, which has taken such a devastating toll on the gay community -- many of whose members already fight homophobia, rejection by their families and lack of recognition by the state on a daily basis -- perhaps the more appropriate question becomes: How could gay men not be exhausted by the prospect of protecting themselves each and every time they have sex?

In this discussion moderated by blogger fogcityjohn, a psychologist, a public-health veteran and an HIV education researcher hash out from their own perspectives the many factors that lead gay men to engage in unprotected anal sex -- and what needs to be done about it.


Guest Panelists

fogcityjohn

fogcityjohn, blogger for TheBody.com

fogcityjohn: Welcome to TheBody.com. This is John reporting. I am also known to some of you as the blogger fogcityjohn. Today, we are here to talk about gay men, or men who have sex with men [MSM], and unprotected anal sex, the practice colloquially referred to as barebacking. Now, we all know that unprotected anal sex poses a high risk for transmission of HIV. And yet, despite widespread awareness of that risk, many men are still engaging in unprotected anal sex. And so today, I hope to explore a few aspects of this issue, including perhaps how widespread the practice is; what motivates men to engage in unprotected anal sex despite knowing the risk of HIV transmission; and in addition, finally, are there possible interventions or strategies that can help men adhere to safer sex practices.

With that, I would like to introduce the guest panelists. I am very, very pleased to have with us today, from Berkeley, Calif., Walt Odets. Walt is a Ph.D. in clinical psychology who has been practicing since 1987. He is also the author of numerous articles on the topic of HIV prevention, and the book In the Shadow of the Epidemic: Being HIV-Negative in the Age of AIDS [for an excerpt from this book, click here].

With us from Atlanta, Ga., is Rashad Burgess. Rashad serves as the chief of the Capacity Building Branch, Division of HIV/AIDS, at the Centers for Disease Control. Prior to joining the CDC, Rashad worked at the Chicago Department of Public Health, Division of STD/HIV/AIDS Public Policy and Programs.

And in New York, we have Jeff Parsons. Jeff is a professor of psychology at Hunter College of the City University of New York, and co-director of the Center for HIV/AIDS Educational Studies and Training. He is also a member of the doctoral faculty in the Social-Personality subprogram, and the director of the Health Psychology concentration at the Graduate Center, City University of New York.

Gentlemen, welcome to all of you. I'm very pleased to have you here.

Jeffrey Parsons: Thank you. It's great to be here.


Language and Homophobia: What Are We Talking About When We Talk About "Barebacking"?

fogcityjohn: OK. Now, before we get to the main portion of our topic, I'd like to just ask you all briefly about the issue of language. I'm a lawyer by profession, so language is important to me. And I just wanted to ask all of you if there were what you would call appropriate ways to discuss this topic, appropriate terms that we should use.

I ask this because I did a recent post on this topic at TheBody.com, and someone objected to the use of the term "barebacking." So I'd like to ask you what you thought. How should we talk about this?

Walt Odets, Ph.D.

Walt Odets, Ph.D., a longtime psychotherapist who has written extensively on HIV prevention and the psychological and social issues facing gay men

Walt Odets: I'd like to respond to that. This is Walt. I think that what we're after here is helping people to think about behaviors that transmit HIV, not about specific sexual behaviors. And the term "barebacking" implies that any unprotected anal sex poses a risk for transmitting HIV. So that would be my objection to it. We're pathologizing behaviors, rather than helping people think about when HIV might be transmitted. And that's one of those broad terms that I think encourages that confusion.

fogcityjohn: Indeed. Rashad Burgess, any thoughts from you?

Rashad Burgess: Well, I think, having clarity around what is it we're talking about is actually important. What I would say is that when you look at the science to mean, on one hand, you have "barebacking" used very broadly to describe any unprotected anal intercourse. And usually it's used in the context of gay men.

And then on the other side, you have "barebacking" used to really identify those that identify themselves as folks that bareback, or identify as a particular group of people who identify as a subculture of barebackers.

So I would argue that we should probably be as broad as possible in the use of the language "barebackers," and those being, individuals who partake in unprotected anal intercourse, irrespective of whether or not they themselves identify as a barebacker.

fogcityjohn: Jeff Parsons? Any thoughts from you on this topic?

Jeffrey Parsons, Ph.D.

Jeffrey Parsons, Ph.D., a professor of psychology and co-director of the City University of New York's Center for HIV/AIDS Educational Studies and Training

Jeffrey Parsons: Yeah. I completely agree about the need to keep a barebacking identity separate from what we might construe as barebacking behavior or simply unprotected anal sex that poses a risk. I also think that intentionality gets pulled into this a lot, and that "barebacking" is often used as a term to refer to intentional unprotected anal sex. Whereas, unprotected sex that happened because the condom broke, or the person had every intention of using a condom, but somehow, one was not used, that doesn't get classified as "barebacking."

So I agree with Walt that, in some respects, there is a bit of pathologizing of it as a behavior. But I do think it's important to recognize that some gay men do identify themselves as barebackers, and have integrated that into a part of who they are, and part of their community.

fogcityjohn: Well, then, I think what I'll try to do, and maybe we should try to do in this discussion, is simply discuss this as unprotected anal sex, and we can talk about issues of intentionality, as well. But I'm going to try, just for purposes of today, to stay away from the term "barebacking."


Prevalence: How Widespread Is Unprotected Sex Among Gay Men?

With that understanding, I would like to get to what I think is probably the heart of the matter. First of all, what do we know about how widespread the practice of unprotected anal sex is among men who have sex with men? Because I think that a lot of HIV education seems to assume that the default setting is that guys are having protected sex. And I'd like to ask you all: Is that a reasonable assumption? Is that true? Or, what do we know?

Walt Odets: I think it's an erroneous assumption. I'd like to back up just for an instant, if I could? "Barebacking" is a term that's widely used and recognized to identify high-risk sex. And if two men, neither of whom has HIV, there is no risk of HIV transmission there. I think I'm saying more succinctly what I said before.

But certainly there's a tremendous amount of unprotected anal sex, and I do think that in this context that we have to make distinctions between negative men, positive men, knowledge of HIV status, and so on.

fogcityjohn: That's an excellent distinction that I probably should have made myself. Because I think we're probably not concerned with, say, two HIV-negative men in a relationship, who have negotiated safety, if you will. What we should probably be focusing on are men who either are negative, or don't know their status, and who are, despite the risk of HIV transmission, continuing to engage in unprotected anal sex with men whose status they may not know. Would that be fair?

Walt Odets: Yes, I think so.

Jeffrey Parsons: To be honest, I would be a little concerned about the first part of that -- this notion that two HIV-negative men in a relationship with negotiated safety and not having concerns. The epidemiological data is increasingly showing that a significant number of new infections are happening in the context of main partner relationships. And I think we sometimes make the mistake of assuming that when somebody is confident in their knowledge that they are HIV negative that may not be the fact.

And so I do think that we have to recognize that we can't just assume that for two people who believe themselves to be negative in a relationship that unprotected anal sex does not pose a risk.

Walt Odets: Yes. But that goes to, I think, more the issue of whether or not their knowledge is accurate; their assumptions are accurate.

Rashad Burgess

Rashad Burgess, chief of the Capacity Building Branch of the Division of HIV/AIDS at the U.S. Centers for Disease Control and Prevention

Rashad Burgess: This is actually a very important issue, particularly in the context of gay men, where, because the background prevalence of HIV is respectively so high, so many gay men are unaware of their HIV status, even though there's a considerable frequency of testing. Individuals will believe that they are HIV negative, and have an operating assumption that they are negative, and enter into relationships assuming that they are negative when they actually are not.

And so one of the challenges we face in having this discussion is having a different perspective for those that we believe to be negative; oftentimes, that belief is not held true. And we have study after study where individuals who thought they were HIV negative, after being tested during the entry point into study, found out that they actually weren't negative.

fogcityjohn: OK. So obviously, having accurate information on that point is clearly quite difficult. But that leads to my original question. Do we have some sense of how many? What percentage of men do in fact adhere only to protected sex? And how many, some or all of the time, are having unprotected sex?

Rashad Burgess: I don't think we have a definitive answer to the proportion of gay men who have sex with men who definitely only have unprotected anal course, or primarily have unprotected anal intercourse. I mean, you look at studies; it ranges significantly.

I pulled some data up, and it ranges from 12 to about 46 percent. So it's a considerable range. It's specific to region of the country; the city, particularly; some differences in terms of race/ethnicity; differences in terms of age; differences in terms of HIV status. So I think that it's difficult to make a broad statement about the proportion of gay men that are partaking in unprotected anal intercourse, because it does vary significantly.

Walt Odets: John?

fogcityjohn: Yes, Walt?

Walt Odets: Just to go back to part of the original question: You used the term "negotiated safety." This is something that originated in Australia about 15 years ago. And it refers to two men that enter in a relationship who have presumably determined HIV status and determined the kinds of sexual behaviors that would occur outside the relationship, if any, and have found a way to have unprotected sex.

I agree with Rashad and Jeff. This is something that often has failed. But we have almost entirely in the United States failed in prevention efforts to educate men in that process. We simply pathologized the behavior and prohibited intervention, and don't discuss it, and don't help them to think about it, help them to understand how they can make that determination.

I see this in psychotherapy patients all the time, very sophisticated people, who really don't know how to go about that.

fogcityjohn: Well, what I'd like to ask you to do, Walt, is, if you could hold that thought for a little later on when we talk about some interventions. Because I think that's a really interesting and important issue. But I would like to get there a little later.


Motivations: Why Would Gay Men Put Themselves at Risk?

If we could, I'd like to move to what I think is the principal question. And that is: Why? Why, in this era of widespread awareness of the risks of HIV, are men still having unprotected anal sex? And I'd just like to hear from each of you on what your own knowledge and experience shows on that. Maybe we could start with you, Walt. As an individual psychotherapist, what have you found?

"We have liked to feel that [unprotected anal sex] was somehow dispensable -- and it's really not, emotionally. ... [W]e haven't helped men to think about what they are doing."
-- Walt Odets, Ph.D.

Walt Odets: Well, it's a natural behavior, and it's of emotional significance. And I think gay men naturally engage in it. We have liked to feel that it was somehow dispensable -- and it's really not, emotionally. So, again, we haven't helped men to think about what they are doing.

It's a very narrow range in which HIV is transmitted. Anal sex has the emotional import for gay men that vaginal intercourse has for heterosexuals. And it can't be dismissed. And we can't expect that that's going to done all the time, under any circumstances, with a condom.

It's compelling. It's emotionally compelling. And that would be the sort of crux of my answer to that.

fogcityjohn: OK. Rashad Burgess?

Rashad Burgess: I would actually agree with Walt, with respect to it being emotionally compelling for gay men. I mean, sex is not only a physical act; it's very much an emotional act. It's an act that brings intimacy, love, pleasure. And so to not start with that understanding can lead you down a road of significant misunderstandings of sex between gay men.

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But I would also add to that, that I think is really important, is that, you know, given nearly 30 years into the epidemic, and many of the benefits of treatment, the context of HIV -- it's very different. And many communities of gay men do not ... do not have in their face the actual risk, in that moment of making a sexual decision, of HIV.

Additionally, as we have people -- gay men -- this background prevalence of HIV is significantly high in a number, particularly with gay men of color. You really do have individuals at times making choices that ... but yet, not being fully, fully informed. And so they perceive themselves as being at low risk for HIV, while they're doing the things that we all would say are high risk. But yet, them not having appreciation for the actual prevalence of disease -- which results in them actually taking certain risks that they may not have taken if they had a full appreciation of the actual context.

fogcityjohn: Let me make sure I understand you. So you're saying that ... For example, I know, Rashad, you've done a lot of work in the African-American community. Are you saying that people may have, men may make the assumption that their risk behavior is ... their behavior is not risky, and it is, in fact, because of simply the prevalence of HIV within the community in which they live?

Rashad Burgess: That's exactly, that's exactly it. That's exactly it.

fogcityjohn: OK.

Rashad Burgess: That's exactly it.

fogcityjohn: Jeff Parsons: What do you think? What has your work shown are the reasons that men, say ... Why do men engage in this practice, with knowledge of the risks?

Jeffrey Parsons: I certainly agree with what's already been said. Sex without a condom feels better. And it does have more emotional importance for men that, I think, can't be ... Well, it shouldn't be dismissed. But I think Walt's correct; it is too often dismissed, particularly in the majority of the prevention work that we do.

And I certainly think that the majority of gay men out there are not trying to engage in behaviors that put them at high risk for HIV. So I think that what's also been said about the majority of gay men are engaging in behaviors that they think are harm reducing. They think that they are serosorting by having unprotected sex with people that they either think, or at least have been told, are the same HIV status as them. And so men are doing behaviors to try to minimize the risk, for the most part.

But I think that there are also a couple of other factors that do come into play. One of them has to do with substance abuse. And people who are active substance users, who have binge episodes, are simply not able to use all of their, sort of, cognitive and planning skills and abilities to either make or maintain the commitment to use a condom for anal sex.

And the other has to do with, sort of, depression and other mental health issues that you see men, gay men, who are experiencing significant levels of depression turning to unprotected sex as a way to just try to feel a connection to another person. And it ties very much with what Walt was saying about the intimacy and the emotion aspect of unsafe sex.

And so I think that the rates of depression among gay men, and the rates of substance use -- I think that both of these do play an important factor.

Rashad Burgess: This is Rashad. I think I want to add one piece. And I think it's important, in terms of setting context. Because, on the one hand, yes; we're talking about gay men having unprotected anal intercourse, with knowledge of risk.

"Gay men use condoms far more than heterosexuals, pretty much across the board."
-- Rashad Burgess

But I think it's also really important to note that across the board whether or not, if you're looking at our national behavioral surveillance, or you're looking specifically at a number of cities and studies, gay men use condoms far more than heterosexuals, pretty much across the board. And so I do think that is an important context to ... an important piece of information to put out there when talking about the risk of gay men.

fogcityjohn: Actually, I did not know that. I'm glad to hear that my community is at least doing, making an effort in this regard. And I guess one thing that that brings up is, you know, can any of you comment on what it is specifically about the unprotected aspect of anal sex that is so crucial? Because, of course, we're not talking about people not having anal sex at all; we're talking about guys using condoms when they do it.

Can you address exactly what makes the difference? Obviously, unprotected anal sex feels better. But what is the emotional aspect of that? Any ideas on that?

"The minute the condom becomes part of the act: this is a reminder to both people that there's something dangerous associated with the act, that instead of making love, they could be killing each other."
-- Walt Odets, Ph.D.

Walt Odets: I'd like to comment on two aspects of that. One is that the presence of the condom ... the minute the condom becomes part of the act: this is a reminder to both people that there's something dangerous associated with the act, that instead of making love, they could be killing each other. And that certainly is something that people want to avoid. So the association of the condom is certainly an issue.

The other is that the exchange of body fluids, the thing that we talk about as the prohibited behavior; the exchange of body fluids is an act of intimacy. It allows one man to have a part of another man inside of him. And that itself is compelling. And that obviously, that exchange of body fluid obviously requires unprotected sex.

So I think those are two big issues. There are many others, of course.

fogcityjohn: What, for example, Walt, what other ones would you see beyond those two?

Walt Odets: Well, there are several other things. The receptive partner often feels that he has to comply with the desires of the insertive partner. Part of allowing someone inside of you puts you in a passive, or receptive, position. And I think very often the receptive partner is compelled, for those emotional reasons. I'm not simply talking about intimidation; but this is emotionally part of the act.

I think that the substance use that Jeff mentioned is often an issue, that people's judgment changes. I think with alcohol, for example, we see a real narrowing of focus and attention. And this, then, excludes all kinds of considerations, like HIV.

I think there are just a number of emotional issues. You're asking a very complex question about something that happens in private and that is driven by conscious and unconscious thoughts and feelings. It's clearly very complicated.

fogcityjohn: Yeah. I realize that the question doesn't have a simple answer. And I'm just sort of hoping maybe we can, maybe you all can touch upon some of the things that, in your experience, you found as motivators. Rashad Burgess, do you have ...?

"When you look at the traumas that gay men often experience ... it does lead to a yearning for intimacy that takes great precedence over the need for someone to prevent themselves from getting HIV."
-- Rashad Burgess

Rashad Burgess: I would add two things. I mean, I'm coming from a little bit of a different angle than Walt. I think, when you look at the traumas that gay men often experience -- as children, as adolescents, as teenagers, and then as young adults -- oftentimes, it does lead to a yearning for intimacy that takes great precedence over the need for someone to prevent themselves from getting HIV.

And so, the rejection of family members, getting thrown out of your home, needing a place to stay ... I mean, the levels of stigma that just exist in many parts of our society will result in individuals having certain emotional needs that that level of intimacy, and intimacy with that level of risk, will oftentimes fill, for those individuals.

fogcityjohn: Jeff Parsons?

Jeffrey Parsons: The one other thing I would add -- I certainly agree with everything that's been said -- is that there are individuals who like to take risks. There are individuals who, that's a part of who they are; that's a part of their personality. And although I don't believe that the majority of them actively are out to become infected, I do believe that a lot of them think that they can play the game of roulette and always keep winning. These are often men who have had repeated episodes of unsafe sex, and yet have repeatedly tested negative.

And so they can develop this almost perception of invulnerability. They just don't think that they are going to get it, or that the chance of them getting it is so small that it's simply acceptable to take risks on occasion.

Walt Odets: Right.

fogcityjohn: And do you think that there is a, I guess, a sense in which men have sort of let their guard down, in the age of effective treatment? Is that a factor that affects their decision making?

Rashad Burgess: Complacency is definitely playing a role here -- in part, because of the benefits of treatment. I mean, when you exist within many communities, and you know of people who are HIV positive that are living healthy, active lives, it does impact the perception people have of the disease and its impact.

Walt Odets: Let me add something there, just to tag something on there. There are people who, consciously or unconsciously, would like to acquire HIV. And I'm not talking about something pathological here. In a relationship where you have a so-called serodiscordant couple, this is a big rift between people. This is a big separation.

And there's only, in terms of HIV, one way to repair that rift. It's for them to get a partner to contract HIV, and to reconnect the relationship in that way. And I think that that's relatively common in relationships. Serodiscordant relationships are emotionally difficult, very often.

fogcityjohn: And so, Walt, you're saying, basically, that in a serodiscordant relationship, acquiring HIV may be seen as an expression of intimacy?

Walt Odets: Yes. And connection. And repair within the relationship. I've seen that in many couples.

fogcityjohn: Very interesting. I'd like to go back to something you said, Rashad. Because you mentioned childhood trauma as a factor in this. And I was wondering, sort of a bit more generally: Is homophobia and the stigma that surrounds same-sex sexuality; is that something that plays a role in this? And if so, how?

Rashad Burgess: I would say it absolutely does -- particularly when you're looking at the risk-taking behaviors of individuals, looking at the risk-taking behaviors of young gay men. I mean, you have young gay men: many experience sexual molestation. Many experience mistreatment by their peers, or by their family members. And so the way in which many find intimacy, or find even security is through relationships through their partner relationships and/or relationships even with older men who, at times -- not exclusively, but at times -- there are certain risks that are taken because this person needs a place to stay, or this young person doesn't have any other resources of their own. And so I think stigma, homophobia, has an enormous role, as well as the impact it has on their own self-esteem, to even be willing to say, to negotiate, safety.

fogcityjohn: Jeff Parsons? I'm sorry. Go ahead.

Walt Odets: Yeah, no. I think what Rashad said is a big one. Jeff mentioned depression earlier on. But self-esteem, which is often connected with problems of depression; the self-esteem issue is a huge one.

Adolescents, gay adolescents, even now -- and this has lessened somewhat -- even now go through a feeling of being isolated, being alone, sometimes of being unique, and a distinct experience of being undesirable. And what they find out as they get older is that their body is very desirable to other people. And that is a very powerful thing. When someone is desiring you, it's a very difficult thing to kind of interrupt and start giving him instructions about how to desire you. And a condom would be one of those instructions. So I think, particularly in younger people, as Rashad said, that their self-esteem is a very, very important issue.

fogcityjohn: To follow up on that point, it does seem that we have a fairly high incidence of new infections, though, in men who are more in my age group -- you know, in their 40s. What's behind that, do you think? Because obviously what you're talking about, in terms of adolescents, coming into adulthood, you know, those things are, I would imagine, sort of in the past for men of my age. What do you think is behind the new infections we are seeing in men, say, in their 40s, in middle age?

Rashad Burgess: Well, let me say: One, you're absolutely, you're absolutely right. You see across the board, not only young gay men getting infected, but actually, we look at infections amongst men that are in their 40s and 50s; the far majority are amongst men who have sex with men almost across the board. There are a few exceptions in America, but very few.

I mean, I think there are a whole host of factors, some of which we've already talked about, that for young gay men are applicable to older gay men.

One thing we have not talked about, that I think is ... that I've experienced many gay men in their 30s and 40s speaking about is issues around loneliness. I don't know if there are others that want to comment on that, but when many gay men wrestle with -- you know, we said depression -- but issues around just pure loneliness, and what does it mean to be an aging gay man in a culture that, in many ways, really values youth ... and if not in, necessarily, age, at least in appearance. And so I think that sometimes that does result in people taking risks that they maybe didn't, would not have taken, when they were younger and they were very desirable, but yet had high self-esteem and resources. And now that they have aged, and are aging, you know, are willing to take certain risks because they are dealing with issues around loneliness and the need to be desired.

Walt Odets: I agree with that. And this is an inversion of the adolescent thing.

Rashad Burgess: Right.

Walt Odets: Where the adolescent discovers desirability, the older man discovers the loss of desirability.

"Youth are likely to say, 'Look, with everything else that I've been through, I can handle HIV.' And we hear the same thing from older gay men who are seroconverting ... : 'Look, you can live 20, 30 years with HIV. I'm already in my 40s. Why isn't it OK for me to just kind of finally be able to relax about safer sex?'"
-- Jeffrey Parsons, Ph.D.

Jeffrey Parsons: And what can happen with both groups -- the sort of young, gay man who is desperate for that boost in self-esteem, to feel desired, perhaps has been the victim of discrimination or some kind of abuse. The HIV, or possibility for HIV infection, then just becomes really secondary. It doesn't get viewed as a major thing. I mean, these youth are likely to say, "Look, with everything else that I've been through, I can handle HIV."

And we hear the same thing from older gay men who are seroconverting, where they say, "Look, you can live 20, 30 years with HIV. I'm already in my 40s. Why isn't it OK for me to just kind of finally be able to relax about safer sex?" And again, if it's tied to a particular contextual situation that is about them feeling desired, loved, wanted, to alleviate perhaps some of that loneliness that they're experiencing, they're more likely to take risks.

Walt Odets: There's also just some exhaustion over a lifetime with dealing with problems like this. And I think we do see in older men -- you know, it's related to what Jeff and Rashad are saying -- but it's a kind of throwing in the towel on protecting oneself. It becomes exhausting. Twenty-five years, a quarter of a century, of trying to avoid an infection, is tiring.

fogcityjohn: I can certainly confirm that in my own case. I think that was certainly a part of my own ... one of the reasons I became infected. So I think that's a very, very important point.

Rashad Burgess: If I could just say one ... and I said this to a colleague of mine: There's not an expectation that non-gay people, heterosexuals, would use condoms for 70 years of their actual sexual life, or 50 years, or however long people are sexually active. And I think that part of what we, as a community of gay men and of HIV prevention providers, researchers, policy folks, is how do you deal with a population of people who has been working very diligently -- I mean, very, very diligently -- to prevent getting HIV? But they've been doing it for 30 years.

And I think that the issue around exhaustion is very real, particularly for people who were in their teens or young adults in the late '70s, early '80s, and who did not get infected then.


Interventions: What Kinds of Support Do Gay Men Need to Make Sex Safer?

fogcityjohn: Well, that is a good segue into the next segment I hope we can talk about for a bit. And that is sort of interventions or solutions. And what I wanted to ask all of you is: Are there ways in which either you as psychologists, public health officials, HIV educators, you know, can intervene with men who have sex with men, and support them in adhering to safer sex practices?

You know, earlier, Walt Odets, you talked about kind of teaching men how to talk about this issue. And I'd just like for each of you to address, sort of, you know: What can we do? What have you seen that has worked? And Walt, maybe we could start with you.

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Walt Odets: Yeah. I think we have to look just for a moment at the history of prevention. It initially was informational, and then it shifted to an instructive approach. And the instructive approach was essentially a condom every time, for everything -- all kinds of sex, not just anal sex. And the informational thing is necessary. The prescriptive thing, I think, is wrong. It gives men impossible instructions, and it doesn't help men to think about things.

GMHC [Gay Men's Health Crisis], when Richard Elovich was there many years ago, did a campaign where they would show different kinds of scenarios. And they'd show two guys sitting on the edge of the bed, talking. And one would be saying to the other, "You know, we've been having unprotected sex and we've never even talked about it." And then the tag line on the entire series of the campaign was, "Think about it. Talk about it."

So this is a way to use a cliché in empowering people to actually come up with their own approaches to prevention, rather than expecting them to be compliant with simple instructions.

The other thing -- and I'm going back to what Rashad brought up earlier -- is that the self-esteem of the community and the general mental health of the community is critical to prevention. Without that, it can't be done. People who are not happy kill themselves sometimes. And we've certainly seen that among gay men.

So there have been programs: Gay City, in Seattle, was a program which was about the general welfare in a community. This is something that is much better understood in the other English-speaking countries I'm familiar with, in England, and Australia, and Canada.

But we haven't done that in this country. By and large, the federal government hasn't been willing to pay to help gay men feel good about themselves. If we look at some of the British prevention, it's extraordinary in its perception of that issue. So that has to be the foundation. The "think about it, talk about" it part then fits on top of that, in a way that I think is much better as instructive work.

fogcityjohn: Rashad Burgess, I wanted to ask you: You were quoted in the January 2002 issue of POZ magazine as saying, quote: We have to think nontraditional beyond handing people a condom. And I'd like you to elaborate on that. I know that was eight years ago.

Rashad Burgess: Yeah, that was eight years ago.

fogcityjohn: But what are your thoughts today? What's nontraditional? Obviously, you seem to be saying just handing people a condom and telling them to use it is not enough. What should we do?

"We have to make sure that the communities of gay men feel good about themselves, and believe that their lives are worth saving."
-- Rashad Burgess

Rashad Burgess: Well, I mean, I think a couple of things. I think we really have to look at HIV prevention in a very holistic, comprehensive way. And I would actually very much start with where Walt is at. We have to make sure that the communities of gay men feel good about themselves, and believe that their lives are worth saving.

We also have to recognize the fact that, in many areas of gay men, nearly half the population is already HIV positive. And so we have to be willing to look at, you know, how treatment, and the benefits of treatment, can actually play a role in HIV prevention. And so there are discussions going on now around community viral load, and actually what would it mean to actually really ensure that entire communities are maximizing the benefits of treatment, so that the overall viral load is reduced, if not undetectable?

But I do think we're also going to have those individuals; we have to have programs that are for those individuals who are HIV negative, but are your risk takers. And I think it was Jeff that spoke earlier about the fact that there are some people who are just risk takers. And it's not because something bad happened to them; it's just that that's their makeup.

And you know, we have behavioral interventions. And we diffuse effective behavioral interventions -- they're known as our DEBIs -- to help do some of that work, more intensive work that has been proven on behavioral science -- using behavioral science theories -- that really help move people to a place of utilizing condoms more, getting tested for HIV with greater frequency.

As well as ... The last thing that I would say is just general awareness. We know that you can exist in an entire gay environment, and never hear about HIV, or never see a condom, or see any sort of discussion. People are going to think it's not as much of a problem as it was before. And so it is still about also raising of awareness. And those of us who have been in the field a long time sometimes make incorrect assumptions that people are completely informed and aware. And what we have to remember is, we have completely new generations of gay men that live in our communities that we have to engage and reengage in HIV prevention and in HIV prevention messages.

fogcityjohn: Jeff Parsons?

"There's not as much funding available for programs that are designed to deal with some of the underlying issues like depression and loneliness."
-- Jeffrey Parsons, Ph.D.

Jeffrey Parsons: Yeah. I think part of that sort of need to think outside the box, and goes directly to what Walt said -- that the majority of our prevention programs are either outdated, or so exclusively focused on condoms that it misses the broader needs of gay men in today's society. And it's frustrating that the funding that's available for prevention programs is really always sort of looking at, you know, what can you do specifically about the safer sex? And there's not as much funding available for programs that are designed to deal with some of the underlying issues like depression, loneliness, those kinds of things.

And so I think that if we were able to package HIV education and risk reduction in the broader context of dealing with things that gay men actually care about and are interested in, that it could go a lot farther in having some positive effects.

The other thing I'd like to add is that we do sometimes forget about the group of gay men who are out there -- and it's a large group -- who are very happy, very satisfied. They're not depressed. They're not lonely. They're not engaged in risk behaviors. They're not seroconverting. They're actually doing very well. And I think -- and I can certainly say this as a researcher -- that too often we don't get to focus on that group. We don't get to actually talk to them and research them and find out: What are they doing to stay safe, and to stay healthy, and to stay well adjusted?

We tend to have all of our sort of emphasis and focus on those who are not doing so well. And so I think we miss a really big opportunity to find out what are the factors that are helping this large group of gay men stay perfectly safe throughout their lifespan.

fogcityjohn: Interesting. So we could actually learn from the gay men who are succeeding, as opposed to sort of focusing all our attention on those who are having trouble adhering to sort of protected sex.

Jeffrey Parsons: They are obviously doing something right. And empirically, we don't know what it is, because we've not really done the research to find out effectively sort of what are they doing, and what are the facilitators to them being able to stay safe.


Conclusions

fogcityjohn: Well, gentlemen, we're coming towards the end of our time. I would just, at this point, like to ask each of you if you have any final thoughts that you would like to leave our listeners with on this topic. Anything we haven't gotten to? Something you want to expand upon? Why don't we start with you, Walt?

"Every time a state passes a regulation against gay marriage, we're going to have more people infected with HIV. ... The association of HIV with black men involves some of the same kinds of issues. We can't expect to abuse people and then have them take care of themselves."
-- Walt Odets, Ph.D.

Walt Odets: Well, I would just kind of sum up something that we've been talking about -- and that is that, for example, on an issue like gay marriage, which has been so much in the news -- every time a state passes a regulation against gay marriage, we're going to have more people infected with HIV. This goes back to the whole, broad wellbeing of the community. That kind of stuff is hateful and destructive. The association of HIV with black men involves some of the same kinds of issues.

We can't expect to abuse people and then have them take care of themselves. But we have a very broad societal problem in this country. And the HIV epidemic is, in part, simply an expression of that. And I think that that societal situation is something that has to change. It's inhumane and inexcusable that we're still talking about those kinds of issues.

fogcityjohn: Agreed. Rashad Burgess?

Rashad Burgess: I would actually start off really saying that it's, one, important that we, as Americans, recognize the value of gay men, in all of our lives, in the many facets of our lives -- whether it be the business owners, whether it be folks' uncles, or family members, other types of family members, the partners that gay men have. Because it is a community that, it's imperative, understands that their lives -- and as a gay man, that our lives, and my life -- is worth saving.

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It is important to recognize that HIV is still a real problem for gay men, in the context that gay men are still getting infected. I mean, still represent a significant portion of the epidemic. Nearly two-thirds of the infections amongst men in American happen amongst men who have sex with men. And in some populations of gay men, particularly African-American gay men, nearly half the population, based on some of our data, is HIV positive.

And so it is really, really imperative that we, as a community, are having this type of discussion, from the place that our lives, one, are worth saving. But also that it's based in reality, that HIV is a real issue, and that we have to be willing to deal with it and face it ... and wrestle with what does it mean to be working very diligently and hard at preventing HIV -- getting HIV -- for 20 and 30 years.

The last thing I would say is that we have to be willing to think about new strategies. You know, looking at structural interventions, looking at what does it mean to really be thinking about having gay men really utilizing the treatment, optimizing the benefits of treatment, so that we can reduce the viral load, which impacts transmissibility. And so this is really an important issue. We're not out of the woods, in terms of HIV infections amongst gay men. And gay men that think they don't have to deal with this anymore are not well informed, from where I sit.

fogcityjohn: OK. Jeff Parsons?

Jeffrey Parsons: I think one of our biggest challenges is reengaging our communities to get re-involved in this issue again. In the '80s, you know, the gay bars had condoms everywhere. They had posters. They were doing eroticizing safer sex workshops in the back rooms. It was a real community-oriented effort to try to address the situation of HIV in the gay community.

I think part of the challenge to do that in 2010 is that the gay communities, as they used to exist, don't necessarily look the same. You've have such migration of gay men, particularly into broader communities, into the suburbs, into young gay men who don't necessarily just go to gay bars; they often go to mixed or straight bars with their straight friends. And there's not as much of the sense of community defined geographically.

And so I think we really need to look towards building relationships with our allies, building relationships with broader communities, to readdress and reengage about issues related to HIV in our communities.

Walt Odets: The thing that Jeff was talking about, about reengaging the community in prevention, is certainly a very important issue. But we've had, since I've been involved in the epidemic -- you know, since the mid-'80s, actively involved in prevention work -- we've had a pattern where, every time we get a hopeful treatment, we abandon prevention. We can see a very clear ... There was a four-year cycle, up through about 1990, where we had four years of prevention, four years of hopeful treatment that then was announced a failure, and so on.

And we have to find some way to integrate hope about treatment, and support for positive men, with prevention for negative men. And we've never been able to do that.

In 1996, prevention completely collapsed. There was no interest in it at all. And we've been riding the protease inhibitors. They have, in fact, transformed the character of the epidemic. They are a huge improvement over what we had before '96. But they have stifled prevention. Prevention in the context of successful treatment can feel like raising doubt about the efficacy of the treatment, and pulling support away from men who are positive.

That's the thing we've never been able to do. And we're still not doing it. We still don't know how to integrate that. When we do prevention, we're saying it's better to be uninfected. And that feels hurtful to positive men.

fogcityjohn: Well, I think, as a positive man, I can tell you, Walt: It is better to be uninfected.

Walt Odets: But at an emotional level, it can be alarming, and hurtful.

fogcityjohn: Yeah.

Walt Odets: And feel abandoning. And we have to find some way to do both of those things.

fogcityjohn: Well, gentlemen, I want to thank all of you for joining us today. I feel in a way that we have only scratched the surface of this topic. It's a very, very important one.

But again, I want to thank you for being here today. And thanks to all of our listeners for joining us, and for TheBody.com, this is fogcityjohn, signing off. Thank you.

This transcript has been lightly edited for clarity.




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