"Barebacking" in a Diverse Sample of Men Who Have Sex with Men

In recent years, sexual risk behavior and STD rates have been rising among men who have sex with men (MSM). During this period, the sociocultural phenomenon called "barebacking" emerged among MSM. The researchers propose reserving use of the term for intentional anal sex without a condom, with men who are not a primary partner, among men who have heard of the term. A key aspect of this definition is intent: the individual consciously seeks unprotected anal sex. Intentionality distinguishes barebacking from poor planning or spontaneous decisions about condom use. Also key is that the sexual partner is non-primary; therefore, the behavior is not in the context of "negotiated safety."

In this study, the researchers examined the prevalence of barebacking among HIV-positive and HIV-negative MSM, the perceived HIV serostatus of their barebacking partners, and the specific sexual behaviors that occurred during their most recent bareback encounter. They assessed the men's reasons for barebacking and where men met their partners. Finally, they examined whether men who barebacked had a higher general sexual risk behavioral and attitudinal profile compared with other men.

The researchers conducted a cross-sectional survey of MSM in the San Francisco Bay Area from July 2000 to February 2001. Of the 554 participants, 28 percent were African-American, 27 percent Latino, 31 percent white, and the remainder were of another race/ethnicity or a combination. All were 18 or older, lived/worked in the Bay Area, and reported having had sex with a man in the previous 12 months. Thirty-five percent of the men reported they were HIV-positive; 61 percent reported they were HIV-negative; 4 percent did not know their serostatus. Thirty-six percent of the men had a bachelor's degree or higher. Seventy-nine percent identified as gay; 19 percent identified as bisexual; 2 percent gave another sexual orientation.

More than two-thirds of participants had heard of barebacking. Increasing levels of education and income were associated with having heard of barebacking. Of men who were familiar with the term and thus potentially familiar with the sociocultural phenomenon of barebacking, 14 percent had barebacked in the previous two years. Of those who were aware of the term, 22 percent of HIV-positive men and 10 percent of HIV-negative men had barebacked. There were no differences in the prevalence of barebacking by race/ethnicity, education, income or sexual orientation identification. The median number of bareback partners in the previous 12 months was three.

A strong pattern of serostatus-assortative behavior was found for receptive anal sex (i.e., HIV-positive men with HIV-positive partners; HIV-negative men with HIV-negative partners). A greater portion of HIV-positive than HIV-negative barebackers reported unprotected receptive anal sex with an HIV-positive partner. More HIV-negative than HIV-positive barebackers reported unprotected receptive anal sex with HIV-negative partners. There was no difference by participant serostatus in unprotected receptive anal sex with partners of unknown HIV serostatus. Many men who barebacked reported unprotected receptive and insertive anal sex with men of different or unknown HIV serostatus during their most recent bareback encounter. Half of the HIV-positive and more than half of the HIV-negative barebackers reported being drunk on alcohol or high on drugs during their last bareback encounter. Eighty percent of barebackers said their chief reason for barebacking was to achieve greater physical stimulation.

The researchers reported that this was the first quantitative study strictly defining and describing the sociocultural phenomenon of barebacking in a diverse sample of MSM. "New approaches are needed to reduce the prevalence of barebacking and to address, more generally, the increasing incidence of sexual risk behavior, STD and, potentially, HIV infection among MSM. Interventions must take into account that men who bareback are more likely to report that their recent sexual risk behavior in general has resulted partly from the availability of improved treatments and declining rates of AIDS diagnoses and deaths. Prevention messages should simultaneously address specific risk behaviors, perceptions of HIV disease in an era of largely successful drug therapy, and issues of treatment resistance, side-effects and failure."

"Unique programs that target men by their HIV serostatus are needed, such as CDC's Serostatus Approach to Fighting the HIV Epidemic (SAFE) initiative; motivations for barebacking and sexual risk behavior in general may differ by whether individuals are primarily putting themselves or others at risk of infection."

"Finally, our data suggest that most men who bareback are likely to use a future rectal microbicide, even if such a product were protective only 50 percent of the time it was used," the researchers reported. "More collaboration is needed in laboratory research, clinical trials and behavioral studies to identify safe, effective, and acceptable rectal microbicides."

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