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22 Dec 2011

Gay men having unprotected sex think that having HIV is still a big deal, but that it’s now harder to transmit

According to a study of Australian gay men, HIV optimism remains a useful indicator of one's likelihood to take risks during sex and one's beliefs about HIV transmission risk in particular may reflect willingness to pursue pleasure over risk, or, alternatively, morbid fear of any risk.

A study of Australian gay men examining unprotected sex and the beliefs that are associated with it has found that the concept of ‘treatments optimism’ needs to be unpacked. While some men do think that having HIV is less serious than it used to be, there is more of an association between unprotected sex and men believing that treatments have made HIV-positive people less infectious.

"Rip & Roll" safe sex campaign posters, which feature a real-life gay male couple in an embrace, at a busstop in Brisbane, Australia. The camaign was reinstated after it became clear the complaints were part of a concerted campaign by the Australian Christian Lobby.

But writing in the journal Sexually Transmitted Diseases, the researchers warn that the relationships between information, beliefs and behaviour are not straightforward, with individuals managing risk, desire and pleasure in complex ways.

Soon after the advent of combination therapy, commentators began to explain unprotected sex in gay and bisexual men in terms of ‘treatments optimism’ – the theory that reductions in illness and death had caused men to be less concerned about HIV infection, and so more willing to have unprotected sex. While a number of studies have confirmed an association between beliefs characteristic of treatments optimism and risk behaviour, it is unlikely that such beliefs – held by a minority of men – are sufficient to explain rising infection rates in gay men. 

Moreover, there has always been controversy over whether treatment optimism leads to unprotected anal sex, or whether it is a way in which men rationalise their sexual behaviour, after the event.

Quantitative data

In 2009 Garrett Prestage and colleagues recruited men via social networking and gay dating websites to take part in an anonymous cross-sectional online survey. A total of 2306 men completed the survey, with 2138 answering all the questions mentioned here.

The average age was 35 and the majority of men were university educated. One in ten had been diagnosed with HIV. Whereas 28% of men without HIV reported having unprotected sex with a casual partner in the last year, 58% of positive men reported doing so.

Men were asked about their beliefs concerning HIV and antiretroviral treatment. While 55% of men agreed that “HIV is no longer a death sentence”, only a minority of men agreed that “HIV is less serious than it used to be” (28.5%) and that “HIV is becoming a controllable disease like diabetes” (31.1%).

Men who agreed with one of these ‘HIV health optimism’ statements tended to agree with the others.

Fewer men agreed with a series of statements about HIV treatment and reduced infectiousness. Only 7.6% of men agreed that “HIV-positive men who are on treatments are unlikely to pass on HIV if they fuck without a condom”, 7% agreed that “HIV treatments take the worry out of sex” and 6.6% agreed that “I fuck without condoms more often because of HIV treatments”.

Once again, men who agree with one of these ‘HIV transmission optimism’ statements usually also agreed with the others.

Men with diagnosed HIV were consistently more likely to agree that HIV treatments have improved the health of men with HIV and made transmission less likely (p <0.001).

Also, men who had had unprotected anal sex with a casual partner in the past year were generally more likely to agree with these statements than men who had not (p <0.001).

The researchers then conducted multivariate analysis to identify the factors independently associated with unprotected sex. In each case, while ‘HIV transmission optimism’ remained an important factor, ‘HIV health optimism’ no longer was. In other words, while beliefs about undetectable viral load and infectiousness were associated with not using condoms, beliefs about HIV being a more manageable condition were not.

Among men who were HIV-negative the last time they tested, unprotected sex was associated with ‘HIV transmission optimism’ beliefs (adjusted odds ratio 1.26, 95% confidence interval 1.20 – 1.33). The association was similar for HIV-positive men (adjusted odds ratio 1.31, 95% confidence interval 1.13 – 1.52).

Qualitative data

In order to get a better understanding of men’s rationalisations and motivations, the researchers invited a group of 40 men who had completed the online survey to take part in in-depth interviews.

The researchers found that most men had a firmly-held, though often somewhat abstract, commitment to a concept of ‘safe sex’ and an ongoing concern about HIV as a significant issue affecting gay men. However men’s personal responses to this belief varied. Four key themes emerged during the interviews.

Some men remained deeply concerned by HIV. While they recognised that HIV is no longer a death sentence, they had a strong desire to avoid transmission. One man said: “HIV is a background threat - always there and something to be mindful of when having sex, regardless of a partner's status. I know the impact it can have on health, well-being and lifestyle, despite advances in treatments, and don't want it.”

Some men expressed limited concern about HIV. One HIV-negative man said: “I have friends who have been positive for eighteen years and they are very successful and very healthy. With medication it’s not such a big thing anymore!” Some men with diagnosed HIV did not think they were likely to infect others: “Treatments, having an undetectable viral load, the Swiss study and anecdotal evidence make me feel pretty certain I won't pass on HIV.”

Some men were morbidly fearful of HIV. For them, HIV had changed very little since the advent of treatments. In some cases, their constant fear of HIV had profoundly affected their ability to enjoy sex. One man said: “It is a death sentence. It is an enormous issue in my life and never leaves my mind. It holds me back from having sex.”

Some men suggested that HIV was not particularly relevant to their lives. They thought little about HIV or the possibility of its transmission. “Well HIV isn't an issue for me as I am not infected and I count myself very lucky as I do take risks by having bareback sex. To be honest I really don't give it much thought…”

The researchers note that individual men could sometimes express more than one of these themes at the same time. Moreover, contradictions between beliefs and behaviour were apparent. Men who were very fearful of HIV were not always consistent condom users; a number of men who considered the impact of HIV to be much diminished remained vigilant about safer sex.

Interpretation

Garrett Prestage and colleagues note that there is an association between ‘HIV transmission optimism’ and risk behaviour in this group of Australian men. However they raise questions about how men come to hold their beliefs about HIV.

The beliefs that men hold about ‘treatments optimism’ or ‘transmission optimism’ can reflect many different things, the researchers suggest. In some cases, beliefs depend on the information men have access to. Similarly, some men’s beliefs are partially based on their own experience of sex or of life with HIV.

In other cases, beliefs are informed by desires: optimistic beliefs about HIV transmission can sit comfortably with a desire to have unprotected sex, while scepticism about reduced infectiousness can reflect an overwhelming desire to avoid transmission. Finally, beliefs are informed by different personal attitudes toward risk. Some men are risk-averse, while others are relatively adventurous and inclined to take risk in the pursuit of pleasure. 

“Measures of HIV optimism should be complemented by analysis of the complexities of individuals’ assessments of both risk and pleasure in specific sexual contexts,” they conclude. 

References 

Prestage G et al. Is Optimism Enough? Gay men's beliefs about HIV and their perspectives on risk and pleasure. Sexually Transmitted Diseases, online ahead of print, 2011. (Free abstract here). 

Prestage G et al. Pleasure and Sexual Health: The PASH Study. National Centre in HIV Epidemiology and Clinical Research, Sydney, 2009. (Free full text here). 

This article was first published by NAM/Aidsmap.com and is republished with permission.

Reader's Comments

1. 2011-12-23 02:19  
SO in the short word, what does the whole thing try to tell us? I am sorry, I saw too many words, I don;t understand. Please someone explain it in a rather easy vocabulary. Thank you.
2. 2011-12-23 10:10  
@post #1:
it's trying to say that ppl are still willing to take risks & engage in unprotected sex coz they believe that HIV is not as serious as it used to be a few decades ago (prob coz of medication available to surpress the condition).
3. 2011-12-23 14:19  
There is this concentration on HIV, but there many other Sexually Transmittable Diseases which you need to be aware of. Most of them will not display obvious signs in the heat pf the moment.

Condoms during and personal hygiene before & after sexual contact are important to minimize the risks of infection. No one is immune though never allow fear to ruin your love life - suppression of emotional desires can damage you mental equilibrium.
4. 2011-12-23 23:06  
Colin, I agree with you as to the fact that there are many other Sexually Transmitted Infections/Diseases that we as gay men need to be concern about. The issue of HIV being a treatable virus has allowed many of us to relax and practice unsafe sex. We develop this mindset that we will not contract it IF... But most people think that way, until they actually contract a STD or STI.

Shabuya, I wish that you were able to understand what they were trying to express with all the words. There is some really good information there and it is best to learn as much as you can about such things for your personal health, for you are ultimately responsible for it. And it is great that you admit your lack of understanding and is seeking support in the area of understanding. Knowing is half the battle.

Colin you make another great point about personal hygiene. It is very important to maintain a healthy and clean body to reduce the risk and the spread of STDs/STIs. It is always wise to practice the use of condoms during oral sex. Dental dams are another good method to reduce the spread of contraction of STIs. If you don’t have a dental dam you can use a cling clear plastic wrap. It works just as well and it is a barrier especially when practicing anal oral sex. Just make sure the side next to the anus is moisten or lubed for maximum pleasure for the person receiving.

Seanadlt you did a wonderful job providing a summary of the long article. It is nice to see mature adults taking responsibility for their lives and helping others to improve their sexual health and growth. We should not live in fear of sex. Sex is a very natural thing and to be safe and to practice sex with a healthy mindset makes the experience all the less frightful. HIV and other STIs are still a serious problem and we must consider it a problem and do what we can to reduce the risk of contracting or spreading STIs.

It really all comes down to choice. I say, and this goes for me as well, make the choice that promotes excellent health.
5. 2011-12-25 08:14  
Condoms and dental dams during oral sex is so ..impersonal. It's akin to having sex with a plastic device. I understand the risks but I can't bring myself to suck on lubricated silicone or other plastics.
6. 2011-12-25 08:46  
My interpretation of these findings is that campaign-designers face the challenge of balancing Optimistic and Pessimistic messages in their promotional communications when trying to reach out to a diverse group of people who perceive HIV very differently.

Those individuals who are irrationally fearful about HIV may become even more fearful of getting voluntary screening and information if they are exposed to campaigns that paint HIV very negatively. On the other hand, if campaigns paint a too positive image of HIV, giving the impression that getting HIV doesn't hurt at all since effective treatment is available, then optimistic individuals may be tempted to practice riskier sexual acts.

Awareness-raising campaigns are very effective in guiding people towards a general direction but not in educating them to see the big picture and, by so educating, empower them with the intellectual ability to decide for themselves what actions to take. In the case of anti-HIV campaigns, if we try to give people too negative an impression of HIV in order to warn against 'Treatment Optimism', then we may scare them and discourage them from taking any action (such as screening, counselling, treatment) at all. On the other hand, if we try to give them too positive an impression, assuring them that HIV isn't a death sentence, then we may cause 'Treatment Optimism'.

Either way, the only outcome that such campaigns aimed at guiding people towards one direction (more optimism or more pessimism) would deliver limited desirable effects. If we do not offer Comprehensive Sexuality Education in schools, we cannot empower people with the intellectual ability to choose their own direction, after they themselves have weighed the potential pain and pleasure of each.

But that is not to say that awareness-raising campaigns have zero value. In the absence of CSE, they are indispensable. What we need to do, though, is to lobby the government to work more quickly in introducing CSE to schools. We may not see result in the short term, and those who'd left school may not benefit from school CSE, but if we don't start to plan for our younger generation today, they will grow up to face the same challenge that we now do.
7. 2011-12-26 14:06  
i agree with collin
if you're not going to have a good time
then might as well not have it in teh 1st place.
but the suvery does help give an insight on the sexual prowerss of the males sapiens
8. 2011-12-27 01:51  
just use a condum as much as you can. and use good judgement.
9. 2011-12-31 01:38  
No one can prove HIV causes AIDS, not even in Court in front of the Judge! Time to wake up guys!

http://www.youtube.com/watch?v=8izreKH8OcE
10. 2012-01-17 12:43  
Oh, Christ... here come the AIDS deniers again... HIV causes AIDS, it has been proven in countless laboratories, ergo whether or not it can be proven in court matters as little as you do.

11. 2012-01-20 17:09  
To No.3, I strongly agree with you
"There is this TOTAL concentration on HIV, but there are many other Sexually Transmittable Diseases you need to be aware of."

Indeed the TOTAL concentration on this phantom HIV is unjust because other Sexually Transmittable Diseases are highly transmittable ie. 2-3 sexual intercourses will get anyone infected; whereas the Padian Study (http://www.youtube.com/watch?v=liLT2Mb11ao) shown that HIV infection will require 1000 acts ! By over spending and over focusing on HIV, we are all neglecting the other diseases which affect more people and kills more Lifes such as heart disease, malnutrition, malaria, TB and cancers etc.

To No. 10, a denier is a person who doesn't want to look at the data and facts, but keep calling names at people who don't agree with them.
"HIV causes AIDS, it has been proven in countless laboratories"
Can you please kindly point out which laboratories exactly HIV has been proven to cause AIDS? At least some reference will give your statement a stronger stand. Any 3 year-old can say HIV causes AIDS, because that's what they've been told.
Comment edited on 2012-02-02 06:49:56
Comment #12 was deleted by an administrator on 2012-11-12 12:45

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