After diagnosis of hepatitis C, some gay men willing to consider risk-reduction practices

Qualitative study identifies need for better hepatitis C prevention information for gay men with HIV

Roger Pebody
Published: 27 November 2013

HIV-positive gay men living with HIV in France need better information about the sexual transmission of hepatitis C, according to a researcher who interviewed 31 men about their experience of living with hepatitis C.

The moment of hepatitis C diagnosis appears to offer an opportunity for prevention work – during a period of emotional turmoil, men are open to absorbing information and reconsidering their sexual choices, according to the study published in the current issue of Culture, Health and Sexuality.

With one exception, almost no qualitative research has been published on the experiences of gay men with HIV who have acquired hepatitis C. As part of a larger epidemiological study, Jean-Yves Le Talec of the University of Toulouse therefore interviewed 31 men about how being diagnosed with acute hepatitis C fitted into their personal history, sexuality and health concerns. The interviewees all lived in major French cities and were aged between 33 and 58 years.

Interviews were conducted between 2006 and 2008.

All the interviewees said they were “deeply involved in sex”, with most respondents meeting partners through websites for men with HIV wishing to bareback, sex-on-premises venues and informal networks of friends who organised sex parties.

Hepatitis C can be passed on during sex that could lead to contact with traces of blood. Acquiring hepatitis C has been associated with unprotected anal sex, fisting, sharing sex toys or pots of lubricant, or injecting or snorting drugs.

All interviewees either occasionally, regularly or consistently had unprotected anal intercourse with casual partners. Only around half reported fisting and not all reported having group sex. Drug use was commonly (but not universally) reported, often to enhance sexual pleasure and performance, but only one man said he had injected drugs.

Around two-thirds of respondents used the word ‘barebacking’ to describe their sexual practices and presented unprotected sex as a conscious choice. They generally sought out sexual partners who were also living with HIV and saw serosorting (choosing partners with the same HIV status) as a way to escape a feeling of responsibility towards another person. They felt that these choices allowed them to have sex that they enjoyed, with an acceptable level of risk.

One man commented:

“Well, my sexual activities give me a way to relax, to let go. It goes so far that it has probably brought me to consider only practices without condoms, so that I can find the way to fully free myself and let go.”

On the other hand, a minority of interviewees had a much less ‘self-controlled’ vision of their sexual practices. They described unprotected sex in terms of ‘compulsion’ and ‘relapse’.

“There is always the desire for risky sexual encounters, always this dependence, you see. Just like a drug addict or an alcoholic who wants to kick the habit, but…”

These men did not present themselves as intentionally taking risks, but described themselves as not being in full control of their sexual activity and of now paying the price.

While some of the respondents had been aware of the possibility of sexual transmission of hepatitis C before their own diagnosis (often because someone they knew had had it), clear information about transmission routes hadn’t been available.

Most men’s acute infection was detected, unexpectedly, during a routine HIV check-up. Few had experienced symptoms and the diagnosis generally came as a surprise. Doubt, disbelief, anger and a sense of unfairness were commonly reported.

Men were rarely able to link the infection to a precise moment, situation, location or partner.

“It’s not clear, because I still don’t grasp how I got it. I knew it was something about blood, but I don’t see where there could be blood in my sexual practices.”

After diagnosis, many men lacked libido, reduced their sexual activity or reconsidered their sexual practices:

“Things are still dead calm! I haven’t been out anyway since… I had no sex for two weeks. Complete abstinence, because there is a blockage.”

Most interviewees only felt able to disclose their hepatitis infection to a few people:

“I talked about it with my boyfriend who lives with me, then with two or three partners I see from time to time... This disease is shameful, you know! It’s revealing risky practices and so on. If I had to disclose hepatitis to my close friends, it would mean, in their minds, that I still have risky sex, that I’m messing around.”

This man said that it was easier to talk about having HIV than hepatitis C virus (HCV):

“It may be stupid, but if HIV is the gay cancer, then you could say that HCV is the junkie cancer, so it’s somehow similar, isn’t it... I’m queer, I get fucked, I get fisted, no problem, but I don’t want to be what I’m not. Facing people around me, I’m worried about the way HCV is perceived in the society. If that wasn’t the case, I would have spoken more openly about it.”

But with time, the initial emotional turmoil faded away, and many men felt more optimistic, especially if they had spontaneously cleared the virus or if treatment was successful. Many men resumed the sexual behaviour they had had before diagnosis.

“When I was diagnosed with hepatitis C, I thought that it was perhaps time to settle down and to take precautions, to be much more careful. But I know it’s going to be hard to do, yes I know. In real life, I cannot control myself.”

Many men who assumed a barebacker identity had no desire to change their behaviour or give up on sex that was associated with intense physical pleasure, social connections and a sub-cultural identity.

“I know full well that [hepatitis] may happen again, I’m well aware of that, but in principle I’m not going to change my sexual practices.”

Others did not anticipate a sweeping change of sexual lifestyle, but intended to make specific changes, such as selecting partners more carefully or not sharing sex toys.

“I think that we are going to do less, with much less partners, and above all with much more precaution and hygiene... We are not necessarily going to change our sex life, but the way to do things.”

Concluding, the researcher notes there was a brief period after diagnosis during which some men were open to reconsidering their choices – healthcare providers should discuss prevention at this time.

“HIV-positive gay men need better information about HCV transmission associated with unprotected sexual practices, in order to implement effective risk-reduction strategies, such as wearing gloves when fisting, paying attention to bleeding, not sharing sex toys, using lubricant, limiting enema use and asking their partners about their HCV-status. They also need to be informed about HCV drug-related risk practices (sharing straws when sniffing, sharing needles when injecting), associated or not with sexual practices,” he says.

Moreover, the number of HIV-positive gay men who acquire hepatitis C a second, third or fourth time (see reports from London, Amsterdam and across Europe) underline the need to identify effective prevention interventions for this group.

Reference

Le Talec JY When ‘raw sex’ turns to a ‘raw deal’ … taking the opportunity to think about sex? Interviews with HIV-positive gay men diagnosed with acute hepatitis C. Culture, Health & Sexuality 15: 1133-47, 2013.

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