Three-quarters of Australian gay and bisexual men who report
unprotected anal intercourse with casual male partners say that they “often” or
“always” employ some sort of risk reduction strategy with those partners. Many
attempt to select partners who they believe have the same HIV status as
themselves (serosorting); a significant proportion use condoms most but not all
of the time; and smaller numbers practice ‘strategic positioning’ or withdrawal
The study shows that a simple, black and white division of
gay men into low risk ‘condom users’ and high risk ‘men who don’t use condoms’
is misleading. However that is sometimes the impression given by behavioural
Martin Holt of the University of New South Wales presented
the data to the 20th International AIDS Conference in Melbourne
yesterday. It is derived from an analysis of the responses to two large-scale,
cross-sectional community surveys of Australian gay and bisexual men in 2011
and 2012. A total of 15,615 completed the surveys.
Overall, 38% had no casual partners (and are not included in
this analysis, even if they did not use condoms with their partner), 28% always
used condoms with casual partners and 13% had no anal sex.
That leaves 21% who reported anal sex without a condom with
at least one casual partner in the previous year – this group was the focus of
Moreover as risk reduction strategies differ according to
HIV status, the analysis made comparisons between the 2339 men who had tested
HIV negative and the 603 men who were diagnosed with HIV. The small number of
men who had never tested for HIV were excluded from the analysis.
Holt was interested in risk-reduction strategies the men
used “often” or “always” with casual partners, including:
(having a partner perceived to have the same HIV status) when having anal sex
positioning when having anal sex without condoms – in other words, the
HIV-positive partner taking the receptive position (bottom).
before ejaculation during anal sex without condoms.
HIV-positive men who didn’t consistently used condoms with
casual partners reported serosorting (60%), condoms (22%), strategic
positioning (17%) and withdrawal (15%).
HIV-negative men were more likely to report using condoms
most of the time, but serosorting was still the most widely reported tactic
(44%), followed by condoms (41%), strategic positioning (24%) and withdrawal
Three-quarters of men reported using more than one strategy;
the strategies most commonly combined were serosorting and condom use.
There was a very strong association between using these
strategies and disclosing HIV status to sexual partners. This was the case both
for HIV-positive and HIV-negative men.
For example, for HIV-negative men, those who disclosed to
some sexual partners were almost twice as likely to practice a strategy as
those who did not (odds ratio 1.76, 95% confidence interval 1.39 – 2.21) and
those who disclosed to all partners were three times as likely to have a
strategy (odds ratio 3.43, 95% confidence interval 2.66 – 4.42).
HIV-positive men who always disclosed were seven times more
likely to use these strategies (7.11, 95% CI 3.70 – 13.67).
HIV-negative men who had a regular partner were less likely
to practice any risk reduction strategy if their partner was untested or HIV
Martin Holt concluded that interventions should aim to
improve the consistency with which gay and bisexual men employ risk reduction
strategies. Men should be encouraged to disclose their HIV status, to make
effective agreements with their regular partners about casual sex and to choose
the best strategy in different scenarios. Alternative approaches such as PrEP
are likely to be appropriate for those men unable or unwilling to use existing