course, many HIV-positive gay men use condoms as a matter of course and do not
fist or go to sex parties: they are likely to be as safe from contracting HCV
as it is possible for a sexually active gay man to be. At the other end of the
spectrum, fisting, group sex and drug use appear to present the greatest risks.
But what about those HIV-positive gay men who choose to serosort but do not
engage in more hardcore activities like fisting and group sex? These men may
face the biggest uncertainties about HCV risk – in the face of which, the most
frequent advice is caution.
Martin Fisher puts it, "We would like to be able to say, 'HCV is
transmitted like this, and therefore here is what you need to do to avoid
getting it.' Unfortunately I think we're at too early a stage to be able to
give such definitive guidance, and I think we have to be honest about that. We
simply have to tell people what we know: that there probably is an increased
risk with any sexual activity with exposure to semen, and almost certainly more
so with blood."
to Daniel Fierer, the bottom line is "awareness in the gay community that
you can get HCV sexually. This is a
new and unfortunate risk in serosorting. Let's assume the risk is significant,
and take precautions. That may not be popular, but it is simple."
challenge is that men who have chosen to serosort may already have disengaged
from standard safer-sex messaging. (Dire, but overblown, warnings of
reinfection with HIV ‘superbugs’ may well have bolstered scepticism toward
"condoms for all, all the time" messages.)
says Marc Thompson of the Terrence Higgins Trust (THT),
was a significant challenge for his organisation in providing information to positive
men who bareback. "We knew we were dealing with men who were already quite
well-informed about safer sex issues, who didn't engage with typical safer-sex
messaging, and who had made decisions around their own sexual health
first step, then, was not to talk but to listen. In a series of focus groups,
and others at THT met with the men
likely most at risk for HCV, those who frequently fist, have rough sex, and use
drugs. Those who had already been co-infected with HIV and HCV had a clear
message for their peers: hepatitis C is not just another STI. "Gay men may
think of sexually transmitted infections (STIs) as things that can often be
treated fairly easily: a trip to the clinic, a couple of pills. The men in our
groups wanted us to stress how debilitating hepatitis C is, and how completely
different HCV treatment is from the treatments for other STIs." That
message – that HCV treatment is lengthy and hard to tolerate – was "loud
and clear," says Thompson.
brings us back to the question: in the absence of certainty about what's risky,
what is the best prevention advice? "We're just trying to present all the
info as it stands," says Thompson. "We're not the condom police, but
we have not ruled out unprotected anal intercourse as a means of HCV
transmission, so that has to be put out there, along with all the other
information we have to date."
one more factor is probably contributing to hepatitis C transmission as well as
worsening life for those infected: the fear, shame and stigma of the disease.
Gay men with hepatitis C have said they feel “grubby, skanky, isolated and
ashamed." They have called HCV "the big new white elephant in the room”,
something gay men are "scared of, but that nobody is talking about."
Men with HCV have described an "us and them situation" in which their
dual diagnosis excludes them from the “camaraderie of just being HIV-positive.”21
as a community we have a mandate to help HIV-positive men avoid co-infection.
Yet, as we continue to battle stigma against people with HIV, it would be a sad
irony if our own community opened its arms to people with one virus but turned
its back on those with another.