The forces encouraging sexual risk behaviour are large and widespread, but the forces for precautionary behaviour are meagre and narrowly focussed, argued Ford Hickson of Sigma Research at the CHAPS conference of gay men’s health promoters in Brighton last week. Rather than describe HIV prevention in the UK as failing, he suggested it would be more accurate to say that it is inadequate.
Other sessions at the conference included one of the first qualitative studies of the experiences of gay men co-infected with hepatitis C and HIV, and an examination of how HIV-positive men have adjusted their behaviour in the light of prosecutions of HIV transmission.
- The power of sexual pleasure. "If you do not understand sexual risk," he commented, "it is probably because you don’t appreciate sexual desire."
- The rapid expansion of the gay scene into "a large business sector supplying services for sexual contact and locations to have sex".
- The continued denigration of homosexuality in society, and the associated emotional isolation and low mood of many gay men.
- Men’s self-medication with alcohol and drugs, which is problematic in a culture which excuses risk-taking while under the influence.
- The widespread belief that ‘real sex’ is anal sex.
- The commodification and fetishisation of barebacking as a transgressive behaviour. "Gay sub-culture has long legitimised the eroticisation of unacceptable thoughts," Hickson suggested, and barebacking porn is one manifestation of this.
- Individualistic cultural norms that reject notions of responsibility. "The idea that you would sacrifice something yourself in order to protect or care for someone else seems, at the moment, to be deeply alien to gay culture and HIV prevention approaches," he said.
- Optimistic biases in our thinking: telling ourselves that risks are smaller than they really are.
Reviewing the forces towards precautionary behaviours, he rejected the notion that in the age of combination therapy, gay men no longer see HIV as something worth the effort of avoiding. Hickson reminded the conference that the majority of uninfected men support criminal prosecutions for HIV transmission, would decline any sexual contact with a man they knew had HIV, and if anything, have an excessive fear of HIV.
However he suggested that many of the other precautionary forces were misdirected. He criticised behavioural approaches that are too narrowly focussed on identifying and treating ‘high-risk’ individuals, and denounced public discussions of the epidemic that give the impression that "straight Africans moving to the UK with HIV are actually young straight Britons acquiring HIV".
Moreover, he suggested that the forces for precaution have become reduced to NHS services provided by a few charities. "As the amount of money has contracted, competition for these meagre resources has become a major preoccupation," he said. "Leadership has been replaced by salesmanship and collaboration has been replaced by competition."
Sam de Croy, on behalf of the principal researcher Jan Mojsa, presented findings from a qualitative study of the lived experience of hepatitis C and HIV co-infection. The presentation reflected the experiences of gay men attending a co-infection support group at Body Positive North West.
A common thread was that co-infection encouraged men to reflect on their life so far, re-evaluate patterns of behaviour, and make changes. This was particularly clear in terms of sex and relationships. The participants tended to describe their pre-hepatitis sex lives as ‘full’ or ‘promiscuous’. Most had acquired hepatitis at a sex party, and part of their sense of identity was connected with being good sexual performers.
One man commented: “I only ever put energy into two things and that was sex and work you know, and I thought there was a point when I was doing both things very well…” However hepatitis had put a stop to both: “You can’t work properly. You don’t feel like you want to have sex and shouldn’t put anyone else at risk and physically you’re so frail from the interferon...”
All the men were now looking for relationships that were more characterised by emotional intimacy and companionship.
Another theme was a sense of being isolated. The men tended to ‘get on with things’ on their own, and were reluctant to ask friends for help when dealing with illness and treatment side-effects. Isolation could also be a symptom of depression, and all the men had previous experience of depression (before co-infection). Interferon treatment exacerbated this, and despair, suicidal thoughts and perceptions of personality changes were common.
However the participants did not always feel that clinic staff had given enough support before they started hepatitis treatment, or had fully involved them in decisions. They were not always emotionally prepared for the side-effects and the impact on employment.
Criminal HIV transmission
Only a minority of HIV-positive gay men who recently engaged in unprotected anal intercourse have even a basic understanding of criminal HIV transmission, Dr Catherine Dodds of Sigma Research told the conference.
Sigma Research recently published Relative Safety II, a study examining the behaviour of 42 HIV-positive gay men who had engaged in unprotected anal intercourse. As part of the study, the men were asked a number of questions to establish their understanding of criminal HIV transmission.
Their answers showed that only a minority of men (approximately one-third) knew that HIV-positive individuals in the UK had been convicted for ‘reckless’ HIV transmission, with similar proportions knowing that the convictions had been for grievous bodily harm, that the cases had hinged on the complainant’s lack of consent because the accused had not disclosed his or her HIV status, and that this was a ‘serious’ issue.
Some men reported that they took care to disclose their HIV status to sexual partners. One individual even went so far as to save web logs of internet chat to prove that he had disclosed his HIV status in the event of a criminal complaint being made.
However, other men had adopted the opposite strategy, and told the investigators that they were taking additional precautions to conceal their HIV status to protect themselves from the risk of prosecution.
This suggested to Dr Dodds that the prosecutions were not increasing the likelihood that HIV-positive individuals would disclose to potential sexual partners.
Hickson F Who’s failing who? 12th annual CHAPS conference, Brighton, 2009.
De Croy S Hep C and HIV. 12th annual CHAPS conference, Brighton, 2009.
Dodds C Stage management. 12th annual CHAPS conference, Brighton, 2009.