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.
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.
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).
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.
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.
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).