Barebacking: not a simple phenemenon, US research shows

This article is more than 21 years old.

Three separate studies on how gay men make decisions on when and how to bareback were presented on Tuesday at the Tenth Conference on Retroviruses and Oppportunistic Infections in Boston, providing a deeper understanding of how unprotected anal intercourse (UAI) has become an accepted part of gay life in the US.

In the first study, Jeff McConnell of the Gladstone Institute of Virology and Immunology, argued that gay men in San Francisco are now taking “safer risks” by making sure that the riskiest sex usually happens with sexual partners perceived to be of the same serostatus. Sixty-two HIV-positive gay men enrolled in ‘Positive Partners’ - an ongoing study into the prevalence and clinical relevance of HIV superinfection - who continued to have UAI with either regular or casual partners, were asked for details of their sexual history over the previous three months. Half of these men had at least one episode of UAI with partners who were either HIV-negative or of unknown HIV status. Twenty-nine percent of these man were the insertive UAI partners at least once.

In total, these 62 men had sexual encounters with 335 different people, and although they had had a lot of sex, the researchers narrowed down HIV exposure risk to 3.3 exposures per person. This was because the majority of sex with HIV-negative or unknown HIV status partners did not include UAI, and when UAI occurred with partners of different HIV-status (12% of all sexual encounters), the HIV-positive partner was almost always the (slightly less high risk) receptive partner, a strategy termed “sexual positioning.” Significantly, the HIV-positive men in the study were three times more likely to have UAI with another HIV-positive man compared with HIV-negative or unknown status men.


unprotected anal intercourse (UAI)

In relation to sex, a term previously used to describe sex without condoms. However, we now know that protection from HIV can be achieved by taking PrEP or the HIV-positive partner having an undetectable viral load, without condoms being required. The term has fallen out of favour due to its ambiguity.


Insertive anal intercourse refers to the act of penetration during anal intercourse. The insertive partner is the ‘top’. 


Receptive anal intercourse refers to the act of being penetrated during anal intercourse. The receptive partner is the ‘bottom’.


Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).


When somebody already infected with HIV is exposed to a different strain of HIV and becomes infected with it in addition to their existing virus.


One of the conclusions of the San Francisco study was that these HIV-positive men did not differentiate between HIV-negative partners and unknown HIV status partners when it came to barebacking. But a pan-US study from the Center For Disease Control in Atlanta, looking at high risk sex between HIV-positive men in monogamous relationships (of unknown length) between 1995-2000, found that there was a difference. Here, 1761 (45%) out of 3939 HIV-positive men recruited in the CDC’s SHAS study reported having one steady sex partner at a time. Of these, 791 (45%) had an HIV-positive partner, 720 (41%) an HIV-negative partner and 250 (14%) a partner of unknown HIV status. This was a culturally diverse group, of which 47% were white, 26% black and 23% Hispanic. The majority (51%) were aged between 30-39, identified as gay (84%), and were college educated (52%).

In total, 674 HIV-positive men in a monogamous relationship were aware of their HIV status throughout the study period.

The researchers found that 21% of the HIV-positive men reported at least one episode of UAI with their negative or unknown HIV status partner in the previous year, of which 13% were insertive, 44% receptive and 44% both insertive and receptive. Significantly,19% had UAI with a partner known to be HIV-negative, whereas 30% had UAI with a partner of unknown HIV status. In a logistic regression model, the researchers found that HIV-positive men who did not know for certain that their partner was HIV-negative were nearly twice as likely to engage in UAI. Sexual positioning strategies were not measured, however.

Finally, researchers from the Medical and Health Research Association of New York City attempted to discover whether the internet is a hotbed of barebacking activity. Last summer they recruited 6000 gay and bisexual men through chat room banners on the US website and asked them 60 questions about their sex, drug and alcohol habits during the previous six months. 2934 questionnaires were completed and eligible for the study.

As would be expected with users, the majority of the respondents were white, well-educated, good-earners and had sex only with men. HIV-positive men made up 7.6% of the sample. All 50 US States were represented in the survey, as well as a wide age range: 46% were between 18-29; 46% 30-49; and 8% over 50. Eighty-four percent said they had met sexual partners online.

Overall, 60.5% of respondents reported at least one incidence of either insertive and/or receptive UAI in the previous six months. The researchers found that 64% of those who used the internet to meet sexual partners had UAI, compared with 58% of those who didn’t use the internet, which they found to be statistically significant.

More significantly, they found that HIV-positive men who met partners online were 1.5 times more likely to have UAI than HIV-negative men. Overall, HIV-positive men, regardless of internet use, were 1.4 times more likely to report UAI than HIV-negative men.

However, the researchers did not ask whether the men they met online were the same men with whom they had UAI, nor whether they selected to have UAI with other HIV-positive men. The study provocatively implied that the internet was a new high-risk meeting ground for gay and bisexual men. However, since the respondents were a highly sexually experienced population (almost a quarter reported more than 100 lifetime partners with 6% reporting more than 10 partners in the past month) with illicit drug use over 40%, it seems likely that these men are simply taking their current risk behaviours to the internet, rather than the internet creating a new virtual barebacking phenomenon.


McConnell J et al. Sorting Out Serosorting with Sexual Network Methods. Tenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 41, 2003.

Denning P H et al. Unprotected Anal Intercourse Between Steady Male Partners with Nonconcordant HIV Serostatus.Tenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 920, 2003.

Chiasson M A et al. Internet and High-risk Sex among Men Who Have Sex With Men. Tenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 37, 2003.