New paradigms

I’m in Sydney, sampling a day of the Australian sexual health and HIV medicine conferences.  Most of the really exciting social research is presented these days at biomedical conferences, because they are prestigious.

Working in the community health sector, a day is all my PD budget can afford, unless I approach a pharmaceutical company to sponsor my attendance. It’s a big problem if community workers can’t afford to take part, because we need that knowledge too.

Graham Hart from University College London just gave an incredibly lucid presentation on the change in paradigm he’s seeing in HIV prevention.

Where research used to focus heavily on individual behaviour, and how it interacted with the biology of STI, now we’re looking at the behaviour (and structure) of people in groups, and the overall ecology of STI, plus time,  because epidemics change as they ‘mature’.

In the past decade, we’ve seen a very mild upward trend in the number of men who have unprotected sex with casual partners.  Hart puts up UK data showing about 20% of gay/bi men had this kind of sex in the previous year.

He puts up another slide showing the number of men who report ‘serosorting’ (deliberately choosing a partner who reports the same HIV status for unprotected sex) has increased from about 7 to about 18% in the past decade.

This he attributes to the impact of the Internet, although I’m told serosorting showed up in Australian data from the 1980’s — almost as soon as the HIV antibody test became available.  My guess is that serosorting is not, actually, a new development; having a name for the phenomenon is what’s new.

This is why we need a sociology of HIV prevention research and practice, since there are trends and patterns in how long-existing practices ‘in the real world’ get named and tagged as the ‘next big thing’ in HIV prevention.

In fact, Hart touches on this issue.  He talks us through a range of new approaches, including biomedical and ‘social structural’ interventions.

Biomedical techniques include circumcision, lubricating gels with anti-HIV ingredients, and pre-exposure prophylaxis (PrEP) which is basically taking PEP before you fuck unsafely.

Hart points out that even circumcision, the most effective biomedical intervention found to date, is less effective than consistent condom use.

He tells the audience, “don’t give up on condoms just yet.”

I couldn’t agree more.  With Ford Hickson, I’m very, very skeptical of the claim that “condoms are failing”.  Ford points out that people who say prevention is failing want it to fail so they can take the money and do it themselves.

(And not because they’re bad people.  That’s just a consequence of how funding processes put us in competition, not collaboration, with each other.)

Instead, our benchmark should be about 70-80% of gay/bisexual men practicing consistent condom use during casual sex… or maybe even most of the time. That’s about the best any country ever been achieved.

Setting that benchmark lets us ask how we divide up and target the rest.  Only 1-2% of them are the “barebackers” that 99-100% of media coverage and community debate has focused on.  The rest are just guys who occasionally have unprotected sex.

That includes me, by the way.  Once, ever.  With a guy in a sauna.  It was his first time being fucked.  We knew and liked each other.  I knew he was a consistent condom user with his other partners.

With these ‘occasional’ guys, as Michael Hurley says, the infrequency of the occasions is a marker of their general commitment to safe sex.

When it is infrequent, although there are fewer occasions of risk, the intensity of risk might actually increase, because those men have less practice in risk reduction techniques that can help prevent HIV transmission during unprotected sex.

And if it occurs without planning, they may not be prepared to ask questions about their partner’s history of occasional unprotected sex and sexual health testing.

There have been resources in Australia that talk about those ‘risk reduction’ techniques, such as HIV-Positive Gay Sex (AFAO), but nothing I know about that has talked honestly to gay men about occasional unprotected sex.

We really need to start doing that, and I’m hoping tomorrow’s policy forum on “HIV from Epidemic to Endemic” will help start that conversation.

In closing, I want to ask a provocative question.  It picks up on Hart’s message “don’t give up on condoms just yet.”  He wasn’t talking to gay men.  He was talking to an audience of people working in sexual health medicine: doctors, nurses, researchers, and policy people.

Here’s my question:  is it possible we might be pushing for biomedical interventions that are less effective than condoms just because professional audiences are bored by hearing about condoms?