June Crawford

Sexual negotiation in the AIDS era: negotiated safety revisited.

Objective:To test the safety of the ‘negotiated safety’ strategy — the strategy of dispensing with condoms within HIV-seronegative concordant regular sexual relationships under certain conditions. Method:Data from a recently recruited cohort of homosexually active men (Sydney Men and Sexual Health cohort, n = 1037) are used to revisit negotiated safety. The men were surveyed using a structured questionnaire and questions addressing their sexual relationships and practice, their own and their regular partners serostatus, agreements entered into by the men concerning sexual practice within and outside their regular relationship, and contextual and demographic variables. Results:The findings indicate that a significant number of men used negotiated safety as an HIV prevention strategy. In the 6 months prior to interview, of the 181 men in seroconcordant HIV-negative regular relationships, 62% had engaged in unprotected anal intercourse within their relationship, and 91% (165 men) had not engaged in unprotected anal intercourse outside their relationship. Of these 165 men, 82% had negotiated agreements about sex outside their relationship. The safety of negotiation was dependent not only on seroconcordance but also on the presence of an agreement; 82% of the men who had not engaged in unprotected anal intercourse outside their regular relationship had entered into an agreement with their partner, whereas only 56% of those who had engaged in unprotected anal intercourse had an agreement. The safety of negotiation was also related to the nature of the safety agreement reached between the men and on the acceptability of condoms. Agreements between HIV-negative seroconcordant regular partners prohibiting anal intercourse with casual partners or any form of sex with a casual partner were typically complied with, and men who had such negotiated agreements were at low risk of HIV infection. Conclusions:The adoption of the strategy of negotiated safety among men in HIV-seronegative regular relationships may help such men sustain the safety of their sexual practice.

Sustaining safe sex : a longitudinal study of a sample of homosexual men

ObjectiveTo assess the maintenance of safe sexual practice. (We use the term ‘safe’ sex throughout the paper, since ‘safe’ is the term adopted by the Australian National Committee on AIDS.) DesignMaintenance was assessed by comparing sexual behaviour with both regular and casual partners reported in a 1986/1987 survey (time 1) with behaviour reported in a second survey in 1991 (time 2). MethodThe 145 homosexually active participants were a non-clinical sample recruited in 1986/1987 by advertisement and followed-up in 1991. A structured questionnaire was administered at both times. Items included questions about the nature of the mens sexual relationships and their sexual practices. ResultsOur findings indicate that the majority of men had sustained safe sex practices. HIV prevention strategies adopted included condom use, avoidance of anal intercourse and negotiated safety (i.e., the negotiated practice of unprotected anal intercourse within regular partnerships of concordant serostatus). ConclusionsNegotiated safety is not the same as relapse.

In a minority of gay men, sexual risk practice indicates strategic positioning for perceived risk reduction rather than unbridled sex

Abstract The aim of this analysis was to examine gay mens sexual risk practice to determine patterns of risk managemtent. Ten cross-sectional surveys of gay men were condtrcted six-monthly from February 1996 to August 2000 at Sydney gay community social, sex-on-prmises and sexual health sites (average n=827). Evely February during this period, five identical surveys were conducted at the annual Gay and Lesbian Mardi Gras Fair Day (average n=11 78). Among the minority of men who had umprotected and intercourse which involved ejaculation inside with a serodiscordant regular partner, there was a clear pattern of sexual positioning. Few regular couples mere both receptive and insertive. Most HIV-positive men were receptive and insertive. Most HIV-positive men were recptive and most HIV-negative men were insertive. Among the minority of men who had unprotected anal intercourse which involved ejaculation inside with casual partners, there was also a patterns of sexual positioning. Whereas many casual couples were both receptive and insertive (especially those involviug HIV-positive respondents), among the remainder HIV-positive men tended to be receptive and HIV-negative men tended to be insertive. These pattenu of HIV-positive/receptive and HIV-negative/insertive suggest strategic risk reduction positionings rather tlran rrlere sexrial preferences among a minority of gay men. If so, they point they point to complacency but to an ever more cornplex domain of HIV prevention.

Unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men

Objective:A range of risk reduction behaviours in which homosexual men practise unprotected anal intercourse (UAI) has been described. We aimed to assess the extent of any reduction in HIV risk associated with these behaviours. Design:A prospective cohort study of HIV-negative homosexual men in Sydney, Australia. Methods:Men were followed up with 6-monthly detailed behavioural interviews and annual testing for HIV. The four risk reduction behaviours (behaviourally defined) examined were serosorting, negotiated safety, strategic positioning, and withdrawal during receptive UAI (UAI-R). Results:In 88% of follow-up periods in which UAI was reported, it occurred in the context of consistent risk reduction behaviours. Compared with those who reported no UAI, the risk of HIV infection was not raised in negotiated safety [hazard ratio = 1.67, 95% confidence interval (CI) 0.59–4.76] and strategic positioning (hazard ratio = 1.54, 95% CI 0.45–5.26). Serosorting outside negotiated safety was associated with an intermediate rate of HIV infection (hazard ratio = 3.11, 95% CI 1.09–8.88). Withdrawal was associated with a higher risk than no UAI (hazard ratio = 5.00, 95% CI 1.94–12.92). Patterns of UAI differed greatly according to partners serostatus. Men who reported serosorting were less likely to report either strategic positioning or withdrawal. Conclusion:Each behaviour examined was associated with an intermediate HIV incidence between the lowest and highest risk sexual behaviours. The inverse association between individual behaviours suggests that men who practise serosorting rely on this protection. The high prevalence of these behaviours demands that researchers address the contexts and risks associated with specific types of UAI.

‘serosorting’ in casual anal sex of Hiv-negative gay men is noteworthy and is increasing in Sydney, Australia

This paper addresses the question of whether HIV-negative gay men engage in ‘serosorting’ in casual encounters. Serosorting, defined as engaging in unprotected anal intercourse with casual partners who they report to be HIV negative, has been increasing among HIV-negative gay men in Sydney. Prevention and intervention programmes are urgently needed to alert HIV-negative gay men to the risks associated with ‘serosorting’, and remind them of the need for consistent condom use.

Cultures of sexual adventurism as markers of HIV seroconversion: A case control study in a cohort of Sydney gay men

A case control analysis within an ongoing cohort study was used to examine differences between seroconverters and men who remained HIV-negative. The cases were interviewed within one to 13 months prior to their seroconversion. Their responses to a structured questionnaire were compared with those of HIV-negative controls drawn from the same time period and from the same longitudinal study, Sydney Men and Sexual Health. Data collected from both cases and controls included: demographic and contextual variables, knowledge of HIV transmission, sexual practices, drug and alcohol use and attitudinal factors. The aim was to compare the sexual behaviours, and the social and cultural contexts of such behaviours, of men prior to their HIV seroconversion with men who did not seroconvert. Twenty-three men had seroconverted within the cohort. Cases were identified by a positive HIV antibody test or self-report of positive HIV status following a previous negative HIV test. Three-hundred-and-sixty-nine controls were selected on the basis of being HIV negative at interview in 1994, and having at least one subsequent medically-confirmed negative HIV antibody test. Univariate predictors of seroconversion were: being in a regular relationship with a known HIV-positive partner, drug use, and engaging in a range of anal and esoteric sexual practices. Practices commonly used to enhance sexual pleasure, such as group sex, watching and being watched having sex, the use of sex toys and dressing up/fantasy, were engaged in more frequently by seroconverters. Engaging in these esoteric sexual practices was highly correlated with drug use, involvement in the gay community and engagement in a wide range of anal practices. In the multivariate analysis independent predictors of seroconversion were: younger age; being in a regular relationship with a known HIV-positive partner; believing withdrawal to be safe with regard to HIV transmission; and range of esoteric practices. These results indicate the importance of the social and cultural contexts of particular sexual practices and consequent HIV transmission. Sexually adventurous men may be at increased risk for HIV because they seek sex within particular sexual sub-cultures.

Gay men's current practice of HIV seroconcordant unprotected anal intercourse: serosorting or seroguessing?

Abstract We explored seroguessing (serosorting based on the assumption of HIV seroconcordance) and casual unprotected anal intercourse (UAIC) associated with seroguessing. The ongoing Positive Health and Health in Men cohorts, Australia, provided data for trends in seroconcordant UAIC and HIV disclosure to sex partners. In event-level analyses, we used log-binomial regression adjusted for within-individual correlation and estimated prevalence rate ratios (PRRs) and 95% confidence intervals (95% CIs) for the association between the knowledge of a casual partners seroconcordance and UAIC. UAIC and HIV disclosure significantly increased during 2001–2006. HIV-positive men knew partners were seroconcordant in 54% and assumed it in 13% of sex encounters (42 and 17% among HIV-negative men). Among HIV-positive men, the likelihood of UAIC was higher when a partners status was known (Adjusted PRR = 5.17, 95% CI: 3.82–7.01) and assumed seroconcordant because of seroguessing (Adjusted PRR = 3.70, 95% CI: 2.56–5.35) compared with unknown. Among HIV-negative men, the likelihood of UAIC was also higher when a partners status was known (Adjusted PRR = 1.88, 95% CI: 1.58–2.24) and assumed seroconcordant (Adjusted PRR = 2.12, 95% CI: 1.72–2.62) compared with unknown. As levels of UAIC remain high, seroguessing increasingly exposes gay men to the risk of HIV infection. Because both HIV-positive and HIV-negative men often seroguess, education and prevention programs should address the fact that HIV-negative men who engage in UAI due to this practice may be at high risk of HIV infection. HIV prevention should take into account these contemporary changes in behaviors, especially among HIV-negative gay men.

Undetectable viral load is associated with sexual risk taking in HIV serodiscordant gay couples in Sydney.

Objective:To determine whether reporting that the HIV-positive partners viral load is undetectable rather than detectable is associated with unprotected anal intercourse (UAI) in HIV serodiscordant gay couples. Method:A cross-sectional study nested within two cohort studies, the Health in Men (HIM) cohort of HIV-negative men, from July 2001 to December 2003 and the Positive Health (PH) cohort of HIV-positive men, from February 2002 to August 2003. The study participants were 119 men in an HIV serodiscordant regular relationship of at least 6 months duration (45 HIV-negative men from HIM, 74 HIV-positive men from PH). The main outcome measure was the occurrence of UAI within the relationship in the previous 6 months. Results:Eighty-two men reported no UAI and 37 reported some UAI. Of couples in which the HIV-positive partners viral load was reported to be undetectable, 39.4% reported UAI compared with 20.8% of those where viral load was reported to be detectable (P = 0.04). In multivariate analysis, significant predictors of UAI were younger age [odds ratio (OR), 0.94; 95% confidence interval (CI), 0.87–1.00; P = 0.05], greater HIV optimism (OR, 4.98; 95% CI, 1.25–19.8; P = 0.02) and reported undetectable viral load (OR, 2.88; 95% CI, 1.13–7.37; P = 0.03). Conclusions:Most serodiscordant gay couples do not engage in any UAI. UAI within such relationships is significantly more likely to occur where the HIV-positive partner is reported to have undetectable viral load. UAI in HIV serodiscordant relationships is problematic even if viral load is undetectable because of unknown risk parameters, viral load variability and the possibility of drug-resistant strains of HIV.

Women negotiating heterosex: Implications for AIDS prevention

Abstract The AIDS epidemic has made it imperative that sexual behaviour be changed. This paper examines heterosexual negotiation, which will form the focus for behaviour change. The processes involved in such negotiation are little understood. Research was carried out using the method memory work, which generated and theorised data relating to womens past experiences in sexual encounters. The method, originated by Haug, provides a way to examine how sexuality is produced and reproduced through reflection and reconstruction of past experiences. Memories are analysed by examining gaps and absences, cliches and metaphors, in the search for the common understandings and taken-for-granted assumptions which set the boundaries within which encounters take place. The memories obtained can be partly understood in terms of three discourses documented by Hollway. These are the male sex drive discourse, the have/hold discourse, and the permissive discourse. The data may also be understood in relation to three permissible figures for women identified in Irigarays analysis, namely virgin, wife-mother, and whore. The paper acknowledges that these theoretical perspectives are quite distinct, even contradictory, but nevertheless finds that each in its own way illuminates the data. It is shown that some common understandings underlying sexual encounters render negotiation not only impossible but largely unintelligible. The permissive discourse may possibly provide space for some negotiation, but the paper concludes that it is essential to develop a truly woman-centered discourse of sexuality out of which male sexuality can be problematised.

How has the sexual behaviour of gay men changed since the onset of AIDS: 1986–2003

Objective: To report changes in sexual behaviour among gay men in Sydney from 1986 to 2003.