Strategising safe sex

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01 Dec 2014

These days, ‘safe sex’ (meaning a very low likelihood of transmission of HIV) isn’t just restricted to condom use alone. The one-size-fits-all approach no longer applies. Now, it’s a whole different ball game.

Hugging the analogy to my chest and running with it, back in the day sex was ping pong. The game was simple enough to understand: there was protected sex and unprotected sex, condom or no condom. The rules were black and white. Today, the game is more complex; think International Rules Football (a hybrid of Aussie Rules and Gaelic Football for anyone interested).

“Sex hasn’t been black and white — condoms or no condoms — for quite some time,” said ACON CEO Nicolas Parkhill. ACON has released a list of risk reduction strategies that reasonably constitute safe sex (provided certain parameters are met). They are: condoms, PrEP, sustaining HIV suppression, serosorting, and negotiated safety agreements.

The first strategy — our old friend the love glove — remains an effective barrier against the transmission of HIV. Men who use condoms every single time they have anal sex are up to 70% less likely to acquire HIV in their lifetime than men who don’t use them.

But in the real world who uses condoms 100% of the time? In the heat of the moment they can be passion killers — once you’ve finally managed to tear open the packet with your teeth, you’re as stiff as week-old celery. And when you’re not quite — how shall we put it? — compos mentis, it’s easy to throw caution to the wind. So given 30 years of condom promotion has failed to end HIV, surely the more prevention methods in our Bat Belts the better.

Which brings us to PrEP. PrEP involves an HIV-negative person taking an anti-HIV drug once a day. If taken as prescribed with strict adherence, PrEP has been shown to reduce the risk of HIV transmission by up to 99%.

While many in the HIV sector believe PrEP to be an important new component of an effective combination prevention response, there are others who are concerned it will lead to an explosion of unprotected sex, accompanied by increased rates of sexually transmitted infections

“We know from research that many of the men interested in PrEP already have low rates of condom use,” said Parkhill. “So while it may be counter intuitive, PrEP could reduce the rate of some STIs in these men, as to access PrEP, men will need to see a GP every three months at least which creates more opportunities to offer STI testing and to break the cycle of transmission.”

Number three on ACON’s list of risk-reduction strategies is a supressed viral load. According to several large international studies, a positive person on antiretroviral treatment maintaining an undetectable viral load (UVL) reduces the risk of HIV transmission to low to next-to-zero.

Earlier this year, interim findings of the PARTNER study (which aimed to assess the risk of transmission between poz-neg couples engaging in condomless sex) showed a transmission rate of 1% a year where couples engaged in any anal sex, and 4% for anal sex with ejaculation where the HIV-negative partner was receptive. In a nutshell, the positive partners were virtually non-infectious.

Fourth on the list: serosorting. This is a strategy that aims to limit condomless sex to people of the same HIV status. In order for this strategy to be effective, men must not only know their own status but also be sure of the status of their partners. “HIVpositive men have been using serosorting for many years,” said Parkhill. “We have always respected gay men’s capacity to manage this complexity, by and large successfully.”

However, serosorting in casual sexual encounters is not an effective prevention strategy for HIV-negative men, as ascertaining the current HIV-negative status of even a familiar casual sex partner is inherently unreliable.

Fifthly, and finally, negotiated safety agreements. This is where two HIV-negative men —having established they share the same serostatus — agree to limit condomless sex to their relationship only. Negotiated safety requires that both parties have an explicit agreement about always practising safe sex outside the relationship.

Such a strategy requires transparency and a commitment to revising the agreement should it be broken. “The model of agreement promoted is one where there is an overt agreement to discuss slip ups,” said Parkhill. “Obviously, this is not a great thing to happen, and different couples will take different approaches. We would recommend returning to sex with condoms — or another form of protection — until both partners have reconfirmed HIV-negative status.”

There are some who will dismiss condomless sex strategies altogether. Gay men who engage in ‘unprotected’ sex are reckless, dangerous — irresponsible, they say. “We don’t think anyone should be judged or stigmatised,” said Parkhill. “We would make the case that sex on PrEP or effective UVL is protected sex, as is sex with condoms.”

But after decades of being told to always wear a condom, isn’t there a risk gay men could find the condomless strategies confusing? After all, it flies in the face of ingrained community norms. “Having a range of choices to protect against [HIV] is — in our view — a benefit,” said Parkhill. “Ensuring we equip men with this information and support them to make informed choices is the key challenge here. Pretending these [strategies] don’t exist would seem to us to be the greater risk.”