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?

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8 thoughts on “New paradigms

  1. I like the question, but I think we need to distinguish between people who want to replace condoms with biomedical methods because of spurious claims of ‘failure’ and those professionals who want to add them to the mix.

    • Very good point, and I agree. (edited to add:) But I’m not really talking about individuals in this post — more writing in a simplified way about a novelty-seeking dynamic in the professional culture of public health researchers & practitioners.

  2. This is a bit of a leading question, Daniel. You make the presumption that biomedical interventions currently being researched are “less effective than condoms” but we don’t know yet the effectiveness of PREP, or viral load sorting, or other technologies. There’s a good chance that some of these might be as effective, or more so, than condoms. But we don’t know yet.

    I don’t believe condoms are sustainable as the be-all HIV prevention method over the long term. Unless a cure or a vaccine comes along, that ‘mild upward trend’ in UAI-c will continue to move upward, so research into other, potentially highly effective, prevention technologies is not only justified, it is desperately needed.

    • The judgment “less effective than condoms” actually came from Graham Hart, not me, and it was a summary of the current state of evidence — not what might be around the corner. I think it’s great to research those alternatives, but if that research encourages the bogus (yet popular) belief that condoms have “failed”, then we’re likely to see more infections as a result in the meanwhile. It will be a good 5-10 years before we see PrEP or microbicides available to gay men in Australia.

      • Im not sure I understand the connection you’re drawing between the attitudes of a small number of HIV sector folk (‘condoms have failed’) and a rising rate of infections. I don’t think HIV educators have as much influence as perhaps they like to think.

  3. It’s true that ‘sero-sorting’, like ‘negotiated safety’, was being widely practiced before prevention educators named it or did the research necessary to publicly describe how to do it safely.

    And return to a focus that includes the behaviour of people in groups would also be very welcome. Adult behaviour change is normally about cognitive, behavioural AND social psychology.

    Group or cultural approaches were a feature of much early Victorian prevention ed which set out consciously to create a ‘safe sex culture’. It worked.

    Of course both the expression of gay sexual culture (including but not only the sex itself) have changed since the 1980’s. So have the forums in which cultural norms are formed, expressed and challenged (including but not only online).

    That means the forms of cultural intervention must be different.

    In my view, the solution must include letting people who have HIV talk as directly and frankly as possible to those who do not about why getting HIV is not a good idea, why they wish they didn’t have it.

    Whether as individuals or in groups, we make decisions by weighing up the known pros AND cons. If the cons are invisible, infections will continue to climb, to level off (perhaps) only when enough people personally KNOW a person with HIV to see first hand that HIV is too high a price to pay for almost any form of sex.

    • This is a grrreat comment. Thanks for posting and for god’s sake please consider getting back into the sector…

      From cognitive psychology (specifically, prospect theory) we know that availability, or ease of mental recall, is a key heuristic (mental shortcut) that people use to judge the likelihood of a risk. (And also that people use these heuristics far more than they calculate risk by weighing pros and cons or likelihood and severity.)

      This explains why ‘safe sex culture’ is so crucial — the circulation of informal narratives and discourse provides a constant stream of reminders and reinforcement that we could never hope to match with spending on campaigns.

      I would love to see first person narratives by people living with HIV talking about how they became infected.

      Not necessarily talking about the cons of having HIV, because ‘othering’ is another common heuristic used to disidentify from warning messages by saying ‘it’ll never happen to me’.

      Talking about the everyday, could-happen-to-anybody ways in which people get HIV would (a) remove the moral judgment that facilitates that ‘othering’ and (b) help the neg men realise it could happen to them too.

      If you do it well – make it honest, raw and real – then it will be memorable, and that’s what you need to increase the mental availability of the possibility of HIV infection.

  4. Thanks Daniel. Thoughtful & thought provoking as usual.
    The call for people talking about how they became positive reminds me of a project Eric Rofes and some other guys were working on – I think they called it test/positive/now – I don’t know what it’s status is now. It did a really nice job of bridging that liminal space between “this is familiar and comfortable as someone who is negative” and “positive as other”.

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