This article by Mathew Rodriguez first appeared on TheBody.com here.  

As a licensed therapist working with people living with HIV, Damon Jacobs heard about pre-exposure prophylaxis (PrEP) as an HIV prevention strategy. When he found himself newly single after being out of the dating game for almost a decade, he re-entered a dating pool that was not at all condom-friendly. To deal with this, and to finally come to terms with his distaste for condoms, Damon began taking PrEP in July 2011 to stay HIV negative.

Now, almost two years later, he's never missed a single dose -- and he's become an advocate for education around PrEP, though he acknowledges that it may not be the right strategy for everyone. From dispelling myths around anti-condom attitudes to advocating that people be able to talk to their doctors about all aspects of their sex life, Damon reminds us that sex isn't dirty, and we can have sexual pleasure, but we have to be smart and know our own bodies.

Can you tell us a bit about your background and experience in the HIV community?

I'm a licensed marriage/family therapist in New York state. I'm also licensed in California. That means that I work with people in relationships. Sometimes I work with couples in the room. Sometimes I work with individuals who are in couples.

I was getting my formative education and training in psychology in the San Francisco Bay Area in the mid-early 1990s, in the early days of HIV/AIDS -- or, actually, it was after the first wave. That was a time when loving people with AIDS and knowing people with AIDS meant losing people with AIDS. You would see people one day and then the next day, you wouldn't see them. That was before we had treatments. And that really affected a lot of the way that I continued to want to be active in the HIV prevention, education and treatment community -- also as a therapist, as someone who could help people infected and affected by HIV to have lives that were still meaningful and purposeful and pleasure-filled.

That's really been the mission that I've had for the past 15 to 20 years, is trying to promote a sense of empowerment, and mental and spiritual health for people infected and affected with HIV -- people that are, often, in relationships with other people who are HIV positive, and a lot of serodiscordant relationships (meaning that one person is negative, one person is positive) -- and helping them negotiate the boundaries and agreements and how they discuss issues around sexuality, around sexual expression.

When was the first time that you remember hearing about PrEP?

The first that I remember hearing about PrEP was actually around Thanksgiving, the day before Thanksgiving, of 2010. I try to keep up with the latest research, and I had just heard about this study. I didn't really know anything about it. I just heard that there was this study called "I-Something." I thought it was like an Apple computer or something, because it was called the "iPrEx study." I heard about some sort of pill that could potentially prevent someone who was negative from becoming positive. And I thought, "Well, that could be interesting." Then I didn't really think any much more about it for another six months.

During those six months, a long-term relationship of mine was coming to an end, and I was getting back into the dating world. Also, the cruising world. I realized that in the seven years that had passed since I was last single, a few things had changed. For one thing, the partners I was meeting had a very different attitude around condoms than they had had in the early 2000s. They didn't want to use condoms. And to be honest with you, there were times I didn't want them to use condoms, either. For the very first time in my life, I was in this confusing state of, "Wait a second, I've been this prevention advocate about condoms and lube for all these years. And here I am, not exactly holding myself to the same standards."

So, I heard about this information session about PrEP that was going to be happening at GMHC in about June of 2011. And I thought, "Well, I just want to know more about this." I didn't think it was going to apply to me in any way. But when I got there, there were some of the researchers and some community advocates that were sharing the information that was available. And when I heard the researchers say that the variable aspects of efficacy in the iPrEx study ranged from 44 percent and 90 percent ... well, 44 percent wasn't going to sell me. I wasn't going to play that game. But when I heard that it was 90 percent amongst participants in the study who actually took the medication consistently, between 90 and 92 percent, that's when my ears perked up. I was like, "Wait a second, maybe this is something for me. Maybe this is something that would not only positively impact the people who I work with and my friends and my clients, but maybe this is something I would benefit from." Again, I was having a much more difficult time maintaining the consistent use of condoms than I had had before. Realizing that there could be a medication that could actually assist me in maintaining my HIV-negative status by about 90 to 92 percent made me want to learn more about it.

I talked to the researchers, and I got some of their information after this event at GMHC. I then learned more about the iPrEx study, and by that point the CDC (U.S. Centers for Disease Control and Prevention) had a page on their website for doctors to go to if they wanted to prescribe this as an off-label medication, because it was not yet approved by the FDA (U.S. Food and Drug Administration) at this point. It would still be a year away before the FDA would approve it. But there was still plenty of information about the iPrEx study and information and guidelines for doctors -- even in 2011.

So, I printed all that out, took it to my doctor, who I have a very good relationship with, and said, "Look, this is what I'm learning. This is what the research is saying. And, I'm having a harder time in my early 40s staying safe than I ever had in my 20s or 30s. I think this might be the right thing for me." He looked it over, he thought about it, and said, "Yep, I agree with you." That's when I started PrEP. I started July 19, 2011, and I've not missed a single dose since. We are now in March of 2013.

What I've since learned and what I've become more knowledgeable of, what we've become more aware of, in the time since the iPrEx study, is that the participants who took Truvada (tenofovir/FTC) seven days a week -- who did not miss a dose -- appeared to be 99 percent less likely to contract HIV. The original estimate that they were putting out there was around 90 to 92 percent. Maybe it was always known, or that knowledge was not made readily available, that that subsection of the 2,500 participants who took this seven days a week appear to be 99 percent less likely to get HIV.

Now, condoms, which I've relied upon to stay negative, despite having positive partners, despite having positive boyfriends, which I always have, those are about 98 percent effective. So I knew when I was being sexually intimate with a positive partner with condoms and lube, there was 98 percent protection, and I could work with that. With PrEP now, with 99 percent efficacy -- if taken everyday -- wow. Wow. Revolutionary.

It confuses me why more people don't know about this. It may not be the right decision for everybody. For me, I really had to think about it from a medical perspective. From an emotional, sexual perspective, I had to think whether this was the right choice for me or not. But, the fact is, it has been approved by the FDA for this use since July 16, 2012. And the majority of the people I know, the majority of the people I talk to, don't even know it exists, much less that it has been approved -- and that many insurance companies pay for it. It baffles me how we can have such an effective tool in the fight against HIV and so little information out there about it.

Can you tell us about your PrEP regimen? How do you remember to take your pill, and when do you take it?

I have a pretty consistent routine, and I always have. Well, not always, but as long as I've been health conscious. I take vitamins. I'm not a health food nut; to be honest with you, I hate healthy food. I live off pizza. That's the thing. But, I take multivitamins. I take multivitamins that are rich with all these dried-up vegetables; they come from a special farm in Wisconsin. They're really good for you. So, that's really an important part for me, is to maintain a vitamin regimen and to eat breakfast every single day. Which is another thing we often do, all of us do, to neglect our self-care. It's so important. And I drink coffee. So, I wake up; I have my breakfast; I have my vitamins; I have my coffee. That was already an established routine in my adult life. Those are important things I do to take care of myself and start the day right. PrEP was just one thing to add into that. It wasn't anything that was inconvenient. It hasn't been something I've forgotten. It's just with the vitamins now. It's on the same little thing that the vitamins sit on, so I don't forget.

Did you feel that you had to go through a Truvada "coming-out process" where you had to tell people in your life that you were making a decision to go on PrEP? I mean friends and family, not sexual partners.

Who likes to talk about anal sex with their friends and family? I mean, I kinda do, because that's the field I work in, and those of us who work in the HIV field often do anyway. Nevertheless, it's not always a common conversation that you have at the dinner table with your parents. And before it was approved, honestly, I was concerned about talking about it. I was concerned that my insurance would cease supporting this if I was open about it. The shift in me now telling my friends and family and trying to get the word out there is because the FDA did approve it. It's all on the record with the insurance companies.

So, yes, it was weird. I had to explain this to my parents before talking about this publicly, because I'm friends with my mom on Facebook, and I thought that, quite possibly, she's going to see some of my shenanigans. So, I explained to them, "If I was a woman and I told you I wanted to take birth control pills, would you support me?" And my parents were like, "Yeah, we'd support you on that." Then I said, "Well, if I told you that there was a pill that could actually prevent me from becoming HIV positive by almost 99 percent, would you support me on that?" And they said, "Why would you need that?" Ugh, not what you want to hear. So, basically, I explained to them the idea of oral prophylactics, of prevention, of responsibility, of prioritizing my mind, my body, my spirit. That's consistent with the work I've always done, both personally and professionally. And this was very much in alignment with that. That they got; that they understood.

The other thing with friends is just that people don't believe it -- because there's so little information out there, because this has not really been covered very much. So, the friends I told about this, they didn't disapprove, they were just scared. They didn't really believe that this works. They didn't think this was real. They just thought I was going out and being self-destructive. They don't think that now, but in the beginning when I was starting to talk about this, my friends were concerned that I was on this binge of self-destructive, hedonistic, bug-seeking anarchy. And didn't really understand. So again, I did my best to show them the research, show them the data that were out there. Explain to them that this was being done with a doctor. Time has shown that, OK, we're on the right path here. We know what we're doing.

How do you broach the subject of PrEP with potential sexual partners? Do you feel like you can say, "Oh, it's OK, I'm on a pill." Run us through that whole song and dance.

Well, as I said, dating in 2013 is really different from 2003, and one of the biggest differences is that the condom conversation doesn't happen half of the time. In San Francisco in the 1990s, there was no treatment, and half of the men in San Francisco were positive. So, it was pretty much a given that, if I was going to be sexually active, that 50 percent of the people I was going to meet were going to be positive. So I just assumed everyone was positive, regardless of what they told me, and acted accordingly. But there was often a conversation; there was some acknowledgement that a condom was being used.

A lot of guys don't use condoms and don't talk about condoms. Now, from an education, from a prevention standpoint, that's terrifying! But it's also for real. But to answer your question, it doesn't always come up. The conversation doesn't always happen.

When I am with a partner, or if I'm dating someone who is positive, they will tell me that they're positive, and I will tell them about PrEP, and sometimes the response is "Phew! Good!" And other times, the response will be, "Well, we're still using condoms, because never in a million years would I knowingly put someone at risk for HIV. I just won't do that. That's not my principle." And that's a response I often get from the positive community. Here's what I say: "All right, cool, I understand. But here's what I also want you to consider. Daily use of PrEP has been shown consistently in different research studies to be 99 percent effective in preventing HIV. Daily use of antiretrovirals by someone who is positive has been shown to be about 96 percent effective in reducing the transmission of HIV. On my side, I've got 99 percent protection, on your side, you've got 96 percent protection. The likelihood that I will be getting HIV from you at this point in time is pretty miniscule."But, to be political on another subject, when you look at the escalation of gun violence in this country, and you see that about 30 murders a day are happening in America in which people are being killed by guns, I feel like the likelihood of me getting shot right now is higher than the likelihood of me becoming HIV positive with those odds. So, I put it like that to partners and then I say, "So, what do you think?" Sometimes, they say, "Nope, I still will not have sex without condoms." And there are people who are like, "OK, I see where you're coming from. Let's get busy." And I respect people's right to use condoms. Which is one of the biggest misconceptions about people who take PrEP. We're not the anti-condom police.

They think that you're the "barebacking brigade"?

Radical barebacking brigade! On the streets! We're talking about PrEP as one strategy to prevent HIV, not the strategy to prevent HIV. It is one strategy to prevent HIV. Along with condoms, along with positive people knowing that they're positive and taking antiretrovirals so that they cannot give HIV to another person. It has been an opportunity for people in serodiscordant relationships, including myself, to experience more intimacy and more pleasure than ever before in the 32 years of this thing called AIDS. And I, honestly, didn't know if I would ever see that in my lifetime. I really didn't think I would ever see that in my lifetime, to be honest with you. It's really been a revelation in that way. So, to answer your question, sometimes I talk about it, sometimes I don't.

Does the condom conversation ever come up around STIs (sexually transmitted infections) other than HIV, since PrEP only protects against HIV? Or do people just not talk about it?

I'm telling you from my experience: People are not talking about HIV and they are definitely not talking about STIs. I'm not saying that's good. I'm not saying that's right. I'm not saying that's healthy. I'm just saying that's the reality of many hookups and of many of the conversations, or lack of conversations, out there.

This is why it is so so so important for people to have medical care with a doctor who they trust, who they respect. I always say, "If you can't talk to your doctor about getting fucked up the ass, then you have the wrong doctor!" You need to have a doctor who you trust. If you feel judged or criticized or condemned by your doctor because you have a healthy sex life or a sex drive, find a doctor who you trust. They are out there. In some areas they are easy to find, and in some areas they are not so easy to find.

You are a consumer. Not the patient. You are a consumer. That's a very different paradigm. Because a "patient" is passive, and just has to do what the doctor tells them do. A "consumer" can say, "If you don't treat me with a certain level of respect, and if you don't engage in a sophisticated, adult, respectful conversation with me about anal sex, then I, as a consumer, can go to somebody else who is willing and able to do that with me." That's the reason we have to have really positive relationships with the medical community, because part of taking PrEP is that it's so important to see your doctor consistently, have your blood drawn consistently, and get tested for other STIs, because PrEP does not offer ANY protection against syphilis, gonorrhea, herpes, all that fun stuff. There's no protection there. So, I do get my blood and urine drawn from my doctor every three months to screen for that.

If someone were to come up to you and ask you, "Hey, who should be in the conversation about PrEP?," what groups would you name?

We know, statistically speaking, that there are about 50,000 new infections in the United States every year. For those of us who want to champion prevention efforts, I think we did a great job in the '90s of bringing down new infections. I used to stand on the corner of Sanchez and Market in San Francisco with those pins that said "100%" and give out condoms and lube and pins, because the message was "100 percent condoms and lube all the time!" Not fully understanding at that time how we were inadvertently creating a shame around those people who didn't use condoms and lube all the time, and kind of making their voices silent.

But, I will say this: If you look at the infection rates during the '90s and the early 2000s in this country, they continued to decline until 2004. Since 2004, almost the last 10 years, it's been about 50,000. So, who are these 50,000 people? In New York City, it's overwhelming black gay and bisexual men between the ages of 18 and 25. These are the group of people that are testing newly positive most frequently in New York, and I think that's also occurring in major urban areas across the United States. This is the population that needs to know about this. It's important that 40-year-old white guys know about it too -- like me! It's really important that everybody knows about it, but especially to help the message get into the communities where HIV is being transmitted at the highest rate.

Fifty thousand new infections in this country is 50,000 too many, especially now that we have a new, effective prophylactic prevention tool. There's no need to have 50,000 new infections in this country. There's no need to have 25,000 new infections in this country. But what if we could at LEAST reduce the number of infections by 50 percent? Wow. Wouldn't that be something? Well, you know something? PrEP, even when taken inconsistently, has been shown to be 44 percent effective. Even with people who took it once or twice a week. Forty-four percent is not enough, but it's still more than what we've had for the last decade. It's more than what just condoms and lube are doing if they're not used. So, I would say that anyone who is sexually active right now -- regardless of age, regardless of gender -- because we're also seeing a lot of new, I don't think it's that many, but there's always been a subsection of men who are in their 50s who did survive that first wave of HIV/AIDS, survived it as HIV negative, and experience something called condom fatigue. Or just think "Screw it" or "Hey, the meds are out there" or "At this point in my life, I'm going to die from something else, so why not, who cares about HIV." That's also the group who needs to know that there is a non-latex alternative to safer sex. So, it needs to be out there for people who are on Grindr, on any of those cruising websites, and are hooking up, and are not using condoms 100 percent of the time. We simply do not have any reason for the infection rates in this country to continue to be that high.

Have you had any personal medical side effects from taking PrEP?

Not a thing. I would not even know I'm taking it, except it's a little blue pill that I take every day. No nausea, no nothing. My doctor is monitoring my blood to see if there are any side effects that I can't anticipate, that I couldn't feel, like kidney impairment or bone density reduction. Knock on wood, so far, so good. I personally have no side effects.

How would you recommend someone start the conversation about PrEP with their doctor?

Bring information with you. The great thing is that now the FDA did approve it. So there's so much official information -- FDA, CDC stuff, the stuff that's on TheBody.com -- there's a lot of really credible websites now that have valid, intelligent information about PrEP.

Talk about the research side. That's what doctors want to know, for the most part. Some of them may say, "That all sounds good, but I don't want to give you a prescription to go out and get HIV." And you say, "Oh, but look, I've actually found out -- study after study -- that if I take this seven days a week, I can be 99 percent protected from HIV. I'm not saying I'm going to go out there and get exposed to HIV." I've even said go and ask your doctor, "What if there was a vaccine for HIV? Would you ask your doctor for a vaccine if that was available? Well, we don't have a vaccine, but we do have something that's 99 percent effective until we do have a vaccine." Or I often say to gay men, "Think about if you were a woman: How would you approach your doctor about taking birth control pills?" The idea is, you can have sex for pleasure without adverse consequences.

Most of us grew up in a sex-negative paradigm, meaning -- especially for gay men -- there's a part of our brain that has internalized, "Sex is bad. Sex is dirty. Sex is embarrassing. Sex is shameful. I 'shouldn't' have these desires. And if I do feel these desires, then it's kind of wrong to feel good about them, or to talk about them." What I try to do is to get people to get around that and talk about sex as an affirmative, healthy activity that people can do. It can be done with respect, it can be a physically gratifying experience, it can be a spiritually gratifying experience, and there's nothing to be embarrassed about for enjoying that.

So know that. Own that. And take the data to your doctor and have a conversation. She or he may need some time to digest all that. They may not have heard of it. If you are the first patient or the first consumer to come to them and say, "Hey, I want this," they might need to digest that a little bit. They might need to look through some of your research or they might need to do some research of their own. They might need to do some consultations with some colleagues. Let them have that. They might need a few weeks. That's OK. But then, follow up, and find out. And if they're not going to support this, you don't have to continue to see them.

Now, all that being said, there may be medical reasons they don't agree with you taking PrEP. If you have certain medical conditions that could make you more susceptible to kidney failure or bone density reduction, your doctor may not advocate for this on medical grounds. But that's different from moral grounds. So I would say be clear in your heart, be clear in your mind, about asking for something that will empower your body, your mind, your spirit. That will keep you healthy in the long run, and don't be ashamed of asking for that.

Have you gotten any negative reactions from any communities about taking PrEP, and if so, how have you dealt with them?

The only negative feedback I've gotten has been when I've done something public or gone on a website or done some kind of presentation where it was on the Web and people would leave comments. These are the kind of websites where anything you put there's going to be negative comments, so I don't even read them to be honest with you. Those are anonymous; they're indirect.

The only negative response I've gotten has been from a specific service organization that has been publicly opposed to this -- that, for their own reasons, which I don't fully comprehend, don't think that it's wise for people to have the education and the information and the tools to keep themselves safe and HIV negative. I can't explain their motivations -- only they can -- and when they try, it makes no sense to me anyway. That's really the only negative feedback I've gotten.

You might be able to tell, I'm a pretty independent thinker. I've kind of always been headstrong and stubborn and done things my own weird way. So, people who know me already kinda know that this is Damon's life, and comments are not solicited. Friends and family who know me have expressed concern and I understand that and I respect that. But no one has come at me with a sex-negative "should" about this.

Is there anything else you want to say to our readers about PrEP? Something you want to touch on?

I certainly hope this makes people think about what's right for them. It's not up to me to tell anybody what's right for them. But if people want to know more, they're welcome to contact me at my email, This email address is being protected from spambots. You need JavaScript enabled to view it. , or contact TheBody.com, or contact your local HIV/AIDS resource organization. Ask more questions. Ask me questions. I don't know everything, but if I don't know, I'm happy to help people get the answers.

But here's the most important thing! This is not a drug that can be taken casually. This is not a medication you start, stop, start, and stop. This is not a Fire Island weekend party drug. This is my concern about PrEP. This is my worry. That is where there is danger for resistance to come in, and I'll explain what that means. What happens with Truvada in HIV-positive people is that Truvada is used in combination with other meds to keep the viral load down to zero, so that someone who is HIV positive can have a long quality and quantity of life. Truvada is used with other meds to make that happen. And so, in someone who is negative, Truvada is used alone. Truvada is the only medication.

What happens is, if someone is HIV positive and starts Truvada alone without other medications, their body can build resistance to Truvada. Let me say that again -- if they don't know they're positive and they start Truvada alone without taking it in combination with other meds, they can build resistance to Truvada. So, someone may think, big deal, who cares, there are 20 million meds out there. The big deal is that the most effective HIV meds on the market and all of those one-pill-a-days contain an element of Truvada in them. So, if you are resistant to Truvada, you are taking a lot of medicines off the shelf that can't help you if you are positive.

This is the danger. This is why it has to be done in tandem with a doctor, with a medical professional. Because what your doctor will do is first make sure that you are HIV negative. That you are not positive. But, today's Thursday, if I'm positive and I don't know it, and I'm like, "Party weekend! Black party! I'm going! I've got my Truvada, I'm ready!" If I take it without knowing I'm positive, then I might build resistance to Truvada and it's going to make the possibility of living a long, healthy, satisfying life as a positive person much more challenging.

So this is what people need to know. Take it with a doctor. Make sure you are HIV negative first. And do not take this sporadically as a party drug. Because that's where people can get in trouble.

This transcript has been lightly edited for clarity.

Mathew Rodriguez is the editorial project manager for TheBody.com and TheBodyPRO.com.

Follow Mathew on Twitter: @mathewrodriguez.

Contrary to some hysterically hyped headlines this past week, HIV is not on the verge of being cured in the next three months, nor have scientists found an effective vaccine.

The truth is that a hopeful compound to force HIV out of hiding is under study, and the results should be known in the near future. Unfortunately, however, even if researchers hit a home run with this drug, it won't likely be a cure by itself and we will still be waiting for the day that we have a vaccine or other types of immune therapy to help the body kill any remaining infected cells. 

Let's unpack the hype. Last week the London Daily Telegraph ran a story on this new compound, but claimed that a cure was just around the corner. The reporter apparently misquoted the researcher and overly hyped what he'd been told. The reporter has since toned down his piece and changed the headline due to pressure from a prominent activist in England and likely due in part to a piece the researchers themselves felt compelled to post to refute the article's claims. Unfortunately, the press outside of London grabbed hold and has been retreading the original uncorrected story since then.

Here is the real story. First, contrary to some reports there is no actual vaccine involved at this point. That's probably the most mystifying and frustrating thing. Instead, there is a class of drugs that helps cause HIV that is bound up inside the DNA of resting immune cells to begin reproducing. If we want to cure HIV, then that's the first thing we'll have to do -- to unmask the hidden HIV. The class of drugs is called HDAC inhibitors.

Thus far, there have been four studies of this class of drug. Two were conducted with a very weak form called valproic acid that ultimately had no effect. Two more recent studies were with a drug called vorinostat and showed at least transient increases in HIV RNA production from latent cells, indicating activity, but the effect was also somewhat weak and didn't have the ultimate effect we'd want to see, which is to reduce the amount of HIV DNA there. That would tell us that we are actually reducing the size of the HIV reservoir.

The researchers in Denmark are using a more potent HDAC inhibitor called panobinostat. All of us in the cure advocacy arena have good hopes about the drug, but it is a very, very long way from being a cure all by itself and the very small Phase I study being run by the Danish researchers has yet to publicly report any results. Panobinostat may turn out to be a potent way to kick start HIV replication, but we'll probably have to pair it with a vaccine in order to kill those latent cells that panobinostat has woken up. Unfortunately, we're quite a ways away from having such a vaccine.

It says something quite sad about the state of science journalism in general that articles like this make it out the door. The hype that never pans out ultimately makes people so skeptical about the kind of work Project Inform advocates for and reports on. It's also sadly the case that stories like this, where the reporter, or the researcher -- or both -- hypes a study and claims a cure is just around the corner are all too common. We'll do our best to set the record straight when these arise.

This article original appeared in TheBody.com here.

This article by Gus Cairns first appeared on aidsmap.com here.  

Data from two national sex surveys in the United States show that gay and bisexual men (men who have sex with men, MSM) reported significantly fewer sexual partners in the previous year in a survey conducted between 2006 and 2010 than they did in one conducted in 2002. This decline was consistent across most ethnicities and age groups, but was particularly marked, and statistically significant, in younger men aged under 24.

In contrast, the proportion who reported having condomless anal sex at least once in the previous year did not change between surveys. In the minority of men who also had sex with women, condom use fell markedly, but on the other hand the proportion of MSM who also had sex with women fell too.  

The proportion of men who tested for HIV or for sexually transmitted infections (STIs) in the last year did not change, although the proportion who had never tested for HIV fell.

The survey

The data come from the last two National Surveys of Family Growth (NSFGs). The NSFG is a survey of 15 to 44-year-olds; participants are contacted at random by phone but due to lower contact/response rates, people under 24, black people and Hispanic people are ‘oversampled’, i.e. a higher proportion are initially contacted than are in the general population.

NSFGs used to be conducted every three to seven years, but in 2006 a decision was taken to conduct interviews (by voice-assisted automated computer interview) continuously. This study therefore compared figures from interviews conducted in 2002 with ones conducted in 2006 to 2010.

NSFG interviewed 4928 and 10403 men in 2002 and 2006 to 2010, respectively. Of these, 197 and 272 reported having a male sexual partner in the last year – 2.7 and 2.1% respectively (this difference was not statistically significant, p = 0.1).

The results

The mean number of male sexual partners MSM reported in the previous year fell significantly from 2.9 to 2.3 between the two surveys (p = 0.035) and was more marked in men under 24 years old (mean 2.9 to 2.1 partners, p = 0.027). The number of partners also fell in men aged 35 to 44 from 3.0 to 2.2, though this was not quite statistically significant (p = 0.07).

The fall in the number of partners was statistically significant in men with incomes under 150% of the US federal poverty level (3.0 to 2.1) and in men living in suburban metropolitan areas (3.2 to 2.1) but not in city-centre areas (2.6 in both surveys). There were declines in partner numbers in white (3.0 to 2.5) and black (2.4 to 1.9) men, though these did not reach statistical significance. In general though, there was a consistent picture of fewer partners among most groups.

There were no changes in condom use for anal sex. In 2002, 57% of men had not used a condom the last time they had sex and in 2006 to 2010 the proportion was 58%. In the minority of men who also had sex with women, the proportion who had not used a condom the last time they had vaginal sex was 46% in 2002 but had become 67% by 2006 tp 2010, and this difference was statistically significant (p = 0.04). However, the proportion of MSM who had had female partners also decreased from 38 to 25% (p = 0.03).

One other notable difference was that fewer men reported transactional sex (sex for money or drugs) in the last year (down from 15 to 3%) and fewer men said they had injected drugs or had had sex with someone who had injected drugs (from 12 to 5%).

HIV and STI testing in the last year did not increase. In 2002 and 2006 to 2010, 41% of men said they had had an HIV test in the last year and in the case of STI check-ups 38% reported having one in 2002 and 39% in 2006 to 2010. The proportion of men who had never had an HIV test, however, fell from 25 to 15%.

Conclusions and comments

The researchers comment on the fact that HIV prevalence and the incidence of STIs increased in gay men during a period when numbers of partners and some other sexual risk behaviours were falling. They note that there have been previous studies in Seattle and Peru where STI incidence and/or HIV diagnoses have remained high even though sexual risk indicators in gay men have fallen. Studies of young black gay men in the US, including one recently presented at the 20th Conference on Retroviruses and Opportunistic Infections (CROI), have consistently shown that they tend to have fewer partners despite considerably higher HIV incidence.

The researchers speculate that this may be due to ‘network factors’: factors about partners that are not captured by the individual risk behaviour focus of most studies. For instance, some studies have found that black gay men tend to restrict sex to partners of their own ethnicity and are also more likely to have sex with men a number of years older or younger than themselves. Both of these would tend to concentrate HIV infection within the black gay community.  

Whether these are the main drivers of US black men’s greater vulnerability to HIV infection, another interesting aspect of this study is that gay men appear to have taken steps that could reduce their HIV risk by using a method that has received little emphasis in HIV prevention programmes for gay men – reducing their number of partners – while not increasing condom use, which has received the most emphasis.

Leichliter JS et al. Temporal trends in sexual behaviour among men who have sex with men in the United States, 2002 to 2006-10. J Acquir Immun Defic Syndr, early online publication, DOI: 10.1097/QAI.0b013e31828e0cfc, 2013. 

This article by Gus Cairns first appeared on aidsmap.com here.  

About 40% of men who answered a community survey for HIV-positive gay men in the Netherlands said they took their viral load into consideration in deciding whether or not to use condoms. This represents about two-thirds of those who actually did have unprotected sex.

This published paper adds new data to this study’s original conference presentation at the AIDS Impact conference in 2011.

The survey found that consideration of viral load was almost as common when having sex with partners who also had HIV as when having sex with partners of negative or unknown status. Disclosure and discussion of viral load was far more common with HIV-positive partners, whereas viral load was rarely discussed with partners assumed to be HIV negative, remaining purely part of a unilateral decision.

The study also found that this group of HIV-positive men, who, as part of a community consultation panel providing advice to the Netherlands HIV Association (NHA), might be assumed to be well informed on HIV prevention matters, were as a group by no means convinced that undetectable viral load protected them from transmitting HIV to partners. Not surprisingly, the more confident individuals were that this was the case, the more likely they were to take it into account as part of a decision to have condomless sex.

The study

The NHA’s Open Online Panel consists of 517 women and men living with HIV who are contacted on a regular basis by email to ask their opinion on important topics in HIV. In this case just the 212 gay men on the panel were asked to complete an online survey about unprotected sex and consideration of viral load.  

This paper only looked at the answers from the 177 men (85%) who said they had an undetectable viral load. Of these, all but two were on antiretroviral therapy.

Results: unprotected sex

One hundred and twenty (68%) of the 177 had ever had unprotected anal sex since their HIV diagnosis and of these 73 (61%, or 41% of the whole group) did it without a condom the last time they had anal sex. 

The researchers asked respondents if their last sex had been with a casual or a regular partner and of the 73 who’d had unprotected sex last time,  43 (59%) said it was with a casual partner and 30 (41%) with a regular one.

The 73 were also asked the HIV status of the most recent partner and 38 (52%) said they were HIV negative or status unknown and 35 (48%) that they were HIV positive. Unprotected sex partners were more likely to be ‘buddies’ if they were HIV positive (15 casual, 20 buddies) and more likely to be casual meets if they were HIV negative or status unknown (28 casual, 10 buddies); this is what one would expect, as HIV status is usually not discussed until people have reached  a level of trust.

Results: considering viral load

Of the 120 who had ever had unprotected sex since diagnosis, 75 (63%) said that their viral load was something they had taken into account when deciding to use condoms.

Interestingly, more said they had taken viral load into consideration with HIV positive partners (44% of the 120) than with men who were HIV negative or of unknown status (38% – some men considered it with both positive and negative partners).

Participants were asked to estimate the perceived protective value of having an undetectable viral load on a scale of one (“absolutely no risk”) to seven (“absolute risk”).  The average score was three (low-to-moderate risk) when considering sex with HIV-negative partners and two (no-to-low risk) when considering sex with HIV-positive partners (where the perceived risk was presumably superinfection). Not surprisingly, men who thought the risk was lower were more likely to have unprotected sex and to consider viral load as one of the reasons involved in doing so.

When having unprotected sex with HIV-positive partners, men said they were more likely to consider viral load with buddies (over half the partners) than with casual partners (only one in five). Conversely, when having unprotected sex with HIV-negative partners, nearly 60% said they considered their viral load with a casual partner but only 40% with a buddy.

With positive partners, all but one of the 14 men who said they had considered viral load had explicitly discussed it with their partner before sex. Conversely, only three of the 20 men who had considered viral load when having unprotected sex with an HIV negative partner had discussed the subject.

Conclusions

It looks as if there are two different phenomena going on. With HIV-negative partners, men who considered their viral load are doing so in the main as part of a unilateral process of considering how liable they are to transmit HIV. In the case of HIV-positive partners, the researchers comment that “further qualitative studies are needed to shed light on the perceived added value of considering viral load”, but speculate that it may take place within the context of broader discussions about HIV superinfection and STIs.

This is a small study of quite a specific group: HIV-positive gay men who were already engaged and informed enough to join a community consultation group. They could therefore be ‘early adopters’ of viral load as a factor to take into account when considering sexual risk.

As the researchers comment, “future investigations should include the perspectives of HIV-negative MSM in the communication around undetectable viral load and unprotected anal intercourse”, and a wider consultation with less-engaged HIV-positive men would be interesting too. 

They also comment that further investigations are needed to establish the risk of transmitting HIV via anal sex with an undetectable plasma viral load.

They comment: “HIV prevention campaigners need such evidence to take an informed stance in the debate around viral load considerations and urgently so, in light of their already frequent use by MSM.”

Reference

Van den Boom W et al. Undetectable viral load and the decision to engage in unprotected anal intercourse among HIV-positive MSM. AIDS and Behavior, e-publication ahead of print: DOI 10.1007/s10461-013-0453-9, 2013.