“I’ve been told that I can look forward to a tremendous reduction in stress and anxiety about seroconverting. I look forward to that. We’ll see. “ 

On April 5, 2013 I took my first dose of Truvada as pre-exposure prophylaxis (PrEP). I won’t deny it. I’ve been feeling very conflicted about starting PrEP.  

Why do I have access to Truvada when the majority of people who need antiretroviral medication to stay alive don’t have access? I got my hands on this bottle relatively easily. The social injustice is not lost on me. I don’t have relatively easy access to this medication because I deserve it more than anyone else.

So what HAVE I done to deserve access to PrEP? Well, a lot of it is sheer luck, actually.

•    Nearly every time I see the news, I am amazed at how lucky I am. I was born in Canada. Talk about winning the lottery. Out of 7 billion people, I am one of only 34 million people living in Canada. Trust me, it’s a great place to live!

•    I’ve been working in HIV for 20 years, including the last 10 years focussed on tracking biomedical HIV prevention research. This provides me with ongoing access to the latest information.

•    I make a good living. I can access healthcare relatively easily and generally for free or at a cost that has little impact on my standard of living.

•    I have a doctor. He’s young (My age. That’s young. Shut up.), gay, and sees a lot of people living with HIV in his practice. So talking to him about my sex life and about PrEP was not difficult. He keeps up to date on research. After a good discussion, he agreed to prescribe PrEP.

•    Not only do I live in Canada, but I live in Québec, the only province to have a universal public drug plan. As long as the drugs my doctor prescribes are on the provincial drug formulary, I am covered for most of the cost. I pay $500 into the drug plan annually, and PrEP will cost me less than $1,000/year on top of that. And if I ever need other drugs for any reason, I will not pay for them. Because $992/year ($82.66/month to be precise) is the most I would have to pay for all my drugs combined.

I’m not trying to be disingenuous. I know that beyond being lucky and privileged, I have access to PrEP because I’ve taken some very concrete steps as well. I did lots of introspection. I tried to reduce my risk as much as possible through other means. I did a lot of research. I actively sought out access. I make sure I’m very diligent about taking my pills.

I always have been very diligent about that. I take all my antibiotics when I need them. I take vitamins daily. When I was on antidepressants, I never missed a dose in 1.5 years. I follow advice from medical professionals to the letter. Case in point: I’ve needed physiotherapy twice. Both times, the conversation during my second visit went something like this:

Physiotherapist: Wow, you’re made remarkable progress in one week. I’ve never seen anyone progress so quickly with this type of injury. Which exercises did you do?

Me: All of them, like you showed me.

PT: You did ALL the exercise I gave you?! How often?

Me: Every day, like you told me.

PT: You did ALL your exercise EVERY day?! How many times a day?

Me: Twice, like you told me.

PT: You did ALL your exercises, EVERY day, TWICE a day?! I’ve never seen this in all my years of practice! No wonder you’re doing so well!

*SLAP* You’re at risk of HIV!

I might make jokes, but I don’t take this lightly.

Every morning when I wake up it’s the first thing I think about. That might stop after a while. But two weeks into taking PrEP, it’s the same thing. I wake up, and as I ponder about whether I want to go back to sleep again for a little longer, I can’t do it. I immediately think: when I get up I have to take my Truvada pill. Because I’m at risk of HIV.

Each and every time I open the cupboard and grab the bottle, I think: how is it possible that I am so lucky to have such easy access to this medication when millions of people who need it to stay alive don’t have access?

Who needs a coffee? I get a slap in my face every morning. Two of them in fact.

*SLAP* You’re at risk of HIV and STIs!

*SLAP* You’re one of the lucky few who has access to this medication and to this prevention option!

I’ve been told that I can look forward to a tremendous reduction in stress and anxiety about seroconverting. I look forward to that. We’ll see. I’m not there yet by any stretch. But at least I get some measure of comfort from knowing that I’m putting chances on my side by reducing my risk as much as I can in my current situation. Doing my best to stay healthy seems like the right thing to do to honour those who don’t have access to this drug.

About the author: Marc-André LeBlanc has worked in the community-based HIV/AIDS movement for 20 years.He does community engagement, capacity-building and policy work related to biomedical HIV prevention research, both in Canada and globally. He is a co-founder of International Rectal Microbicide Advocates (IRMA), serves as secretary on their steering committee, has authored two reports on the global state of rectal microbicide efforts, and leads IRMA’s global efforts to ensure the safety of sexual lubricants. Marc-André loves movies. He got a film studies degree while working full-time, just for the sheer fun of it. He is now leading advocacy efforts to get ice cream and popcorn recognised as new basic food groups in Canada’s Food Guide

This article originally appeared on My PrEP Experience here. 

This article first appeared on the CATIE website here.  

Une version française est disponible ici.  

The importance of HIV testing, knowledge of HIV status and early diagnosis of HIV infection cannot be overstated, particularly given recent advancements in our understanding of HIV treatment and prevention. 

People who are aware of their HIV-positive status can access care and support services and initiate treatment when they are ready. Advances in treatment mean that people with HIV can live almost as long and as healthy as people who are uninfected. To get the most out of treatment, research suggests it may need to be started soon after becoming infected with the virus. Currently, however, many people in Canada are not learning about their HIV status until late in their disease, when they start to develop symptoms or opportunistic infections. At this point, antiretroviral treatment can help improve their health but not as effectively as when treatment is started earlier. 

Knowledge of HIV status is also important for the prevention of HIV transmission. Generally, once people become aware of their HIV infection, they take measures to reduce their risk of HIV transmission. Also, once diagnosed, treatment can be initiated and this can further help reduce the risk of HIV transmission. Research suggests that the majority of HIV transmissions may originate from people who are unaware of their HIV status. 

For those who test negative, testing represents an important opportunity to provide HIV prevention information and counselling. 

According to 2011 estimates from the Public Health Agency of Canada (PHAC), approximately 25% of people living with HIV in Canada were unaware of their HIV status. Therefore, undiagnosed HIV infection represents a major public health challenge and is undermining HIV treatment and prevention in Canada. 

Barriers to testing 

There are several barriers to increasing the uptake of HIV testing and reducing the proportion of people who are undiagnosed in Canada. According to a synthesis of the evidence conducted by the European Center for Disease Prevention and Control and published in 2010, these barriers include: 

• inability to accurately assess levels of risk for exposure to HIV by some clients and providers
• lack of comfort discussing HIV testing and lack of knowledge about HIV among clients and providers
• provider time constraints for risk assessments and pre- and post-test counselling
• cumbersome consent procedures
• fear of stigma and discrimination associated with risk behaviors and/or testing HIV positive 

PHAC guidelines and recommendations 

PHAC recently released an HIV Screening and Testing Guide that “seeks to reduce the number of undiagnosed HIV infections in Canada by offering a framework for care providers to explore options that will enhance their ability to provide HIV testing, as well as to better tailor their testing approaches to meet the specific needs of their practice and clients.” 

These guidelines include the following recommendations to address the barriers listed above and to improve HIV testing in Canada. 

The offer of an HIV test should be made part of periodic routine medical care.The guide acknowledges that targeted testing among populations at highest risk of HIV infection needs to continue but should be complemented with a less targeted testing approach among populations that may be perceived as being lower risk. Research shows that many people at risk for HIV infection (including those who are later diagnosed with HIV) are not requesting, or being offered, an HIV test despite multiple interactions with the health system, likely because of perceived low risk of HIV infection on the part of the client and provider. These interactions represent “missed opportunities” for HIV testing and potential diagnosis of HIV infection. 

Therefore, a major recommendation in the guide is that providers take a more active approach and routinely offer HIV testing to clients—whether or not they have asked for a test. Routinely offering HIV testing to patients will help overcome some of the barriers to testing. Also, it may help normalize HIV testing and further reduce stigma and discrimination associated with HIV. 

To reduce the fear often associated with an HIV diagnosis, which can be a barrier to testing, the guide recommends that care providers emphasize the benefits of treatment and that HIV is now considered a chronic manageable condition. 

Simplify risk assessments. 

The guide acknowledges pre-test risk assessments as a potential barrier to HIV testing. Therefore, it states that instead of providing an in-depth comprehensive HIV behavioural risk assessment prior to offering an HIV test, a more brief assessment is sufficient. This assessment should ensure that clients understand the following: 

• how HIV is transmitted
• the advantages and disadvantages of HIV testing
• how to interpret the results 

After the brief assessment, a client should simply be asked if they want an HIV test. This approach allows the client to assess their own risk without feeling compelled to provide sensitive personal information. This helps to overcome any discomfort the tester and/or client may feel in discussing these issues, which can sometimes be a barrier to testing.  

HIV testing must remain voluntary and based on informed consent. 

The guide states that verbal consent prior to HIV testing is sufficient and written consent prior is not necessary. 

Use a flexible approach to pre- and post-test counselling. 

The guide encourages care providers to use a flexible approach and tailor the extent of pre- and post-test counselling to each client’s unique needs and situation. While providing extended counselling is preferred, the guide acknowledges that this may be a barrier for both the provider and client, particularly due to time and resource constraints. More specifically, the guide states that shorter counselling may be more appropriate for certain testers, such as pregnant women in labour, well-informed patients and repeat testers. The provision of print, video, mobile and web-based resources can help streamline the pre-test process and inform decisions with regards to HIV testing.

 Offer couples testing. 

The guide stresses the importance of testing together for those in an ongoing sexual relationship with a regular partner as it allows: 

• a common understanding of the risks associated with HIV transmission
• a shared understanding of each other’s HIV status
• an opportunity to make decisions about prevention, treatment and care together 

Research studies suggest that couples who test and learn their status together are more likely to adopt preventive measures than those who test alone. 

Integrate HIV testing services. 

The guide encourages the integration of HIV testing into other services, particularly those that test for infections that can be transmitted the same way as HIV and/or negatively impact the health of people living with HIV. 

These services include the following: 

• clinical services for tuberculosis (TB), sexually transmitted infections (STIs) and hepatitis C
• antenatal care services
• sexual Health and family planning services
• drug and alcohol treatment services
• newcomer and travel health clinics
• mental illness treatment and psychiatric services
• cancer or oncology clinics 

Integrating HIV testing into these other services provides additional opportunities to test for HIV and identify undiagnosed individuals. 

While positive results should always be provided in person (preferably by the initial care provider), alternate approaches can be used to provide negative results. 

Ideally, negative test results should be provided in person, however, the guide acknowledges that this can be challenging to do for all individuals. Therefore, providers can use a previously agreed upon alternative for those who are unlikely to return for their test results. These alternative approaches may include a secure telephone call, letter or email. The guide emphasizes that effort should be made to ensure that the information is provided confidentially. 

It is important that clients are not informed that only HIV-positive results will be provided in person. This may create anxiety when a person is asked to return to get their results in person. 

Discuss the window period with those who test HIV negative. 

If someone is “in the window period,” there is a chance that even though they may have been infected with HIV, the test won’t be able to detect the infection and will give a negative result. The window period differs for each type of HIV test and also depends on each individual. To ensure that a person was not in the window period at the time the test was performed, the guide recommends that follow-up testing be performed at three weeks and three months following the most recent possible exposure. However, the guide states that additional HIV testing during the window period, particularly following a “high-risk” exposure, may help identify infection earlier. 

Discuss frequency of retesting with those who test HIV negative. 

The guide recommends that individuals involved in “high-risk practices” be screened for HIV at least once a year. Since many variables determine an individual’s potential risk of HIV infection, the guide does not recommend an exact frequency of HIV testing for different levels of risk. However, when considering the need for retesting, the guide recommends that care providers consider factors such as populations at increased risk for HIV exposure, characteristics of partners and local epidemiology. 

Provide information and referrals—regardless of test results—and link newly diagnosed individuals to care. 

HIV testing is an important opportunity to educate individuals at risk of acquiring HIV and those who are newly diagnosed and link them to additional services. For example, all people tested for HIV—regardless of their results—should be provided with information and linked to services to help them reduce their risk of acquiring or transmitting HIV. Therefore, in preparation for HIV testing, the guide suggests that providers contact care and support organizations to obtain referral resources to provide to clients. 

Research shows that people living with HIV who are linked to and engaged in care have better health outcomes than those who are not. Therefore, newly diagnosed individuals should be referred to an infectious disease specialist who treats HIV. Also, effort should be made to complete baseline testing for CD4 count, viral load, drug resistance and co-infections (hepatitis B and C, STIs, TB) as soon after diagnosis as possible. 

For those who test HIV positive, develop a partner notification plan and discuss public health importance of disclosure. 

Previous and current partners of newly diagnosed individuals represent a population at high risk of HIV infection. Therefore, notifying previous/current partners and encouraging them to get tested may help identify undiagnosed HIV infections. The guide encourages care providers to develop partner notification plans with newly diagnosed individuals. Also, care providers should inform clients that positive test results will be shared with Public Health, which can help with partner notification while maintaining the client’s anonymity and privacy. 

Voluntary disclosure of HIV status to partners has several potential benefits. For example, it may motivate partners to seek testing and/or adopt measures to prevent HIV transmission. Also, it provides an opportunity for the HIV-positive person to receive social support, develop risk-reduction strategies with partners and prevent co-infections. Therefore, the guide states that care providers should emphasize the importance of voluntary disclosure of HIV status to those who are newly diagnosed. 

Conclusion 

PHAC’s new HIV Screening and Testing Guide contains a series of recommendations to increase the uptake of HIV testing, reduce the proportion of people who are unaware of their HIV infection and diagnose people as early as possible after HIV infection. These goals are critical for improving the health of people living with HIV and for preventing HIV transmissions in Canada. One way the guide seeks to meet these goals is by normalizing HIV testing and making the offer of such testing a routine part of medical care. More nuanced and detailed information can be found in the full guide. 

It is important to note that PHAC’s guide is only meant to complement existing efforts and “does not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern and inform the practice of care providers in their respective jurisdictions. Care providers should comply with local Public Health regulations with conducting HIV testing.” 

- James Wilton 

Resources  

HIV Screening and Testing Guide – Public Health Agency of Canada 

WHO guidelines encourage couples HIV testing and counselling and use of antiretroviral treatment for prevention – Prevention in Focus  

Recently infected individuals: a priority for HIV prevention – Prevention in Focus  

Detecting HIV earlier: Advances in HIV testing – Prevention in Focus  

A rapid approach to community-based HIV testing – Prevention in Focus  

How do you know if you have HIV? – Managing your health  

References  

Johnson LF et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Medicine, 10:4. E1001418. 

May M et al. Life expectancy of HIV-1-positive individuals approaches normal, conditional on response to antiretroviral therapy: UK collaborative HIV cohort study. Eleventh International Congress on Drug Therapy in HIV Infection, Glasgow, abstract O133, 2012. 

Van Sighem AI, Gras LAJ, Reiss P, Brinkman K, De Wolf F. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS. 2010 Jun 19;24(10):1527–35. 

Nakagawa F, Lodwick RK, Smith CJ, Smith R, Cambiano V, Lundgren JD, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012 Jan;26(3):335–43. 

Nakagawa F, May M, Phillips A. Life expectancy living with HIV: recent estimates and future implications. Curr. Opin. Infect. Dis. 2013 Feb;26(1):17–25. 

Siegfried N, Uthman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults. Cochrane Database of Systematic Reviews. 2010 Mar 17;(3):CD008272. 

Althoff KN, Gange SJ, Klein MB et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clinical Infectious Diseases. 2010 Jun;50(11):1512–20. 

Fisher, M. (2008). Late diagnosis of HIV infection: major consequences and missed opportunities. Current Opinion in Infectious Diseases. 21(1):1-3.

 Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes. 2005 Aug 1;39(4):446–53. 

Cohen MS, Chen YQ, McCauley M et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505. 

Government of Canada Public Health Agency of Canada (2010). HIV/AIDS Epi Updates. Available from: www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/2-eng.php 

European Centre for Disease Prevention and Control. HIV testing: Increasing uptake and effectiveness in the European Union. Stockholm: ECDC; 2010. 

Government of Canada Public Health Agency of Canada (2013). HIV screening and testing guide. Available from http://www.catie.ca/sites/default/files/EN_HIV-Screening-Guide-2013.pdf 

El-Bassel N, Gilbert L, Witte S et al. Couple-based HIV prevention in the United States: advantages, gaps, and future directions. Journal of Acquired Immune Deficiency Syndromes. 2010 Dec;55 Suppl2:S98–S101.

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. 

“Seed is a gift, it’s love, it’s acceptance. Taking a man’s cum – in your ass, down your throat, rubbed into your skin, whatever - even if you don’t know his name, is closeness. It’s an act of love and trust.  Even if yawl just met. Both the bottom and the top will walk away smiling . . . and content. Now it’s a sleazy affair that boys get cracked out of their mind for. Like it’s an embarrassing nasty secret thing to want. This is so fucked.”

From HIV-positive bareback blogger Geek Slut, quoted in "Unlimited Intimacy  . .". .

Recently writer Tim Dean gave a presentation on the subculture of barebacking and its mores to an attentive audience of 200 at the Gay Men’s Sexual Health Summit in Toronto.  PositiveLite.com editor Bob Leahy caught up with him afterwards and sat down with him for this frank talk.

Bob Leahy: Tim. Thank you for talking to PositiveLite.com – and welcome to Toronto. I’d like to talk to you about your book first of all.  Tell me, how did you come to write about barebacking? What interested you there?

Tim Dean:  I came to write that book because I was living in the Bay Area of San Francisco and I was going out a lot and having a lot of sex – this was in the late 90s – and what I encountered in public sex environments were lots of guys who wanted me to cum inside of them. There was never a conversation about status, there was never a conversation about condoms, and I realized fairly quickly that this was something new in the history of the epidemic that I needed to think about — to think about what was involved and what had changed.

There is a substantial body of research that went in to the book.  Tell me about your research method.  How did you gather the information - through conventional methods?

I would say they were not very conventional methods. Much of the information was what I gleaned from personal experience, that is, hanging out in sex bars, sex clubs, bathhouses to a lesser extent, and also talking to people. That’s something I do in my life and I was using that material to reflect on. I also got very interested in bareback pornography and was able to use my training as a critic to analyze what is going on in this kind of pornography, what makes it different from other kinds of pornography.

Let’s talk about the bareback porn industry in a minute. Writing the book, you chose very consciously to be non-judgemental, is that right? You could have injected your own views in to it, but you chose to be descriptive.  Why did you do that?

That was a very important decision on my part, influenced by two things. One was to take a kind of anthropological approach to the study of sexual subcultures, where you limit what you can learn if you decide ahead of time whether something is good or bad, positive or negative. The other was a kind of psycho-analytic influence where the suspension of judgment allows thinking to achieve its full potential so that it was very, very important to me not to judge.

And what was the reaction to that approach? In your refusal to judge, did people think it sounded like you were endorsing barebacking?

Yes, some people did. And the fact that I wanted to write about this subculture without judging it and on the other hand saying that I’m also participating in this subculture, the refusal to judge was often understood as a kind of backhanded way of endorsing or excusing what I was doing.  I didn’t see it that way at all.  For me, it was an ethical decision to suspend judgement. Some people got that.  Some people read it differently.

So did it feel comfortable writing from the perspective of a participant in the barebacking culture? It’s kind of brave, I think.

It seemed sort of inevitable, in the sense that a lot of what I found out, I found out by doing it. Certainly in the literature I read at the time on “unsafe/unprotected sex” it was always assumed that somebody else was doing it, it was others who barebacked. It was very important to me to dispel that illusion. I was not going to be closet-y about the fact that I was barebacking. There is still a stigma attached to it and it’s hard to come out as somebody who enjoys bareback sex. But I don’t think we actually get anywhere by pretending we are not doing things . . . 

OK, let’s talk more about this. We haven’t defined barebacking.  Are we talking about people who identify as barebackers, part of a barebacking culture, or people who slip up occasionally - or both?

I used the decision when writing the book to use the term “barebackers” very broadly, to cover both the subculture and also people who may not consider themselves ‘barebackers” but who sometimes or occasionally do have sex without condoms, or want to have sex without condoms. It’s too easy to place the blame on a small subset who are very committed barebackers and I wanted to avoid that by using the term broadly.

I wanted to ask you about the allure of barebacking. There are so many stigmas and potential risks, why do people do it?

I think there are lots of reasons. The first and most obvious is that men often prefer sex without condoms, it feels better . . .

You called it “enhanced genital stimulation”.

Yes. That’s the most obvious reason. Beyond that there are all the meanings that are attached to exchanging semen, to receiving someone else’s cum. I think HIV prevention discourses have not been very good at acknowledging how important semen is to gay men – their own and other peoples’. Sometimes you want lots of guys’ semen inside of you.

Well, you’ve talked a lot about disgust with bodily fluids, and you mentioned spit as an example, but semen must be the same kind of thing, that we have a sort of love/hate relationship with it - in that in some contexts these fluids are very hot and in others they disgust us.

I think that’s true. I think that semen, because of HIV and the epidemic, has become even more loaded with meaning, in becoming dangerous, in becoming dirty . . .

Toxic.

Yes, In becoming toxic it has become potentially hotter. That is, on the one hand we are told we must absolutely keep it outside of our bodies, and on the other hand it becomes something very exciting to get inside.

Well, let me throw out a quote from you on that. I think you said “the fact that sex may be unsafe may be the sexiest thing about it.” Is that true?

I think for a number of people that’s absolutely the case. It’s a mistake to think we don’t like risk. Risk can be very exciting.

I suppose you can think then of public sex. We think public sex is very hot because we might get caught. But are we saying bareback sex is hot because we could get infected with HIV?

In some cases, yes. Your question makes me think of straight couples who like to fuck in the bathroom of a plane. There is a risk involved, it’s not comfortable, maybe the sex isn’t all that gratifying because of the conditions, but there is a risk involved which makes it very exciting. And that translates for some gay men in terms of HIV too.

Is the transgressive thing important in bareback sex too, the chance of something bad happening.

Yes, and also stepping away from being a normal responsible adult in our society, and everything that goes along with that. You know part of the appeal of public sex is that it happens outside the house, it happens in a space where someone can be somebody different. Therefore it’s hot. We are also inundated with safe sex messages and sometimes for that very reason stepping away from that and doing something that is “unsafe”,  that’s ”risky”, can be the hottest thing to do.

The other allure you’ve described is in the title of your book. “Unlimited Intimacy.” That’s important for barebackers, isn’t it?

Yes, I think it is. Men who have a lot of casual sex with a lot of casual partners are not in flight from intimacy but actually searching for a particular kind of intimacy. The phrase “unlimited intimacy” came from a barebacker in an interview I read and that seemed to me to be a perfect way to encapsulate intimacy beyond the couple.

So there is nothing more intimate for some people than exchanging bodily fluids?

Right.

Sometimes we talk about casual sex, but it sounds like what you’re describing is very intense sex.

It’s incredibly intense. It’s very meaningful, completely spiritual. If you are having sex with a bunch of strangers, group sex can be something that feels like communion.

I think you’ve mentioned too in the book that there is very much a sense of belonging.

Sure. It’s about finding and making a community with people you don’t necessarily need to get to know to be part of.

OK I want to find out about barebackers and what is their relationship to risk. I think what you say - and this is probably grossly simplifying – is that this is an equation, where barebackers recognize the risk, but then balance it against the pleasure. Is that what’s going on?

Sure, I think that’s part of it. But one of the other things I want to add that’s going on is that the majority of barebackers do NOT want to infect sero-negative guys. They are not trying to put other people at risk. They are interested in an experience of risk for themselves that is maybe more a risk in fantasy than in actuality in some cases.

So they do care about the possibility of HIV transmission?

Yes.

Do you think people think they don`t care.

I do. It's hard for people to wrap their heads around the fact that people can be barebacking and still wish to reduce transmission. I think it's a mistake to think about barebackers as simply irresponsible hedonists.

Tell me why you’ve been using the word “disgust” a lot lately.

I’ve become very interested in disgust for various reasons.  One, in the world of academic theory I inhabit, people don’t talk about disgust, they talk about shame. Shame is connected to identity.  For me, disgust is connected to acts and in order to have a discourse about sexual acts we need to think about and talk about disgust.  Disgust is really complicated because disgust in the context of food simply pushes you away from food.  Disgust vis-à-vis sex or bodily fluids can draw you to those things. Sometimes sex can be intensified by doing things that you actually feel can be kind of disgusting.

Or that other people find disgusting?

Which is why large amounts of bodily fluids, especially semen, are important in the subculture and within some of the porn. One of the things that interests me is that some people find “sloppy seconds”  disgusting, that is using multiple loads, using cum as lube. But a lot of guys, including straight guys, find it very hot.

And isn’t it a staple of bareback porn? I’m thinking of the porn classic Dawson’s 20 Load Weekend?

Absolutely.

Tim, I think one of the take-home messages I got from listening to you is that if we find an act not to our liking, it becomes morally wrong.

I want to make the distinction between moral disgust and sexual disgust so that we can hold on more tightly to the idea that just because you don’t like something does not make it morally wrong. That seems to me very important.

Is anything morally wrong in sex?

Absolutely.

Give me an example of what is morally wrong in the context of barebacking?

I think coerced sex is morally wrong. I think lying to people is morally wrong. I think treating people badly is morally wrong. The ethics have to do not with the act you are actually doing, but how you treat your partner. To me it’s very important in the book — and in my life — to understand that other people are not objects to be used for one’s gratification. Other people are not sexual commodities. We may play out a fantasy in which I use you as my sexual slave and we both may enjoy that, but within the broader context of our encounter I treat you like a human being with respect, etc.

Let’s talk about the breeding, gift-giving subculture. Some people have played it down and suggested it’s mostly fantasy and that it’s very hard to track down real bug-chasers for research, for instance. Is this really a big part of bareback culture?

It’s certainly a big part of the fantasies that animate the subculture. In that way it seems to me important. I think in the process of writing the book and when I was giving lectures, people wanted to know, “How many gift givers, how many people are there out there doing this?” I don’t think that can be answered because the fact is it’s a very exciting fantasy for a lot of people but how that translates into practice is very, very hard to know.

But are there some people out there who really want to be poz?

I think so, yes. They see being poz as an inevitability, as giving them licence to bareback without worrying.

How do you feel about that?

Well, I think part of the reason I want to talk about fantasy is not so much that I’m psycho-analytically oriented – although I am – but because American culture does not have a very good way of talking about fantasy. Therefore it does not have a very good way of distinguishing between what is a fantasy and what is something you actually want to do. I’ve done some work on this around rape fantasies.  A lot of people have a fantasy about being raped, but that doesn’t mean they want to be raped. It means they want to enact a fantasy; and it seems to me you can make an analogy with guys out there who say they want to become poz.

OK, I want to talk about bareback porn.  It’s very different to mainstream gay porn, isn’t it? It looks different, I’m thinking in particular of Treasure Island Media  (NSFW link) which has a home-made feel. Actors can be overweight, older, not conventionally attractive. Why is that?

I’m very interested in Treasure Island Media and Paul Morris’s whole politics, ethics and aesthetics of making porn. He sees himself as a documentary pornographer, documenting what guys are already up to and therefore the guys in his films should not be some kind of fantasy ideal with perfect bodies.  

They should look like us?

They should look like us. They should look like the guys we are and the guys we meet.  Some people don’t like his porn for that reason.  They say the guys in it are ugly. That’s not my view on it. The range of body types makes it real.  It makes it hot. It’s clear you can be older, overweight, you can be hairy, you can have an imperfect body, you can look like a poz guy – and still be a porn star, still be the subject of sexual pleasure. That’s important.

Do you have any views, Tim, on the role of barebacking porn in encouraging or stimulating bareback behaviour?

People want to be able to draw a very clear line between pornography and behaviour – and I don’t think you can draw that line. I think it’s been proven again and again that watching pornography, of whatever kind, will not simply translate into imitating those behaviours. It’s not that pornography has no influence. Of course it has influence over what we find exciting, what our fantasies are.  But what interests me is that even with this iPhone you are recording this interview on we can go in to the bathroom and make pornography and put it on line . . . .

Want to?  (laughs)

(laughs) So that is to say we can all — and lots of people do – make our own porn and put it on XTube and I think that’s an incredibly interesting development.  We can all be pornographers.  If you don’t like the mainstream porn that’s out there, make your own porn – and I think that’s a great thing.

OK. I want to finally get to the intersection between barebacking and HIV prevention efforts. The language of HIV prevention uses words like “intervention” and “counselling” which essentially relate to efforts to change behaviour, or even stop various behaviours. Is there any scope for the world of counselling and interventions to interact with barebackers or do they have their own rationale for what they do and have made up their minds? Are the two worlds apart?

I think there is space for an intersection. When I wrote the book it was very important for me to not to write about barebacking with the desire to understand it in order to stop it. I do think, though, that what counselling offers is a space to think through what one’s desires are, what one’s fantasies are. I think to the degree that counselling makes a space available to sort through the confusion that all of us have in our minds about sex, desire, desirability – that’s good. But if counselling goes in to a situation with the sole attempt to stop something, then it closes off the space in which people can figure out their lives and what kind of sex they would actually like for themselves.

What we’ve seen here is applying a harm reduction approach to barebacking in terms of talking about techniques that might reduce the risk of transmission.  Does that make sense to you?

Yes, it does. But I don’t think it’s all or nothing.  For a long time it was pitched as “use condoms all the time or you are going to become a crazy reckless barebacker who is going to become poz and spread the virus”. It’s not either/or. Thinking in terms of harm reduction makes much more sense.

That’s likely a good place to end.  Tim, thank you so much for talking to us.  You’ve been incredibly honest and forthright about something that challenges many of us.  This has been so useful. It’s been a real pleasure talking to you.

Thank you, Bob

Tim Dean’s book “Unlimited Intimacy, Reflections on the Subculture of Barebacking” is available on Amazon here. 

Tim Dean is professor of English and director of the Center for the Study of Psychoanalysis and Culture at the University at Buffalo. He is the author or editor of several books, including Beyond Sexuality, also published by the University of Chicago Press.