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Jan22

What’s resonating in the community?

Thursday, 22 January 2015 Written by // Marc-André LeBlanc Categories // Dating, As Prevention , Gay Men, Research, Sexual Health, Health, Treatment, Lifestyle, Living with HIV, Population Specific , Marc-André LeBlanc

Marc-André LeBlanc on the Resonance Project, undetectable viral load and PrEP: how Canadian gay men view and incorporate new and emerging HIV information into their sexual practices

What’s resonating in the community?

In the last few years, there has been a lot of new information about HIV risk and prevention, including undetectable viral load, pre-exposure prophylaxis, rapid point-of-care testing… In fact, the HIV prevention landscape has arguably changed more in the last three-five years than it did in the previous 25 years. 

The Resonance Project is seeking to find out if any of this new information is resonating with gay men, and if so, how? The Resonance Project is a community-based research project coordinated by CATIE and funded by the Canadian Institutes for Health Research (CIHR). It is a collaboration between four national HIV organizations, three gay men’s health organizations, and the University of Windsor. For a full list of project partners, check out www.catie.ca/en/resonance.

 

We talked to gay guys

Using fictional  ‘vignettes’ of typical online profiles and dating scenarios as discussion prompts, we conducted 12 focus groups with 86 gay men in Montreal, Toronto and Vancouver. Participants in each city were assigned to one of four focus groups. 

Focus group name

Criteria for inclusion in this group

FG1: Gay men connected to HIV organizations

·         Attended an HIV workshop, training or conference in the last year

FG2: Gay men in serodiscordant relationships

·         HIV-negative or HIV-positive

·         Currently in a relationship that has lasted more than 6 months

·         Partner’s HIV status is different than theirs

·         Did not attend an HIV workshop, training or conference in the last year

FG3: Sexually-active HIV-positive gay men

·         Has ever received a positive HIV test result

·         Has had sex with >1 man in past 3 months

·         Did not attend an HIV workshop, training or conference in the last year

FG4: HIV-negative men at ‘high risk’

·         Has never received a positive HIV test result

·         Has been tested for HIV >2 times in past year and/or has used recreational drugs in past 3 months

·         Has had sex with >1 man in past 3 months

·         Did not attend an HIV workshop, training or conference in the last year

                                                        

What we heard from gay guys

The following is just a preliminary description of what gay men told us about two topics: undetectable viral load and pre-exposure prophylaxis (PrEP). Over the next few months, we will continue to analyze what guys said on these two topics and many others. We will share our findings as they become available. 

Undetectable viral load, PrEP and Risk Calculation

·         For some guys—both positive and negative—undetectability and PrEP each provide sufficient reassurance to have condomless sex, while for others it does not.

·         Many guys remain committed to condom use despite their confidence in either undetectability or PrEP as a way to reduce the risk of transmission.

·         Guys are divided: Are undetectable guys and guys on PrEP safer sexual partners than others?

·         Some guys wonder: Can I trust that a sexual partner was really undetectable or on PrEP? Part of this relates to the fact that unlike a condom, which you can see while you’re having sex, your partner telling you he is on PrEP or has an undetectable viral load means trusting that he actually takes his pills. Some guys also wondered how recent the last viral load test was, and if the viral load had changed since the last test. 

A lot of negative guys are seeking out undetectable partners because a) they’re being tested every 3 months for their blood work and b) they’re concerned about their health and wellbeing and their risk of HIV transmission is zero to extremely low, if any.

Pos, 50+, VAN

The fact that he specifies he’s negative and on PrEP, tested every 3 months… Why would I accept that as a guarantee for my own sexual health as a bottom?

Pos, 35-49, MTL

 

For me, a person who is undetectable and with whom I have a conversation and that I trust, that’s a level of risk I’m willing to take in that kind of situation.

Neg, <35, MTL

It sounds like someone who is very precautious about HIV and taking PrEP. It would not be risky to have sex without a condom, for me.

Neg, <35, VAN

 

I would feel more comfortable but I would still push for the person to use the condom as well.

Pos, 50+, TO

 

I spoke to some health professionals. I couldn’t believe that they were all saying the same thing. Wow. So I started having unprotected sex with my positive partner.

Neg, 35-49, VAN

I would not have sex without a condom. That’s not negotiable.

Neg, <35, VAN

I’m very suspicious of all this stuff.

Neg, 50+, VAN

 

Undetectability as Identity: “The New Negative” 

·         Many positive guys, especially in Vancouver, espouse undetectability as an identity (as opposed to ‘poz’ or ‘positive’) to signify that they are healthy and pose a lower risk of transmission. They felt this helped reduce stigma.

·         Some guys question the impact of identifying as undetectable in a context where the concept is not well understood in the community. 

I always say undetectable is the new negative because it’s next to no risk.

Pos, 50+, VAN

I think that actually does a lot for reducing HIV stigma.

Neg, <35, VAN

I wear my undetectability like a badge of honour. I’m very proud to be undetectable.

Pos, 50+, VAN

 

[Asked what his reaction would be to someone disclosing as undetectable]

Here’s a beer for being honest. Now get out.

Neg, TO

A lot of the guys that I meet have no idea what undetectable means. No idea.

Neg, 35-49, TO

Undetectable is the new vogue. All the cool kids are getting it.

Pos, 50+, VAN

It takes the emphasis off the illness and puts it on my health. HIV-positive has so much baggage attached to it and undetectable doesn’t really have that baggage.

Pos, 35-49, VAN

I’m actually motivated now to take my medications and adhere to them because I don’t want to be anything other than undetectable because my partner is HIV-negative. I’d like to keep it that way.

Pos, 35-49, TO

[Asked about “undetectable is the new negative”]

There’s no such thing… Positive and undetectable is one thing. Positive is another. And negative is another. Let’s not bury our heads in the sand.

Neg, 35-49, MTL

Undetectability’s Impact on Fear 

·         Both positive and negative guys talk about undetectability reducing fear and stigma.

·         However, they also point out that some negative guys make no distinction between positive and undetectable.

·         Some positive guys say it gives then a sense that they were being responsible.

·         Some positive guys worry that it might trivialize HIV. 

I’m having better sex now than I have ever. I allow myself to enjoy where in the past I don’t think I would have been as uninhibited.

Neg, 50+, VAN

It’s liberating in every way actually to know that my blood is not infectious and my body fluids are probably not very infectious.

Pos, 50+, VAN

The fact that statistically I’m as safe, roughly, as a condom; it’s a very nice feeling.

Pos, 50+, VAN

 

[Asked about ways to reduce risk with an undetectable guy]

Stop fucking them.

Neg, 35-49, TO

I watched a lot of people die. When I have made an error that way and it’s happened once or twice, it has cost me weeks of depression. I feel like a gatekeeper in a way.

Pos, 50+, VAN

I agree with you. The word undetectable trivializes the risk of transmission enormously.

Pos, <35, MTL

 

It’s true that knowing that being undetectable greatly reduces the risk of transmission… yes it has occurred to me. It hasn’t fallen on deaf ears.

Pos, <35, MTL

I think the issue that I had as topping was wearing a condom and not being able to keep an erection. Now I can actually perform better and enjoy being a top more without a condom.

Neg, 50+, VAN 

PrEP and The Sex We Desire?

•       Guys question PrEP’s role in the type of sex gay men want. Is PrEP a license to throw caution to the wind or is it a sign of the good gay citizen calculating risk and responding rationally to the threat of HIV infection?

•       Especially for men who find condoms an impediment to sexual satisfaction, PrEP promises enhanced sexual pleasure. 

I wonder, will PrEP end up replacing condoms? Because that’s where we’re heading.

Pos, <35, MTL

I know he’s negative and on PrEP and tested every three months. That’s like everything a bottom could wish for.

Neg, <35, VAN

I respect the guy. He’s doing what he can while still enjoying sex because a lot of guys, don’t enjoy sex when there’s condoms involved.

Pos, 35-49, TO

We’re pill-takers because we like to fuck. So yes, you’re better off not having the virus in your blood, but you’re also better off not having medications and respecting your sexual health.

Pos, 35-49, MTL

We don’t use condoms when I top, and I’m positive. It’s something I think if someone wants to take, it should be available. It’s not at the moment in BC. You have to pay for it. I wish that we had PrEP for my personal situation.

Pos, <35, VAN

We’re virtually in a monogamous serodiscordant relationship and it’s that added level of protection with the risk of long-term medical side effects. For us I think it would be great if it were available.

Pos, <35, VAN

 

If PrEP is available to anyone who wants to take it, does that mean you’ve got a bunch of guys who think they’re invincible and they’re going to go fuck their brains out? I wish that we had PrEP for my personal situation.

Pos, <35, VAN

 PrEP Users: Responsible/Sluts? 

•       Guys alternatively describe PrEP users as sluts and barebackers who think they are invincible on the one hand, and as responsible, thoughtful and knowledgeable individuals who take care of their health on the other.

•       Sometimes they described them as both—responsible sluts.

•      When guys talk about PrEP users as sluts, they sometimes refer to other guys, but they are also sometimes talking about themselves—either as current PrEP users in a couple of cases, or while imagining themselves as potential PrEP users. It often has a mix of judgement and irony, targeted both to others and to themselves. 

It means that they want to have the possibility of unprotected sex, a bit like me. S-L-U-T.

Pos, 50+, VAN

 

He’s had unprotected sex before with somebody with HIV. This is a risk-taker. This is a person that’s a risk taker.

Neg, 35-49, TO

They’re using whatever tools they have to keep themselves safer. Maybe they’re sluts and maybe they’re whatever but they’re at least a little bit more thoughtful.

Neg, 50+, VAN

Intimacy with my spouse is important to me. I can’t stay stuck on the fact that he’s positive and I’m negative. You can’t control love.

Neg, 35-49, MTL

 

I’m on PrEP myself and I’m not a case of ‘I bareback every week’ and I’ve seen the doctor and I’ve had a discussion with her and she prescribed it when I asked for it.

Neg, <35, MTL

I think they’re more likely to be a slut—pardon me—and I’m going to get syphilis from them and more likely will get Hepatitis C from them because they think they’re invincible.

Pos, 50+, VAN

First off he mentioned he’s a negative guy… And then it goes on PrEP. So even more is he trying to keep his status being negative. Then it said tested every three months. Obviously this guy takes his health very seriously. He’s taking these pills to prevent getting HIV.

Pos, <35, TO

 Some general observations 

While we did not measure participants’ level of awareness about undetectability and PrEP, or their level of confidence in the ability of undetectability or PrEP to reduce the risk of HIV transmission, these levels of awareness and confidence do seem to vary greatly. Some guys are quite familiar with those terms and concepts. Others have heard them before, but do not necessarily know what they mean, or have only partial knowledge of what they mean. Still others have never heard of the terms or concepts. Likewise, some guys do not have any confidence that an undetectable viral load or PrEP has an impact on risk, others have high levels of confidence, while others are unsure. While these differences exist across all types of focus groups, we did notice some general trends. Being positive, knowingly interacting with positive guys, or being connected to HIV organizations seems to increase knowledge and confidence levels. Higher-risk HIV-negative participants tend to have lower levels of knowledge and confidence than others. 

A lot of people… The minute you say healthy and undetectable, it’s more ‘okay what is undetectable, can you explain that to me.’

Pos, <35, TO

You’ll find nobody that will give you 100% guarantee. I guarantee you that. But your risk will be much less... It’s like very high risk reduction.

Neg, 50+, VAN

There is no prevention. There is no pill that prevents it as much as we’d like to believe.

Pos, 50+, TO

Pre-exposure prophylaxis. Once a day, taking a dose of antiretrovirals, for negatives to stay negative.

Pos, 35-49, VAN

This [PrEP] is new on me.

Neg, <35, VAN

 

I actually didn’t even hear about undetectable viral load until I moved here.

Neg, 35-49, VAN

I think I’m a little behind on this topic. What does this mean, P… uhm, P… PrEP? You take a pill and you don’t get AIDS, is that it?

Neg, 50+, MTL

-The virus levels, they’re undetectable, no?

-I think it’s under 100 something.

-Is it CD4?

-It’s the virus.

[Toronto participants]

 As mentioned previously, this is just a preliminary description of what we heard on two specific topics. We will continue to analyse the data and to provide more complete descriptions as they become available over the next few months. Check out www.catie.ca/en/resonance for updates. 

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