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. 

What can I possibly write about online hook up sex sites that hasn’t been said?

I’ve been off them for a couple of years since a guy I was seeing made me delete the last of the profiles I had, which was basically to stay in touch with a lot of guys I know in Europe.

The last straw for me came when this guy I was with looked at me and said, “Ya I took some GHB, didn’t I put any in your drink?” I’m no prude, but since I put “NO PNP” in my profile, and the fact I’ve O.D’d on this stuff before, I didn’t take kindly to the prospect of nonconsensual drug use.

Fortunately there was none in the drink, as I know all to well what it tastes like and its effects. It was the fact my choice could have been taken away from me that hurt.

For the last couple of years I’d rely on a couple of dwindling fuck buddies that I could call up. Slowly this was turning into a pretty sexless life.

My return to the avenue of online shopping was prompted by my trip to Tel Aviv. First the guys are super hot there; I had to meet a few. Secondly, I don’t go to bars to meet people anymore, and I don’t drink.

Feeling not that confident anymore, I snapped a webcam shot of myself thinking that at least if they message me it will be the most recent photo I can have. To my surprise, I learned that being “fresh meat” in Tel Aviv, even being me, means there’s a lot of demand. I think over the month I got about 70 messages. I was shocked!

The problem in Tel Aviv is that everyone has their heads buried very deeply in their asses about HIV. Despite there being over 7,000 positive guys in the area, when I disclose I’m treated like I’m the first poz person they’ve ever encountered. I get the questions. I tell them, there are 7,000 guys here who are positive, you’ve fucked many of them, don’t treat me like I’m the first.

Suddenly there is a concern about doing this or doing that, even though they are happy to do this or do that with those who don’t disclose. This different environment that I’m used to took me back a bit. I had to decide what was the best way to do this.

It wasn’t like I have having sports sex on the hour.  I didn’t mention it at fiirst until we were talking face to face. It’s not my favourite way, but at least if someone is going to be an asshole, they can do it to my face instead of just ignoring a message I’ve sent.

Coming back to Canada I decided to create a couple of profiles. I’ve always thought there is something odd about gay Torontonians, and going back online really confirmed it.

Suddenly, (fresh-meat syndrome excluded) on the first site, there was no interest at all. Something happened to me over the course of flying those 6,000 miles back home. This site is exactly the same as it was several years ago - stale with the same 60 to 70 odd guys parked waiting for someone to message them.

The second one is marginally better as I will log on and see a few messages. In each I’ve said I’m positive at the end of my written portion.

I don’t like the sites that force me into disclosing. I usually do anyway, but I’d like that choice. It feels like I’m being outed to be avoided.  I like to have the choice on how I disclose such issues.

The lay of the land has changed quite a bit. I highly suspect the D&D free people are negative looking to bareback “safely.” So in essence we have many barebacking sites even if we don’t call them that.

There is a bit of dishonesty there, as they go out of their way to exclude, but can’t say it’s because of barebacking.

One guy I met off of this site, during our email exchange asked about my status. He’s very young, in his twenties. I wrote him back and expected to hear nothing back. Instead I received a nice reply saying we could still play “safely.”

What I didn’t realize is our two-tiered sex reservation system. Namely, the best sex (first class) is without condoms, flying economy, you use condoms; both of these will get you to your destination, just one is more desirable. So the HIV status question can be more about determining what kind of sex is available. But it's hard to know what are someone's motives. 

Perhaps with Israeli HIV-stigma fresh in my mind, I began to feel like an outsider looking in and much more so than I had ever in the past.

As per a friend’s recommendation I went on a barebacking site. I never ever contemplated such sites before in my life.  To my surprise I got 30 messages in a week. 

Even with people condemning such an act, I did it and was surprised to see that I was no longer on the inside looking out. This is a very low stigma site. I don’t use condoms with other positive guys anyway, so what the hell.

The irony is that the sites that I once scorned and judged are the very ones that I find the most affirming. Really who wants to be at a party where nobody wants you, which is how Manhunt & Gaydar etc. begin to feel like.

I’ve now successfully turned around my sexless life, one of my goals I can cross off of my "to do" list post-Tel Aviv. 

I want to talk about the sexy topic of monogamy. No so much whether monogamy is achievable or whether it goes against our natural inclinations. The internet is littered with that stuff.  Is monogamy impossible? Are men designed to cheat? There are whole books dedicated to the topic: Eric Anderson's "The Monogamy Gap: Men, Love, and the Reality of Cheating" and the bestselling "Sex at Dawn: How We Mate, Why We Stray, and What It Means for Modern Relationships" by Chris Ryan and Cacilda Jetha,  to name a few.

Call me cynical but you know what I get from these articles?  Maybe it’s not so much monogamy that’s impossible, maybe its lifetime relationships. Only having sex with one person may be no problem for a period of time, but when everything that one person does begins to drive you nuts - that’s the problem. Maybe we just aren’t designed to be with one person our whole life, because, let’s face it, people get annoying. But apparently I’m jaded…

What I actually want to talk about is monogamy assumption. Rather, I suppose I want to learn about monogamy and try to understand why it is so often assumed in (largely heterosexual ) relationships. I have been out of the dating circuit for almost a decade, so perhaps something changed while I was busy doing whatever it is one does in a monogamous relationship: taking Friday night walks through Home Depot, shopping for furniture, having scheduled sex. Maybe I have just been ill-informed by damaging television shows such as Sex and the City but I thought single people dated. A lot. I thought single people went out on multiple dates with multiple people. And not even just people who were looking for relationships; people who didn’t want anything serious too, I thought they dated as well.

"In fact, based on my limited findings, it would seem that straight people at least prefer monogamy."

When I started paying attention and asking around, I realized that people do in fact date, but most people don’t date multiple people at the same time. Why, you might ask? Well, the most common answer I’ve gotten is that people aren’t comfortable sleeping with more than one person at a time. In fact, based on my limited findings, it would seem that straight people at least prefer monogamy. And since, if you’re lucky, dating often leads to sex, people therefore tend to only date one person at a time.

 I recognize that this little “study” is extremely limited, but I’m hard pressed to find many people who feel differently.  It seems that even if people are dating multiple people, once they find someone they like, they stop dating the others. Which leaves me questioning- what if you like them all? What if you’re dating multiple people and you like all of them? What if you are sleeping with all of them? What if they’re sleeping with other people? What if they’re assuming you’re monogamous? Which leads me to my next question:

When do you have the monogamy discussion?

Is it the first date? First time you have sex? First time you say “I love you”? It seems to me, from my own experience, from my friends’ experiences, and from my inevitable exposure to pop culture, that exclusitivity is assumed from the beginning- at the very latest from the first time you have sex. Where does this come from, I wonder? Is this bred into us? Is it “natural” to assume once we are having sex with someone they aren’t having sex with anyone else? Are we taught this through pop culture? When did sex suddenly equal exclusivity? And furthermore, how did I miss this?

"Multiple studies suggest that monogamy is neither necessarily assumed nor the norm among gay male couples."  

So, I know this rant is slightly heteronormative. I am aware of this, since I can only truly speak from my own experience and my own interpretations of the world. I recognize that this is largely different among the LGBTQ community, particularly among gay men. Multiple studies, such as The Couples Study and Hoff’s survey of 566 gay male couples in the San Francisco Bay Area, suggest that monogamy is neither necessarily assumed nor the norm among gay male couples.  I’ve been lead to believe by my gay male friends that monogamy is not assumed until discussed.

So why is it so different among straight people? The obvious answer is that they are socialized that way, whereas queer people have always had to challenge “conventional” relationships.  Is the assumption of monogamy just another backwards thing we “breeders” do? Don’t get me wrong, I have nothing against monogamy, I just don’t want it forced on me or assumed, and I sure as hell don’t want to be judged for my aversion to it or mere desire to simply date. 

The challenge for the new Safe Sex 2.0 effort will be trying to capture the attention span of someone who lives life and thinks in 140 characters. In this Internet age, we in the HIV+ and HIV- community (basically that is everyone) have been given the dual-edged sword of the internet as a tool for advocacy and outreach.  The internet is definitely useful in finding the answer to almost anything, and it has exponentially increased the means by which information can be disseminated to the masses.  However, the internet has also created vast, huge, and deep canyons between us, where we are only as connected as our wi-fi signal allows us to be. 

Back in the “old days”, we in the older gay community used to go to gay bars.  At those gay bars there were bowls of free condoms.  They were right there on the bar or by the door so that they were always on hand. Back then, we cared about protecting our community.  Back then it was not as controversial or offensive to talk about or insinuate safe sex. Safe sex was viewed as a normal, healthy part of the greater gay conversation. 

At some point though, this changed. Bars are no longer the meeting places of gay men.  Grindr, Scruff, and Adam4Adam have taken their place. Face to face caring was replaced by the cold glow of a computer screen.  Our community became diffused and fragmented and it dispersed like smoke in the wind. There were always those that didn’t go to the gay bars, just as there are those who do not go online today, but they were in the minority I believe.  

Our sense of community has been replaced by a transactional approach, where one’s personal opinions seem to trump the collective wisdom that has been tempered by experience.  Collaboration and compromise have been thrown down the toilet, to be replaced by the louder squeaky wheel of personal, selfish freedoms.

Now, if you were to talk about safe/safer sex or condoms, a method that is clinically proven to reduce HIV and other STDs, you are yelled at, or someone posts a pages long diatribe about how out of touch you are, and how it is their God-given right to have unsafe sex. They pull one tenuous statistic (that successful HAART treatment prevents 96% of HIV transmissions) and they have built an amendment to the sexual constitution, much like gun proponents clutch onto the 2nd Amendment. They ignore the fact that an undetectable viral load in the blood is NOT equal to an undetectable viral load in semen or in anal fluids/tissues. 

And so, the uninformed and unwilling shun proven methods of safety: condoms, HIV testing, non-sexual forms of intimacy.  (Apparently in the age of Grindr, intimacy seems to be an outdated concept as well.)  And then when they contract HIV, they then have this sense of confusion and incredulity, knowing in the back of their mind that they knew their risk all along but chose to ignore it and live in the moment.  There is even a hashtag for that, #YOLO (You Only Live Once).  

Because one in five urban gay men do not even know their HIV status, it is imperative to again find a way to encourage HIV testing and to advocate condom use. People proceed with actions based upon their perception of risk, as opposed to the actual risk at stake.   Stigma is still very high and the pervasive HIV stigma within the gay community (as well as outside of the gay community) prohibits those at the highest risk for HIV from getting tested. When those at highest HIV risk continue to contract the virus year after year after year, there should be a more aggressive approach to HIV testing and condom use.   

It is ironic that studies have shown that when a person is diagnosed with HIV, that person’s sexual behavior becomes safer. They care more about not wanting to infect others. But on the flip side of that is the callous carelessness that pervades young gay men, who believe their greatest source of angst is over what to wear to a Lady Gaga concert.  These guys repel conversations about HIV/risk/safety like Teflon repels an egg.  If you try to mention HIV, they all the sudden stop texting you back, or they fade from your Facebook...they become silent and they disappear.  

I believe there needs to be a new call to action, one in which the new ways of the internet and the social media expertise of the young are merged with the proven, effective methods of prevention.  And through all of this we must figure out how to burn of the fog that has settled on everyone regarding HIV:  for the older people who are tired and exhausted from 30+ years of advocacy and for the young, know-it-all youth who live in ignorance and bliss.

I wish I had the answer on how to do that, because until that answer is figured out, I fear we will again see a rise in HIV infections.  I believe the coming storm will rival the pre-HAART era. Before HAART, people died because there was no medicine.  Now, I believe stigma and indifference has become just as deadly as those early days. 

About the author: I am 38, a gay male from Knoxville, TN who is not ashamed of my HIV+ status. I am optimism personified. I am strength realized. I am just me.

Website: embacingpozitivity.blogspot.com.Twitter @jjemcdonald 

Click here to read the first installment.  

On April 5, 2013 I took my first dose of Truvada as pre-exposure prophylaxis (PrEP). How did I end up in this situation where I feel like I need PrEP?

As I mentioned in my previous post, a look back at the phases of my sex life gave me some clues about why PrEP makes sense for me now. After more than 20 years of being sexually active, I only recently found myself veering away from perfect 100% condom use.

How did that happen?

Ironically, this is in part because I’ve been working in HIV for 20 years, including the last 10 years focussed on tracking biomedical HIV prevention research. I know what the research is telling us about HIV transmission. I know what proportion of new infections is driven by people who are undiagnosed. I know what undetectable viral load means for transmission risk.

I started serosorting, but not in the conventional sense. More and more, I’ve been dividing guys up into 3 categories.

1. The first category is small. With HIV-negative guys I know and completely trust, we arrive at a form of negotiated safety—if we have been tested for HIV and all STIs recently, and not yet had sex with others, we usually have condomless sex.

2. The second category has been steadily growing—positive guys. We have discussions about treatment, viral load, STIs and decide how to proceed from there. Sometimes without condoms.

3. The third category is basically everyone else—HIV unknown or undisclosed, and HIV-negative men I don’t know well. I consider guys from this third category as potentially being in the acute infection phase, whether they know it or not. This is the category of men with whom I am most adamant about condom use. All too often, their prevention strategy is dubious at best (e.g., “r u clean? how big r u? wanna bb?”). If I see another highly stigmatizing "disease free"/"no poz" message on an online profile, meant to be some kind of stand-alone, ill-informed HIV prevention strategy, I might reach through the screen and cyber-throttle someone.

So gradually, I’ve found myself feeling much less worried about having condomless sex with a positive guy after a conversation with him about treatment and viral load and STIs than about having condomless sex with a guy who says he is negative, but could be in the acute infection phase with sky-high viral load without even knowing it.

Paranoia? Rational, effective, evidence-based risk-reduction strategy? Both? You be the judge.

But let’s be honest. I also started “slipping up” more and more often because, well… sex feels better without condoms. *gasp* That’s right folks. Sex without condoms feels freaking amazing. You heard it here first.

So while I still maintained a relatively high rate of condom use, I found myself having condomless sex every once in a while. Of course, I also know how effective inconsistent condom use is over time (i.e., not very).

An illuminating peek inside the Little Black Book

Three years ago, I started to keep track of my sexual encounters in a proverbial little black book. (OK fine, it’s blue and has a Global Campaign for Microbicides logo and a Rectal Pride for Microbicides sticker on it. It’s super pretty and seemed appropriate). Every time I have sex, I write down what we did, what I know about my sex partner’s HIV status, and whether or not we use condoms. Yup, every time for 3 years. I do this partly so I have very accurate information at my fingertips to relay when I get tested for HIV and STIs. Partly so I have very accurate information at my fingertips when I start to worry. I can look at my list since my last tests and say: look, you had this many encounters, this is what you did with whom, this is how often you used condoms, and this is what you know about his HIV status. Sometimes that helps alleviate the occasional panic attack and insomnia. Sometimes.

I had never seen myself as being “high risk” for the first 20+ years of my sex life. But I’ve been working in HIV for 20 years. So I know the behavioural characteristics of “those people” at high risk. Armed with about 3 years of hard data about my own newly evolving behaviour (i.e., my stylish little blue book), I decided to look at it objectively.

• Multiple sex partners? Check

• History of STIs? Check

• Partners of unknown or HIV-positive status? Check

• Inconsistent condom use? Check

Well then. It’s hard to ignore what this spells.

I like to think I’m at least moderately intelligent. I know how HIV is transmitted. I know how effective condoms are.

I like to think I understand the consequences and the stakes. Yes, people living with HV are doing much better today. But I saw my dad die of AIDS in front of my eyes. I saw countless other friends, colleagues and clients become HIV-positive or die of AIDS. That leaves an impression, to say the least.

I like to think I’m a responsible person. I get tested frequently. I stay informed.

I like to think I have high self-efficacy. I have several years of experience using condoms consistently, and I am more often than not the one wearing the condom, so little to no negotiation is required.

I’m not depressed. I never drink. I don’t so drugs. My judgement is not clouded by any of those.

I’m not in denial. I know that the combination of inconsistent condom use, multiple partners, history of STIs and having partners of a different/unknown HIV status is a very strong predictor of seroconversion over the course of a few years.

If all of this doesn’t make me an ideal candidate for consistent condom use, I don’t know what more it would take, short of using Super Glue to permanently bond a condom to Mr. Happy.

Yet here I am.

So as a smart, responsible, well-informed, sexually active gay man with good self-efficacy and good access to healthcare and accurate information, I’ve come to the conclusion that PrEP makes sense for me at this point in my life. I don’t know how long this new “PrEP phase” will last. But I am glad it is available to me while I need it.

To be continued . .

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 first appeared on My PrEP Experience here.