F AGuide toOAIDSCResearch andU Counseling Volume 14 Number 5 April 1999S

load decreased the risk of transmission. Beyond Complacency: The Effects Similarly, a New York study of men who have sex with men—the Seropositive Urban of Treatment on HIV Transmission Men’s Study (SUMS)—found that men who Perry N. Halkitis, PhD and Leo Wilton, MA engaged in unprotected anal intercourse with partners who were seronegative or of unknown status believed that they were less The interaction between the success of infectious because they were on antiviral HIV antiviral therapy and prevention efforts therapy and had negligible viral loads. A is complex, and it is becoming clear that an study of 298 men attending a 1997 gay optimistic view of the HIV epidemic may pride event in Atlanta found that those who actually lead to an increase in the number 1 had engaged in unprotected anal receptive of HIV infections. Data from several intercourse indicated that they were less sources—for example, a survey of gay men worried about unsafe sex because of treat- in Sydney, a study of young men who have ment advances.2 Of 54 men surveyed in a sex with men in New York, and preliminary 1997 San Francisco study, 26 percent were data on both gay men and injection drug less concerned about becoming seropositive users in New York and San Francisco— now that protease inhibitors were available: demonstrate significant increases in the 15 percent were more willing to engage in rate of unsafe sexual behavior among both unsafe sexual behaviors and risk HIV infec- HIV-infected and uninfected people. tion and 15 percent reported already taking These patterns of unsafe practice are such a risk.3 further demonstrated by the increasing In addition, unsafe sex between HIV- prevalence of other sexually transmitted positive partners, which may lead to rein- diseases around the country as illustrated fection, has also increased in light of the by data from New York and San Francisco. new treatments. The Seropositive Urban Several studies suggest that the new opti- Men’s Study found that HIV-infected gay mistic culture arising from successful and bisexual men in primary relationships antiviral treatment has become the catalyst reported higher rates of unprotected for behavior change that has resulted in insertive anal intercourse with other infect- these increases in unsafe sex. This article ed partners than with uninfected partners. briefly reviews these studies and then eval- Anecdotal reports indicate that some gay uates the beliefs regarding the relationship men in metropolitan areas attend “poz between infectivity and treatment, which bareback parties,” where seropositive gay may fuel these increases in unsafe sex. and bisexual men gather to have unprotect- ed sex with multiple partners. Optimism and Behavior Complicating the effects of optimism Recent studies have indicated that about new antiviral treatments is a misun- increases in unsafe sex may be related to derstanding about the meaning of an beliefs about the lack of severity of HIV “undetectable” viral load reading. For disease. For example, in a New York study of example, a Canadian study found that 14 serodiscordant male couples, 24 percent a significant proportion of participants of respondents engaged in unprotected anal perceived unprotected vaginal and anal intercourse two months prior to assess- intercourse to be less risky and safer ment, and half of the sample agreed that a sexual practices to be less important reduction in the seropositive partner’s viral if viral load was “undetectable.”4 questions by reviewing the rele- Editorial: Transmitting Myths vant literature. Their conclu- Robert Marks, Editor sions offer no concrete answers about probability but do confirm the possibility of transmission There is a type of scientific The data are inconclusive, but data that slips into human con- many studies have found that for in all three of these cases. sciousness, integrated silently, small but significant minorities, June Crawford, Susan Kippax, like viral RNA, I guess, affecting such beliefs play an important and Paul Van de Ven look at the our decisions without requiring role in precipitating unprotected implications of this science in much reflection. The success of sex. It remains unclear, as at the context of the explicit sexual combination therapy has inject- least one researcher has suggest- agreements between partners in ed several assumptions into the ed, whether this significant many couples. They focus on collective consciousness of minority would be having unpro- negotiated safety agreements, those communities most affect- tected sex anyway, that these in which, by definition, both ed by HIV disease. individuals would have found partners are seronegative, Among these ideas are that some other justification for because this is the area where getting infected is no big deal unsafe behavior. there is the most research. because drugs can treat you, that In any case, it is crucial for There’s a faint aroma of com- people using the new treatments providers to understand the placency in the air these days are somehow less likely to infect science behind assumptions and a sense that not only have seronegative partners, and even about infectivity and transmis- the consequences of HIV infec- that having an “undetectable” sion in the context of the new tion changed, but also the sci- viral load is tantamount to being treatment landscape. This issue ence of transmission. In order for seronegative. There has been a of FOCUS clarifies three con- clients to make appropriate deci- great deal of speculation and a cepts regarding the science: the sions about risk, they must rush of studies over the past 18 possibility of transmitting drug- understand the certainty and months seeking to determine resistant virus to seronegative limits of scientific knowledge. exactly how much these attitudes, partners, the possibility of rein- Mental health providers cannot if they exist, affect behavior. For fecting a seropositive person expect themselves to interpret example, do people believe that with drug-resistant virus, and complex studies of basic HIV low viral load diminishes infectiv- the possibility of transmitting science, but they can become ity, do these people increase HIV when the seropositive part- aware of the current scientific unprotected behaviors as a result, ner’s viral load is below the level consensus in key areas and and how many people believe this of detection. Perry Halkitis and inform discussions of risk that and act on this belief? Leo Wilton seek to answer these arise within the counseling room.

References Ultimately, however, the beliefs some become reinfected with a drug-resistant or 1. Halkitis PN. Ad- people have about the effects of treatment more virulent strain of HIV, events that vances in treatment of HIV disease: Complex- success and the meaning of viral load are may complicate treatment. The rest of this ities of adherence and not supported by the scientific literature. article reviews the most recent research on complications for pre- First and foremost, the long-term efficacy viral mutation and drug resistance, the po- vention. The Health of antiviral treatment remains unclear, tential for reinfection, and the meaning of Psychologist. 1998; 20(1): 6-7,14. suggesting that the success of the new viral load and implications for infectivity. treatments may lead to a false sense of 2. Kalichman SC, security. Second, research indicates that Viral Mutation and Resistance Nachimson D, Cherry problems in treatment, medication adher- Like all bacteria and viruses that cause C, et al. AIDS treatment advances and behav- ence, and the natural evolution of the disease, HIV has the potential to alter its ioral prevention set- virus may result in viral mutations and genetic composition, yielding a variety of backs: Preliminary increased drug resistance. Finally, while strains and subtypes. The introduction of assessment of reduced antiviral treatment has been proven to combination therapy, in particular, the perceived threat of HIV-AIDS. Health reduce viral load in the blood, HIV may lie widespread use of protease inhibitors as Psychology. 1998; dormant, potentially in a mutated state, in well as continued use of nucleoside ana- 17(6): 546-550. the lymph and other systems. Recent data logues such as zidovudine (ZDV; AZT), has 3. Dilley JW, Woods also suggest that some people have been significantly increased the prevalence of WJ, McFarland W. Are infected with mutated and drug-resistant mutated viruses that can “outsmart” antivi- advances in treatment strains of the HIV virus, diminishing or ral treatments. According to the Stanford changing views about eliminating options for treatment. While HIV RT and Protease Sequence Database, high-risk sex? New not proven, it appears that this may occur drug resistance arises from mutations in the England Journal of Medicine. 1997; not only with seronegative people but also HIV genome specifically in the regions that 337(7): 501-502. with seropositive individuals, who may encode the molecular targets of therapy: the 2 FOCUS April 1999 protease and reverse transcrip- recent evidence suggests the existence of tase enzymes.5 more than one strain of the virus in a per- Even at viral For individuals who initially son. The effect of such coinfection on succeed on combination thera- antiviral treatment remains unclear. load levels of py, the development of drug Researchers have long identified several resistance is often associated risks to unprotected sex between seroposi- less than 500, with increases in viral load as tive partners. Among these risks have been HIV replication medications fail to control infection with other sexually transmitted infection. Evidence suggests diseases that would flourish in the presence and mutation that even when viral load is of a compromised immune system, and detected at levels less than 500, reinfection with HIV, an event that might still occur. replication and mutation of the activate the immune system leading, ironi- virus can still occur.6 Treatment cally, to further HIV replication in immune failures due to drug resistance system cells. More recently, such practices 4. Kravcik S, Victor G, can lead to disease progression have also been associated with hepatitis C Houston S, et al. Effect and limited treatment alternatives. transmission. Some researchers hypothesize of antiretroviral Equally important, drug-resistant strains that reinfection may have even more serious therapy and viral of HIV may be transmitted to others, simi- consequences when a seropositive person load on the perceived 1 risk of HIV transmis- larly limiting their treatment options. becomes exposed to a drug-resistant or sion and the need for Concern regarding drug resistance has more virulent strain of HIV. Some re- safer sexual practices. emerged largely as a result of the introduc- searchers contend that reinfection may also Journal of Acquired tion of protease inhibitors, although there Immune Deficiency result in increased HIV levels in the blood. Syndromes and has been ample evidence of virus resistant Swiss researchers have identified 159 Human Retrovirology. to medications, including the nucleoside subtype strains of HIV-1 in humans, and 1998; 19(2): 124-129. reverse transcriptase inhibitors zidovudine similar subtypes have been identified across 5. Shafer RW, Winters (ZDV), didanosine (ddI), and zalcitabine other studies in Argentina, Brazil, Thailand, MA, Palmer S, et al. (ddC), and lamivudine (3TC), and the non- and Ukraine.8 The most prevalent in North Multiple concurrent nucleoside reverse transcriptase inhibitors. America, Western Europe, and Australia is reverse transcriptase Research also indicates that a virus can subtype B, while subtype C predominates in and protease muta- contain several mutations and therefore be tions and multidrug Africa and most of Asia. The subtypes A, D, resistance of HIV-1 resistant to drugs in many classes. As sig- E, and F have been found in smaller num- isolates from heavily nificantly, viral mutation in response to one bers. While evidence for dual infections treated patients. medication in a class of drugs, for example, exists, it is unclear if those infections result Annals of Internal the protease inhibitors, may result in resis- Medicine. 1998; from simultaneous or consecutive infection. 128(11): 906-911. tance to all medications in that class. For Researchers at the University of Alabama example, the Stanford project cited above have accumulated evidence suggesting that 6. Crandall KA, Kelsey found that of the 18 mutations induced to CH, Imamichi H, et al. the possibility of humans infected with two Parallel evolution of evade indinavir, 17 evaded ritonavir, and 16 or more strains of HIV is probably greater 5 drug resistance in evaded saquinavir. Another example is that than originally assumed.9 In their work HIV: Failure of non- a similar mutation at one spot can cause with chimpanzees, the researchers were synonymous/synony- resistance to all three licensed non-nucleo- able to infect previously infected animals mous substitution rate side reverse transcriptase medications. ratio to detect selec- with a second strain of the virus and to tion. Molecular Biol- Resistance is closely connected to proper detect the second strain up to six weeks ogy and Evolution. dosage and adherence to medications. For later. Data from a Rio de Janeiro cohort 1999; 16(3): 372-382. example, in one study of 88 people, treat- supports the possibilities of dual infection, 7. Paterson D, Swin- ment failure was directly related to adher- a recombinant strain, or a mosaic composi- dells S, Mohr J, et al. ence rates. The study found that treatment tion. Of the 791 blood donors studied over How much is enough? failure, as measured by viral load level, the course of a year, 3.8 percent had a dual A perspective study of increased from 20 percent to 94 percent adherence to protease HIV infection of two subtypes of the virus, inhibitor therapy using when adherence rates fell from 95 percent and 7.6 percent had a recombinant infec- MEMSCap. Presentation to 70 percent.7 Data from numerous tion.10 Neither of these studies was able to from the 6th Confer- sources, including the Seropositive Urban determine the biochemical effects of dual ence on Retroviruses Men’s Study and the Seropositive Urban and Opportunistic infection and its impact on antiviral treat- Infections, Chicago, Drug Injectors’ Study, indicate adherence ment. Among the possibilities are that the February 1999. levels are approximately 50 percent across second strain of the virus will predominate all classes of antiviral drugs. 8. Kalish M, Stoeckli T, or that a recombinant and potentially more Steffen I, et al. Molec- pathogenic version will develop. ular epidemiology of The Potential for Reinfection HIV-1 in Switzerland. The transmissibility of drug-resistant HIV The Meaning of Viral Load and Infectivity Presentation from the Combination treatment has been accom- 12th World AIDS Con- has implications not only for seronegative ference, Geneva, Switz- but also for seropositive individuals. While panied by improved monitoring of viral erland, June-July 1998. the concept of “reinfection” is controversial, activity and disease progression. 3 FOCUS April 1999 Measures of serum HIV levels, referred nation therapy who had suppressed levels to as viral load assays, have been used as of HIV in their blood did not have virus-free markers of HIV disease progression and semen samples. In another cohort, subjects 9. Fultz PN, Yue L, Wei overall health, determinants of when to with detectable viral load levels in their Q, et al. Human initiate antiviral therapy, indicators of the blood presented with equal or higher levels immunodeficiency virus type 1 intersub- success of antiviral therapy, and, indirect- of HIV in their seminal fluids. type (B/E) recombina- ly, measures of treatment adherence. Such tion in a superinfected assays are currently able to detect HIV at Conclusion chimpanzee. Journal levels as low as 20 copies per milliliter of Risky behaviors seem to be increasing, of Virology. 1997; 71(10): 7990-7995. blood; however, not all laboratories use and this increase may be associated with an tests with sensitivities this low. Recently, optimism regarding the manageability and 10. Ramos A, Tanuri researchers have suggested that viral load reduced threat of HIV disease. This opti- A, Schechter M, et al. Dual and recombi- may have different implications for dis- mism may be based not only on misleading nant infections: An ease progression in women versus men. media attention, but also on confusion integral part of the Although combination therapy can about the effects of treatment on HIV trans- HIV-1 epidemic in reduce the concentration of HIV to levels missibility In response, clinicians and edu- Brazil. Emerging Infectious Diseases. at which virus cannot be detected by viral cators must raise awareness among both 1999; 5(1): 65-74. load assays, this does not signify the com- seronegative and seropositive individuals plete eradication of virus from the body. about the possibilities of viral mutation and Authors But, as noted earlier, many people have resistance to antiviral therapies; they must Perry N. Halkitis, PhD interpreted an “undetectable” viral load to also seek to contradict assumptions about is Clinical Assistant mean that a seropositive person is uninfec- infectivity in light of treatment advances Professor of Applied tious. These extremely low viral load levels and the concept of “undetectable” viral Psychology at New York University and the As- are now referred to as “below the level of load. Because reinfection remains a risk, sociate Director of the detection” to indicate that HIV may still be providers must raise issues of safer sex for Center for HIV/AIDS present and to more clearly communicate people with HIV, even when partners them- Educational Studies that detection is affected by technology as selves are seropositive, As we approach the and Training. He is Co- Principal Investigator much as by the presence of the virus. third decade of AIDS, these messages must of the Seropositive Research suggests that while blood level be stronger than ever because complacency Urban Men’s Study and assays may demonstrate no significant has had an impact on behavior. Intervention Trial, and detectable viral activity, HIV may lie dor- Unfortunately, many AIDS service organi- the former Director of Research at the Gay mant in the immune system, perhaps zations have failed to respond adequately to Men’s Health Crisis. mutating naturally or in response to antivi- the challenges of education regarding new ral treatment. This phenomenon becomes treatments and adherence, the meaning of Leo Wilton, MA is a doctoral candidate in apparent when people with viral loads viral activity, and the dangers of drug- counseling psychology below the level of detection discontinue resistant viral transmission. The AIDS epi- at New York Universi- antiviral treatment or when their strain of demic is now in its adolescence, and our ty, a research associ- HIV becomes resistant to a drug or drugs increased knowledge has transformed it into ate at the Center for HIV/AIDS Educational they are taking—changes that are often a much more complex disease. Providers Studies and Training, accompanied by increases in viral load. must respond with more sophisticated and and a therapist at the In addition, a viral load below the level of relevant strategies that take into account Trustees of Columbia detection does not signify that other body the depth and range of information that we University Community Support Systems fluids, specifically genital fluids, are free of have and the depth and range of the misun- Program. the virus. In one study, subjects on combi- derstandings this information can induce.

among gay and bisexual men. Journal Clearinghouse: Treatment/Prevention of Consulting and Clinical Psychology. 1997; 65(4): 542-546.

AIDS. 1998; 9(10): 579-586. Kelly JA, Hoffmann RG, Rompa D, et al. References Protease inhibitor combination thera- Egger M, Hirschel B, Francioli P, et al. Kalichman SC. Post-exposure prophy- pies and perceptions of gay men Impact of new antiretroviral combina- laxis for HIV infection in gay and regarding AIDS severity and the need tion therapies in HIV infected patients bisexual men: Implications for the to maintain safer sex. AIDS. 1998; in Switzerland: Prospective multicentre future of HIV prevention. American 12(10): F91-F95. study. British Medical Journal. 1997; Journal of Preventative Medicine. 1998; 315(7117): 1194-1199. 15(2): 120-127. Kelly JA, Otto-Salaj LL, Sikkema KJ, et al. Implications of HIV treatment advances Ezzy DM, Bartos MR, de Visser RO, et Kalichman SC, Kelly JA, Morgan M, et for behavioral research on AIDS: al. Antiretroviral uptake in Australia: al. Fatalism, future outlook, current life Protease inhibitors and new challenges Medical, attitudinal and cultural corre- satisfaction, and risk for human in HIV secondary prevention. Health lates. International Journal of STDs and immunodeficiency virus (HIV) infection Psychology. 1998; 17(4): 310-319.

4 FOCUS April 1999 recent study on this type of agreement Sexual Agreements Between and its relation to risk behavior. Men in Relationships Negotiated Safety June Crawford, PhD, Susan Kippax, PhD, and Paul Van de Ven, PhD In the early 1990s, U.S. and Dutch researchers identified what they called “relapse” among men who had been using Since the beginning of the epidemic, condoms consistently but were no longer sexual partners have negotiated agree- doing so. Australian and British researchers ments about sexual activity both within questioned this interpretation, noting that and outside a relationship. Some of the the relapse data did not draw a distinction issues covered in these agreements have between unprotected anal intercourse included types of activity, the use of within regular relationships and unprotect- protection, and sexual activity outside ed anal intercourse with the relationship. casual partners. Over the past Following a debate within several years, the the research community, concept of “nego- Some researchers Susan Kippax and co- tiated safety,” researchers in Australia has gained some criticized coined the term “negotiated currency, refer- “negotiated safety” safety” to describe a pattern ring particularly of behavior they had to agreements as a strategy, calling observed: the partners with- regarding unpro- in a regular relationship tected anal inter- it “negotiated entered into an agreement course within that as long as each engaged gay male relation- danger,” because in no unprotected anal inter- ships in which course outside of the rela- both partners there was room for tionship, then both could are seronegative. engage in unprotected anal Other types of slippage in the intercourse within the rela- agreements are practice. tionship.1,2 It was appropri- less precisely ate in this context to use the conceptualized, term “safety” if both part- but do commonly ners had been tested for occur, for example, the agreement HIV antibodies and found reliably to be between partners in seropositive seronegative, and provided of course that couples—both gay and heterosexual the agreement was kept. —to have unprotected sex since both Since that time, there has been some partners are already HIV-infected. confusion surrounding the discourse of This article looks at the range of agree- negotiated safety. Some have suggested ments among gay men regarding anal that what the researchers put forward intercourse. It focuses in particular on as a description of a pattern of practice negotiated safety and the results of a devised by men as a possible safe sex

Malow RM, McPherson S, Klimas N, et ment advances? AIDS. 1998: 12(12): 011-61-2-9385-6409, june.crawford@ al. Adherence to complex combination 1560-1561. unsw.edu.au (e-mail). antiretroviral therapies by HIV-positive Rosser BRS. The impact of new drug abusers. Psychiatric Services. Perry N. Halkitis, PhD, New York advances in treatment on HIV preven- University, Department of Applied 1998; 49(8): 1021-1022. tion: Implications of the XI International Psychology, 293 Greene Street, East Rabkin JG, Ferrando S. A “second life” AIDS Conference on future prevention 537G, New York, NY 10003, 212-998- agenda. Psychiatric research issues directions. In Wright MT, Rosser BRS, de 5373, [email protected] (e-mail). raised by protease inhibitor treatments Zwart O, eds. New International Brenda Lein, Information and Advocacy for people with the human immunodefi- Directions in HIV Prevention for Gay and Department, Project Inform, 205 13th ciency virus or the acquired immunode- Bisexual Men. New York: Haworth Press, Street, Suite 2001, San Francisco, CA ficiency syndrome. Archives of General 1998: 143-149. 94103, 415-558-8669, [email protected] Psychiatry. 1997; 54(11): 1049-1053. Contacts (e-mail). Remien RH, Wagner G, Carballo- June Crawford, PhD, National Centre in Dieguez A, et al. Who may be engaging HIV Social Research, University of New in high-risk sex due to medical treat- South Wales, Sydney 2052 Australia, See also references cited in articles in this issue.

5 FOCUS April 1999 strategy was being recommended as such of agreement was to have no unprotected an approach. Critics of the strategy called anal intercourse either within or outside it “negotiated danger,” pointing out that the relationship. Negotiated safety agree- there was room for slippage in the prac- ments were almost as common. Again, a tice: for example, the potential for agree- negotiated safety agreement is one in ments to be broken, the fact that reliable which: both partners have tested HIV anti- knowledge of one’s HIV status required body negative; the partners have talked two seronegative with each other and come test results at an to an agreement; and interval of approxi- the agreement includes mately four Few study participants a provision that there months, and the will be no unprotected with negotiated safety anal intercourse out- need for mutual side the relationship. honesty between agreements engaged In general, the Male partners.3 It is clear Call study found a that as a risk reduc- in risky practices. But, close relationship tion strategy, nego- negotiated safety is between type of agree- tiated safety is ment and risk practice. complicated. In not simple; it depends Under the conditions of continuing to a negotiated safety research the kinds on reliable agreement that is fol- of agreements that lowed by both partners, men make and the information regarding unprotected anal inter- behavior in which serostatus and course within the rela- References they engage, the tionship is not a risk Australian team 1. Davies P. Project requires open and practice because both Sigma. On relapse: has found that partners are seronega- Recidivism or rational negotiated safety honest communi- tive. Unprotected anal response? In Aggleton agreements, as intercourse between P, Davies P, Hart G, cation in case a men in serodiscordant eds. AIDS, Rights, well as agreements Risks and Reasons. to engage in no relationships or in London: Falmer Press, unprotected anal partner breaks the relationships where the 1992. intercourse at agreement. HIV serostatus of one 2. Kippax S, Crawford all, may in fact or both partners is J, Davis M, et al. be helpful in the unknown carries some Sustaining safe sex: A sustaining of safe risk, and all unprotect- longitudinal study of 4 ed anal intercourse with casual partners is a sample of homosex- sexual practice. ual men. AIDS. 1993; While many studies have found that regarded as risky. (The Male Call study did 7(2): 257-263. unprotected anal intercourse is far more not investigate oral sex practices at all.) The study found that few people with 3. Stall R, Ekstrand common in regular relationships than in 2,5-7 negotiated safety agreements reported M. The quantitative/ casual partnerships, only a small num- qualitative debate ber of studies separately consider practices engaging in risky practices. Nevertheless, over “relapse” that may differ according to whether they negotiated safety is not a simple and behaviour: Comment. straightforward strategy, depending as it AIDS Care. 1994; 6(5): are with regular or with casual partners. A 619-624. recent large national telephone survey of men who have sex with men in Australia, 4. Kippax S, Noble J, known as Male Call 96, included questions Prestage G, et al. Sexual negotiation about agreements in regular relationships. Comments and Submissions in the AIDS era: Out of 3,039 men who responded to the We invite readers to send letters Negotiated safety survey, 1,070 were in “regular” (sometimes responding to articles published in revisited. AIDS. 1997; referred to as “primary”) male-to-male rela- 11(2): 191-197. FOCUS or dealing with current AIDS tionships of more than six months duration. research and counseling issues. We 5. Bosga MB, de Wit Researchers excluded from the analysis 30 also encourage readers to submit arti- JBF, de Vroome EMM, men in relationships in which both partners cle proposals, including a summary of et al. Differences in were seropositive, leaving 1,040 men who perception of risk for the idea and a detailed outline of the HIV infection with contributed to the analysis discussed here. article. Send correspondence to: steady and non-steady One of the findings from this survey was partners among that over 80 percent of the men in such Editor, FOCUS homosexual men. relationships had agreements with their UCSF AIDS Health Project, Box 0884 AIDS Education and Prevention. 1995; partners regarding sexual practice within San Francisco, CA 94143-0884 7(2): 103-115. the relationship. The most common form 6 FOCUS April 1999 does on reliable and up-to-date informa- and transmission issues. In the light of tion regarding the serostatus of both new treatments that appear to be effective partners. It also requires open and honest in maintaining health for many people communication between partners in the living with HIV, it is possible that negotia- event that one of them breaks the agree- tion of agreements between men, whatever ment. Such an event would necessitate a their own and their partner’s serostatus, return to consistent condom use or the may become even more complicated. avoidance of anal intercourse until sero- The advent of new treatments and the negative status could be re-established. availability of testing for viral load have the potential to increase the complexity Other Types of Agreement of the information that may affect agree- In the Male Call study, a small but impor- ments. For example, a person’s viral load tant minority of men in relationships, may appropriately or inappropriately enter around 11 percent, had “unsafe” into agreements of discordant couples. It is agreements. Such agreements included not only discordant couples who may find those in which partners of different or negotiation more complex. Even among unknown serostatus agreed to unprotected men who are HIV-seronegative, new treat- anal intercourse within the relationship, and ments may bring about change in cultural all arrangements, including those between meanings attached to what is implied by 6. Dawson J, Fitzpatrick R, Reeves seroconcordant partners, that did not being or becoming HIV-seropositive. G, et al. Awareness of include a pact to have no unprotected anal sexual partners' HIV intercourse outside the relationship. As Conclusion status as an influence might be predicted, men with unsafe agree- It is important for researchers to contin- upon high-risk sexual behaviour among gay ments were likely to report behavior that ue to investigate what understandings gay men. AIDS. 1994; 8(6): risked HIV transmission. For these men, men have regarding the new treatments, 837-841. most risk practice was with regular part- whether they incorporate these under- ners, and the risk was due to absence of 7. Detels R, English P, standings (either accurate or inaccurate) Visscher BR, et al. information regarding serostatus. En- into their agreements, and what happens Seroconversion, couraging regular partners to be tested and to their sexual practice in this new con- sexual activity and to disclose their test results to one another text. This research is aimed at providing condom use among may be one way to decrease the number of answers to questions that will help coun- 2915 HIV seronega- tive men followed for men who have unsafe agreements. selors and educators formulate programs up to two years. In the Male Call survey, there were very aimed at preventing transmission of HIV. Journal of Acquired few serodiscordant couples, but from this Immune Deficiency and other studies, it has been found that Syndrome. 1989; 2(1): 77-83. agreements are very common among such couples. In the case of serodiscordant Clarification 8. Van de Ven P, couples, most agreements are to have no French J, Crawford J, In the February issue of FOCUS, the unprotected anal intercourse either within et al. Sydney gay article “HIV Partner Counseling and or outside the relationship, although again men's agreements Referral” omitted information that about sex. In Aggleton a small minority report agreements which helps to understand the value of the P, Davies P, Hart G, permit behavior (particularly within the eds. Families and detuned assay for partner counseling. Communities relationship) that risks HIV transmission. Studies other than the Male Call study The assay is a form of the antibody Respond to AIDS. test that determines if seroconversion London: University have determined that agreements between College of London partners in seroconcordant positive cou- occurred either within the four Press. In press. ples are also common, and that many months prior to antibody testing or at a time greater than four months prior Authors such couples engage in unprotected anal intercourse.8 Although both partners are to testing. Since it can take two June Crawford, PhD is months after exposure to seroconvert, a Research Consultant living with HIV disease, there are other at the National Centre issues such as infection with other sexual- partner counseling and referral guide- in HIV Social Research ly transmissible infections and different lines identify the “critical interview at the University of strains or mutations of HIV that may need period” for people who test “antibody New South Wales in positive/detuned negative” as being Sydney, Australia. to be taken into account when seroposi- tive couples make decisions regarding two months plus four months, for a Susan Kippax, PhD anal intercourse within the relationship. total of six months. The critical inter- is Director of the view period is the time frame during National Centre in It is clear that gay men in relationships HIV Social Research. can and do enter into agreements regard- which identified sexual or needle-shar- ing the practice of anal intercourse both ing partners may have been exposed Paul Van de Ven, PhD and should be located for partner is Deputy Director of within and outside the relationship. Some the National Centre in of these agreements are complex and rely counseling and referral services. HIV Social Research. on accurate understandings of HIV testing 7 FOCUS April 1999 and bisexual men not in long-term relation- Recent Reports ships found that 23 percent who had engaged in unprotected anal receptive Effects of Treatment on Risk Perception intercourse during the previous six months believed that this was safe if an HIV-infected Kravcik S, Victor G, Houston S, et al. Effect of F partner had an undetectable viral load. Of AGuide toOCUAIDS Research and CounselingS antiretroviral therapy and viral load on the per- ceived risk of HIV transmission and the need for subjects who did not participate in unpro- Executive Editor; Director, safer sexual practices. Journal of Acquired Immune tected anal receptive intercourse during this AIDS Health Project James W. Dilley, MD Deficiency Syndromes and Human Retrovirology. period, only 5 percent shared this belief. 1998; 19(2): 124-129. (Ottawa General Hospital; The sample consisted of 298 men—93 Editor and Health Canada, Ottawa.) Robert Marks percent gay and 7 percent bisexual— According to a Canadian study, 22 per- recruited at an Atlanta gay pride festival. Assistant Editors The mean age was 33; and 85 percent Alex Chase cent of seropositive subjects believed that John Tighe taking some form of antiviral therapy were White, 7 percent were African American, and 8 percent were of other Founding Editor; Advisor reduced their risk of transmitting HIV to Michael Helquist others, and 20 percent believed that treat- ethnic backgrounds. Eighty-five percent had tested seronegative, and 15 percent Medical Advisor ment diminished the importance of safer Stephen Follansbee, MD practices for sex and injection drug use. had not tested. Twenty percent had engaged in unprotected anal receptive Design Researchers recruited 147 participants Saul Rosenfield from a university-based HIV clinic, 88 per- intercourse in the previous six months. These “highest risk” subjects were Production cent of whom were men. Subjects reported Tania Lihatsh sources of infection as follows: 77 percent younger and had completed fewer years Shauna O’Donnell through sexual intercourse (89 percent of education than “lower risk” subjects. Andrew Tavoni male-to-male), 8 percent through injection Highest risk subjects were more likely Circulation drug use, and 8 percent through blood than lower risk subjects to state that they Carrel Crawford practiced more unsafe sex than they used Shauna O’Donnell transfusions. Ninety-five percent were on antiviral therapy, and 69 percent were to and that they were less worried about Interns becoming infected because of new treat- Laura Meyers taking at least one protease inhibitor. Rahim Rahemtulla Subjects completed a questionnaire ment efficacy. Highest risk subjects con- assessing their perceptions of the risk of sidered the risks for unprotected anal FOCUS is a monthly pub- HIV transmission from an infected man receptive intercourse to be lower with lication of the AIDS HIV-infected partners taking protease Health Project, affiliated with a CD4+ cell count of about 200 to an with the University of uninfected partner under three hypotheti- inhibitors and lower still with partners California San Francisco. cal scenarios: in the “no therapy” case, the with undetectable viral loads. Among Twelve issues of FOCUS HIV-infected partner received no treat- lower risk subjects, however, perceived are $36 for U.S. residents, $24 for those with limited ment; in the “RTI therapy” case, he was risk remained consistent regardless of a incomes, $48 for individu- taking zidovudine (ZDV; AZT) with lamivu- partner’s treatment status or viral load. als in other countries, $90 for U.S. institutions, and dine (3TC); and in the “PI therapy” case, he $110 for institutions in was on ZDV, 3TC, and a protease inhibitor other countries. Make and had “undetectable” viral load. checks payable to “UC Regents.” Address sub- For each scenario, respondents ranked Next Month scription requests and cor- the relative risk of transmission for unpro- respondence to: FOCUS, The AIDS epidemic has always UCSF AIDS Health tected anal, vaginal, and oral sex, and for posed some thorny ethical issues for Project, Box 0884, San needle sharing. For at least one of these mental health providers. In the May Francisco, CA 94143- risk behaviors, 10 percent believed that 0884. Back issues are $3 issue of FOCUS, Sally Jue, LCSW,a each: for a list, write to the RTI therapy reduced risk, and 20 percent Los Angeles trainer and consultant, above address or call believed that PI therapy reduced risk. (415) 476-6430. reviews a recent model for ethical Respondents also rated the importance of decision making that she and her col- To ensure uninterrupted safer sexual and needle-sharing practices: delivery, send your new leagues developed for the American 10 percent believed that RTI therapy address four weeks before Psychological Association. The model you move. decreased the importance of safer practices, outlines a process for defining and Printed on recycled paper. and 19 percent believed that PI therapy responding to ethical dilemmas and ©1999 UC Regents: All decreased the importance of safer practices. rights reserved. identifies key ethical principles that ISSN 1047-0719 Risk Perceptions among Gay Men are crucial to this endeavor. Also in the May issue of FOCUS, Kalichman SC, Nachimson D, Cherry C, et al. AIDS treatment advances and behavioral prevention Steve Heilig, MPH, Director of Public setbacks: Preliminary assessment of reduced per- Health and Education at the San ceived threat of HIV-AIDS. Health Psychology. Francisco Medical Society, discusses 1998; 17(6): 546-550. (Medical College of HIV-related “rational” suicide and issues Wisconsin; and Georgia State University.) related to societal and personal control. A study of seronegative or untested gay 8 FOCUS April 1999 searchable archive FREE DID YOU KNOW?

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