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HIV-Positive Gay and Bisexual Men

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HIV-Positive Gay and Bisexual Men CHAPTER FOUR HIV-Positive Gay and Bisexual Men Jeffrey T. Parsons INTRODUCTION Behavioral research focused on people living with HIV has shown that the minority report sexual practices that would place their partners at high risk of HIV infection. Reviews of the literature have found that about 70% of heterosexual HIV-positive persons remain sexually active after serocon- version, whereas only a third of these individuals report vaginal inter- course without the use of a condom (Crepaz and Marks, 2002; Kalichman, 2000). Similar rates of unprotected anal intercourse have been documented among HIV-positive gay and bisexual men (Kalichman et al., 2002a; Par- sons et al., 2003). Recent studies have reported increases in sexual risk behaviors among gay and bisexual men in the US, Europe, and Australia (Chen et al., 2002; Ekstrand et al., 1999; Kalichman et al., 2002b; Stolte et al., 2001; Van de Ven et al., 2000). In addition, young gay and bisexual men, and particularly men of color, remain at considerable risk of HIV infection as a result of unprotected anal sex (CDC, 2002; Koblin et al., 2000). In New York City, 33% of young African American gay and bisexual men are estimated to be HIV positive and rates among Latinos are also quite high (Valleroy et al., 2000). Other studies have shown increases in HIV incidence (Calzavara et al., 2002) and sexually transmitted infection (STI) rates among young men who have sex with men (Fox et al., 2001). The number of syphilis cases in San Francisco increased from six in 1998 to 115 in 2001, and cases of rectal gonorrhea among gay and bisexual men increased from 162 in 99 100 CHAPTER FOUR 1999 to 237 in 2002 (Chen et al., 2002; Katz et al., 2002). In New York City, cases of primary and secondary syphilis doubled in 2001, predominately among gay and bisexual men (CDC, 2002). Nearly half of these new cases of syphilis were among HIV-positive men. This is of great concern, as syphilis is more likely to facilitate the sexual transmission of HIV than other STIs (Wheater et al., 2003). These findings underscore the need to more fully understand the safer sexual behaviors of HIV-positive gay and bisexual men. Clearly most men living with HIV neither want to nor intend to transmit HIV (Wolitski et al., 2003). However new infections continue to grow, and in some ar- eas of the US, rates of HIV infection among gay and bisexual men have shown a continued upward trend (Valdisseri, 2003). Gay and bisexual men remain the largest subgroup of persons living with HIV/AIDS in the US; with 14% to 25% of these men living with HIV, a prevalence rate equivalent to that in some sub-Saharan African countries (Catania et al., 2001). HIV-positive gay and bisexual men can transmit HIV to sexual part- ners, primarily through unprotected anal sex (Vittinghoff et al., 1999). Plac- ing a partner at risk of HIV infection is particularly dangerous in cases in which HIV-positive men have developed drug resistance, as medication resistant HIV can be transmitted to HIV-negative sexual partners (Hecht et al., 1998). HIV-positive men who engage in unprotected sex, regardless of the HIV status of their sexual partners, risk rapid loss of CD4 cells (Wiley et al., 2000), acquiring pathogens which may lead to opportunistic infec- tions (Renwick et al., 1998), co-infection with Hepatitis C (Spengler and Rockstroth, 1998), and contracting STIs which can lead to further immune system deterioration (Bonnell et al., 2000). SEXUAL RISK BEHAVIORS OF GAY AND BISEXUAL MEN IN THE THIRD DECADE OF HIV/AIDS The prevalence of unprotected anal intercourse differs by whether the HIV-positive gay or bisexual man is the insertive or receptive partner (Parsons et al., 2003). Studies have shown that many HIV-positive men intentionally position themselves as the receptive partner for unprotected anal sex, as a method of “strategic positioning” perceived to result in sex- ual risk reduction (Parsons et al., in press; Van de Ven et al., 2002). It is unclear to what degree such harm reduction efforts actually decrease the likelihood of HIV transmission, although such notions of strategic posi- tioning to reduce the risk of HIV infection are supported somewhat by epidemiological evidence (Vittinghoff et al., 1999). HIV-POSITIVE GAY AND BISEXUAL MEN 101 Other men make efforts to “serosort” their sexual partners, where they limit the risk of HIV transmission by engaging in sexual activity with only men of seroconcordant status (Parsons et al., in press; Suarez and Miller, 2001). Thus, some men who are HIV-positive limit their sexual activity to other HIV-positive men in order to have condomless sex without fear of transmitting HIV to a sexual partner. Inherently problematic in serosorting, however, is the potential for this approach to fail. First, serosorting assumes that HIV status disclosure has occurred. A recent study of HIV-positive gay and bisexual men found that 42% reported sex without disclosing their status, demonstrating considerable inconsistency in disclosure (Cic- carone et al., 2003). Second, serosorting strategies assume that individuals actually know their HIV status in the first place, which is not always the case. Third, the notion of serosorting assumes that gay and bisexual men are fully honest and accurate regarding the disclosure of their status, an assumption that is not fully supported by the literature (Wolitski et al., 1998). Seropositive and seronegative gay and bisexual men have been shown to make assumptions regarding the HIV status of their sexual partners, typically assuming their partner’s HIV status is concordant with theirs when engaging in unprotected sex (Suarez and Miller, 2001). One study of HIV-positive gay and bisexual men in New York City and San Francisco identified comparable rates of HIV sexual risk practices with HIV-positive and HIV status unknown casual sex partners (Parsons, et al., 2003). Quali- tative interviews with these same men indicated that in many cases it was assumed that unknown status partners were also HIV-positive (Parsons and Vicioso, in press). However, the strong possibility exists that at least some of these HIV status unknown partners were, in fact, HIV-negative, and thus at risk of HIV infection. As such, serosorting may reduce the risk of HIV transmission in some encounters when seroconcordant sex actually occurs between two HIV-positive men, but questions remain about the ef- fectiveness of this strategy in light of serostatus disclosure, the potential for inaccurate assumptions of serostatus, and accurate knowledge of one’s own HIV status. It is possible that increases in new HIV infections are resulting, in part, from faulty harm reduction techniques utilized by HIV-positive gay and bisexual men, as noted above. It is also important to consider the man- ner in which HIV treatment advances of the past decade have impacted perceptions regarding the relative risk of unsafe sexual practices. The avail- ability and success of Highly Active Antiretroviral Therapy (HAART) in improving and prolonging the lives of those with HIV has led to increased optimism and reduced concerns, at least in the US, regarding potential HIV infection (Kalichman et al., 1998; Vanable et al., 2002). For some gay and 102 CHAPTER FOUR bisexual men, optimism regarding the severity of HIV disease has led to increased complacency in terms of sexual risk behaviors and may be fuel- ing increasing HIV infections among this population (Catania et al., 2001; Wolitski et al., 2001). It is doubtful, however, that optimism resulting from medical ad- vances in treating HIV is the only reason for continued unprotected sex behaviors among HIV-positive gay and bisexual men and the correspond- ing increases in new cases of HIV infection. It is more likely that a com- plex set of interconnected contextual factors is responsible for unsafe sex behaviors among these men. Disentangling these contextual factors, and recognizing the critical importance of the varied social environments in which sexual interactions between men occur, could help to shed light on the current situation of the sexual risk behaviors of HIV-positive gay and bisexual men. To fully understand the sexual lives and sexual risk practices of these men, one must consider the ways in which sexually charged venues and environments that men frequent to look for poten- tial sexual partners may shape their behaviors, the sociological impact of the Internet in facilitating sexual encounters between men, the ways in which the increase in the prevalence and acceptance of “barebacking” (intentional anal sex without condoms) in the gay community may exac- erbate sexual risk taking, and the potential for illicit drug use to derail even the most committed intentions to practice safer sex. This chapter examines the ways in which these contextual factors may be hindering the ability of HIV-positive gay and bisexual men to protect their sex- ual partners from HIV infection. Clearly, the sexual lives of these men and the very nature of their sexual interactions transcend the simplistic messages of “no glove, no love” and other prevention messages of the past two decades that implied the need for consistent condom use in all circumstances. SEXUALLY CHARGED ENVIRONMENTS The particular venues in which HIV-positive gay and bisexual men seek and meet their sexual partners directly impact their safer sex deci- sions. Two such venues that are commonly frequented are commercial and public sex environments. HIV-positive men are more likely than their HIV-negative counterparts to use these venues (Binson et al., 2001). Recent research has shown that nearly half of HIV-positive gay and bisexual men from New York City and San Francisco reported frequenting either com- mercial or public sex venues, with a substantial number attending both (Parsons and Halkitis, 2003).
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