Over the past few weeks there has been a lot of talk about the recent increases in NSW HIV notifications. Articles and letters have pondered what’s been happening or not happening, who’s responsible, what we ought to do about it and what all this might mean.
A sudden rise of 13 percent in one year is certainly something to make everyone sit up and take notice. It is good that people are talking about it and trying to work out what to do now. But some commentary has been one-eyed and unhelpful.
I am sure SSOÂ readers have not been shocked to read titillating explanations blaming rampant barebacking, drug and alcohol-fuelled young gay men having carefree sex and the complacency of community organisations for the rise in HIV notifications.
There is nothing like the hint of a crisis to bring out social commentators ready to peddle their latest pet theories and they often misinterpret complex behavioural research in the process.
Steve Dow’s opinion column in The Sydney Morning HeraldÂ Denial Becomes The New Language Of Casual Sex is a recent example.
Dow argues that the proliferation of the term barebacking through the growth of cyber sex glosses over danger, promulgating a culture of denial. He writes provocatively: In the Australian context, barebacking is about taking risks and denying consequences. All this is presented without a single piece of even anecdotal evidence. But his solution to the rise in HIV figures is a campaign to demystify barebacking because the shifting language seems to have left the educators behind.
Dow is an interesting writer who often raises difficult questions but his conclusions here are far too simple. Yes, we need to think about changes in language that gay men use to negotiate sex. Yes, we need to look at the rise of cyber sex. But the moment you focus on one of these issues as the main problem you lose sight of the much bigger, much more complex picture.
There is no single solution. It would be nice if there was but the reality is there isn’t.
The world we live in as gay men, HIV-positive and HIV-negative, has changed dramatically in the last 10 -“ even the last five years. Given the rapid pace of change that we have all been dealing with and the weight of a 20-year epidemic, it is remarkable that the rate of HIV infection has stayed so stable for so long.
Here are five major areas of change that we all have to think about and understand if we are to help each other through the next stage of living with the HIV/AIDS epidemic.
There are now several generations of gay men who have quite varying experiences of the 20-year epidemic. Some are exhausted by close contact over many years; others have no personal experience of knowing someone with HIV or someone who has died of an AIDS-related illness.
Notions of gay identity and how we define ourselves as a community have changed considerably over the 20 years.
The places we meet, our community organisations and the ways we attach ourselves to the community have also changed.
There are degrees of community disengagement from HIV. It used to be the number one issue but now other areas of our lives like parenting or marriage rights compete for attention.
Increases in unprotected anal intercourse with both casual and regular partners have been reported in many Australian cities (and in comparable cities overseas) and these have risen steadily over the last five years.
There is significant -“ though sometimes exaggerated -“ use of illicit drugs within the lived sex culture of many gay men.
The impact of drugs can have many different short and long-term consequences such as the feeling of invulnerability associated with some highs or the feeling of depression and paranoia associated with some long-term use. All these consequences have different impacts on safe-sex practice.
The role of the internet and the emergence of a cyber-sex space provides a whole different environment for sex and sexual negotiations. Critically for educators, such encounters take place away from familiar community institutions and are potentially creating new language and norms of behaviour.
HIV-positive discrimination is being experienced -“ this obviously makes disclosure more difficult, particularly in the negotiation of sex.
n Sexually transmitted infections (STI) have again increased among gay communities and these assist in the transmission of HIV.
RISK REDUCTION STRATEGIES
Risk reduction strategies around who tops and who bottoms based on real or assumed HIV status, or by using clinical markers such as viral load, are also becoming a part of some men’s sexual decision-making.
People make assumptions about their sex partner based on non-verbal and environmental cues, which may or may not be correct.
A small percentage of gay men are not aware of their
HIV status because they have not been tested for HIV for a number of years, have placed themselves at risk of HIV and are assuming their HIV status remains negative.
The use, availability and knowledge of post-exposure prophylaxis has grown.
The introduction of new drug treatments for HIV-positive people in 1996 has had a profound impact on longevity and quality of life.
Changes in HIV treatment since then include deferral of treatment commencement and the use of treatment breaks for medical or quality of life reasons. Different treatment choices may impact on the use and effectiveness of some risk reduction strategies because, for example, they affect a person’s viral load.
This context means there is a need to run multiple-level HIV education messages simultaneously.
Simple reinforcement of safe-sex messages suitable for men new to homosexual sex needs to be balanced with highly complex messages based on improving the understanding and interplay of risk, HIV status, viral load, negotiation and sexual positioning in the lived sex cultures of a well-informed, sophisticated population.
There is limited funding to produce the range of increasingly complex re-sources needed to address our current situation.
It’s a lot to take on when you just want a root, or when you are just starting or ending a relationship. But gay men have negotiated this complex terrain in the past and will continue to do so.
By addressing the reality of the above complexities we are not suggesting that condoms be thrown away in favour of these highly variable risk-based strategies.
They are all more risky than using condoms. People who continue to use condoms either all or some of the time are to be congratulated because, apart from total abstinence, condoms are still the best prevention strategy.
Gay men, whether HIV-positive or negative, have not abandoned safe sex or become complacent about it. In fact, we have done remarkably well both here and overseas engaging with safe sex and getting on with living in a world where HIV is a part of our community and our lives.
It’s tempting at a time such as this to set up the good against the bad and the compliant with the non-compliant. Let’s not head down that path. Let’s work out what we know and what we still need to know.
Let’s establish who we are, how we want to play and what type of sex we want to have.
Like it or not, we need to continue to take responsibility for ourselves, our friends, our lovers, our fuck buddies and those we don’t want to have sex with. Getting informed and communicating is key to understanding our own dynamic culture.
HIV educators and community organisations have not failed, become complacent or made things more complex than they need to be. The complexity they deal with arises from the interplay of all the factors outlined above. What is needed now is active participation, talking, and creative thinking -“ not narrow, simplistic sloganeering.
Dermot Ryan is manager of the Education Team of the Australian Federation of AIDS Organisations (AFAO).