July/August #189 : Hold Your Horses - by Trenton Straube

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Table of Contents
 

Features

Magnetic Attraction

A Shred of Understanding

Hold Your Horses

From the Editor

Accentuate the Positive

Feedback

Letters-July/August 2013

The POZ Q+A

Pride and Policy

POZ Planet

Say What?—Alicia Keys

Greetings from Ptown

PACHA Covers Trans Issues

Making Headlines

Latest Developments

Not Another Gay Sex Disease

Future Lovers

On a Roll

Voices

Yours in the Struggle

Care and Treatment

The Quest to Cure Another Baby

Viral Suppression Without Drugs?

The Genetic Fusion Inhibitor

New Retention Guidelines Urge Partnerships

Mapping Viral and Immune Coevolution

Research Notes

Prevention: PrEP May Be Cost-Effective

Treatement: Can Bees Sting Away HIV?

Cure: HDAC Inhibitors May Fight HIV Reservoir

Concerns: Hep C Transmission Among Gay Men

POZ Survey Says

Accentuate the Negative

POZ Heroes

Chemical Crusader

   
Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


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July / August 2013

Hold Your Horses

by Trenton Straube

Can barebacking be safer sex?

Barebacking
Click here to read a digital edition of this article.

In 1997, Tony Valenzuela was an up-and-coming LGBT rights activist, open about his HIV-positive status and viewed by many as a beacon of the movement’s future. But the goodwill soured when, during an impromptu speech at the Creating Change Conference, he talked about the gay sex that dared not speak its name: barebacking. “Naively, I did not believe it would be controversial to discuss openly what I knew many of us were experiencing privately,” he recalls. But controversial it was. Valenzuela was both pilloried and praised—which landed him in 1999 on one of POZ’s most memorable covers, riding a horse, sans saddle. Meanwhile, the term “barebacking” became branded, indelibly, into our discourse.

Much has changed on the HIV landscape since then, but our attitudes about gay sex remain stuck in the age of the dial-up modem. Just this year, New York City researchers Luis Freddy Molano, MD, and Renato Barucco released the results of their survey on the sexual habits of gay men who seek partners via hookup apps like Grindr. One finding made headlines as if it were a national scandal: Nearly half of them didn’t use condoms.

The ensuing coverage and commentary were framed in disapproval, shame and condemnation. So let’s unclutch the pearls and start a rational conversation about barebacking in 2013, specifically in terms of risk for HIV-negative men.

In its broadest sense, barebacking simply refers to condomless anal sex, usually between men. In the ’90s, still a time of unfathomable loss and grief, the phrase was charged with flagrant transgression. Barebackers had death wishes, according to sensational media reports. They were “bug chasers” and “gift givers,” hedonists with no regard for their fellow brethren. Today, the rhetoric has calmed, but the term barebacking remains problematic.

Many HIV prevention experts tend to define barebacking as intentional condomless sex when a risk of HIV is present. This differentiates it from, say, condomless sex between two positive men with undetectable viral loads. Which raises an interesting point: Not every act of skin-on-skin sex is unsafe.

“Let’s stop calling it barebacking,” suggests Valenzuela, who today, in addition to his gay health advocacy work, is the executive director of the Lambda Literary Foundation. “While sex without a condom can be a fetish for some, for most, it’s simply one of the ways they have sex some of the time.”

In general, surveys going back to the late ’80s have found that roughly half of men who have sex with men (MSM) report not using a condom during anal intercourse. But what, exactly, is revealed by a survey question that asks, “Did you have unprotected sex in the last 90 days?” There’s no context: Was this encounter with a negative partner? Is he your main partner? Have you both been tested?

To get a better handle on this subject, Joshua Rosenberger, PhD, assistant professor at George Mason University, and his team conducted a survey in 2010 of 14,750 MSM and asked about the last time they had anal sex. No surprise that 54 percent did not use a condom. But here’s the standout statistic: In total, only 2.5 percent of the respondents reported ejaculation in their partner’s or their own anus without a condom.

Although HIV risk is present without ejaculation inside the anus, it is much greater with. “Men are engaging in a variety of behaviors that might be risk reduction strategies,” Rosenberger says. “And while I’m not promoting ‘barebacking,’ if there’s no risk of disease transmission”—if both men are negative and monogamous, for example—“then these men shouldn’t be included when we talk about men most at risk for HIV. We need to rethink how we calculate risk.”

Thanks to other researchers such as Alex Carballo-Diéguez, PhD, and Perry Halkitis, PhD, we’re amassing a body of knowledge on gay sexual practices. We know gay men use condoms more than straight guys (who average 25 to 30 percent condom usage). We know that gay guys understand how HIV is transmitted. We know that barebacking, like alcohol and drug use, can offer an escape from racism, homophobia, loneliness, anxiety and depression—and that it can also offer a spiritual and intimate bond, not to mention a thrilling gage of manhood. We know that recent increases in syphilis and gonorrhea rates indicate an uptick in condomless sex. We know that once a couple decide to ditch condoms, they’re less likely to start using them again in the relationship and that they’re more likely to bareback with other partners. We know that condomless sex is more common in Internet hookups, and that it’s more likely in the presence of drug and alcohol use (but don’t place all the blame on Grindr or Manhunt or meth, Halkitis says, because condomless sex will go on without them). We know that positive guys are more likely to bareback—and to do it with other poz men. And we know that African-American MSM and younger MSM report wearing condoms more often than their older white contemporaries.

But wait—we also know that, despite the overall stability of the U.S. epidemic in recent years, HIV rates among young MSM ages 13 to 24 are increasing about 22 percent, according to the Centers for Disease Control and Prevention (CDC). Clearly, these boys are lying about safer sex, right?

Not necessarily, explains Jonathan Mermin, MD, MPH, director of the Division of HIV/AIDS Prevention at the CDC. “If you only look at incidence—the number of new infections per year—you sometimes miss the bigger picture, which is that prevalence—the number of people living with HIV—is going up,” he says. In fact, it has gone up 60 percent in the past 15 years. That means there are more people today living with HIV. The numbers are pronounced in some communities—such as black MSM—and as a result those guys have a much higher chance of coming in contact with someone who is positive, even if they don’t have a lot of sexual partners. Mathematical modeling using a conservative 2.39 percent HIV incidence suggests that half of all gay men who are 22 years old today will be HIV positive by the time they’re 50. Young black MSM face even worse odds.

In other words, a spike in the number of new HIV cases can’t always be directly blamed on a spike in condomless sex.

What’s more, Mermin points out, 60 percent of HIV-positive people younger than 24 don’t know their status. “If you don’t know your status, you’re less likely to take precautions to protect others and less likely to access treatment, which will not only help you live longer but also reduce your chance of transmission [by lowering the amount of virus in your body fluids].”

Jeff Huyett is a nurse practitioner at Callen-Lorde Community Health Center who has been working with gay men since the 1980s. When his clients disclose that they’re going bare, a conversation like this often unfolds: “My boyfriend said he was negative so we decided not to use rubbers.” “When did he last test, and when was his last sexual partner?” “Oh, I didn’t ask that, but I trust him. He’s awesome.” “Well, studies show that most guys are not monogamous in the long term, and if he’s barebacking with you, chances are he has barebacked with others. This person could have HIV.”

It has been estimated that 68 percent of new MSM infections occur within relationships. What’s more, 55 percent of young gay couples ditch condoms before three months—46 percent of them do so without first discussing it. In a cruel twist, it turns out that being in a relationship is a risk for HIV. Which makes sense because, as the late POZ journalist Stephen Gendin wrote back in 1997: “The connection feels closer and more intimate. The sharing of cum on the physical level heightens the sense of sharing on the emotional and spiritual planes.” And what’s wrong with that? Gay men are just as entitled to fully realized sexuality as any other human beings.

Indeed, for some couples who know their status and aren’t fooling around, Huyett says, condomless sex makes sense. He tells such guys to first get tested for herpes 1 and 2, syphilis, and hepatitis A, B and C. And to get screened in three orifices—the throat, penis and anus—for chlamydia and gonorrhea. The same goes for HIV-positive couples.

“In the old days before AIDS,” Huyett recalls, “if you were out fooling around, you went to the health department every three months and got tested and treated [for sexually transmitted infections]. When HIV came around, we started using condoms, and that whole thing went to the wayside.”

Maybe it’s time to revisit this habit. Vigilance against STIs, many of which can go unnoticed, is a vital part of HIV prevention. STIs increase viral load, which makes positive men more infectious, and they increase inflammation, which makes negative men more susceptible.

Condoms help protect against these other STIs, so why not just double down on condom messaging? For starters, explains Susan Buchbinder, MD, of the University of California at San Francisco, such behavioral interventions have increased condom use by only about 20 percent. Much hope has been placed on biomedical prevention, a.k.a. chemoprophylaxis, which allows for condom-free intimacy with less HIV risk. Post-exposure prophylaxis and pre-exposure prophylaxis, PEP and PrEP, are when HIV-negative people take meds to prevent infection; and treatment as prevention, TasP, refers to the idea that positive people on regimens have undetectable viral loads and are unlikely to pass the virus.

These show great promise. For example, men who have trouble using condoms in the heat of the moment might be more compelled to take a daily pill during the sober light of day. But the cold reality is that PEP isn’t easy to attain, PrEP (at nearly $1,000 a month) isn’t affordable for most, and only about a quarter of HIV-positive Americans are virally suppressed.

To reduce their risks without condoms, some guys try serosorting (having sex only with people of your HIV status) and seropositioning (topping if you’re negative; bottoming if you’re positive). But seroadaptation tactics aren’t foolproof, and like chemoprophylaxis, they don’t do a lick of good against other STIs.

Condoms remain the most accessible, affordable and effective protection. With the Bill & Melinda Gates Foundation offering $100,000 grants to build a better condom, and the Origami Condom company developing the world’s first condom specifically for anal sex (it’s silicone and for the receptive partner, not the top), one thing is certain: We’re not giving up on condoms.

Condom use “is never going to be 100 percent,” says Michael Weinstein, president of the AIDS Healthcare Foundation. “But if we don’t promote it, it’s going to go down.” Likewise, if we don’t promote sex education and more frequent HIV testing, we’ll see more virus. Halkitis notes, for example, that many young MSM today don’t fully understand the “window period” of infection (when you might test negative and yet be highly contagious). “We’ve sort of abandoned the education,” he says, “and this new generation needs it.”

Queer empowerment advocate Jeton Ademaj agrees. Serosorting failed to keep him negative, and today he supports chemoprophylaxis as a way to enjoy “natural sex” with lowered HIV risk. In addition to promoting testing and education, Ademaj says, we also must focus on linkage to care and adherence to meds, plus the related issues that prevent them. “There needs to be a bold effort to sell these things to the community, because as a total package, we now have the tools to end HIV.”

In a country that allows abstinence-only education and “no-homo-promo” laws, in a culture that often views sex as a sin deserving of disease, and in an LGBT community that’s more focused on marriage equality and employment discrimination than on HIV, it’s imperative that we speak truthfully about sexual health. We need a public dialogue that’s more nuanced than “wear a condom every time.”

Valenzuela, the ’90s bareback cover boy, says the smartest conversations about condomless sex take place where they began: in gay men’s sexual subcultures such as hook-up apps, websites, sex parties and leather bars. “That’s where I believe there’s a high level of sophistication and self-determination around why and how we negotiate sex without condoms.”

Now, let’s get everyone else to join the conversation.  

Search: Tony Valenzuela, Creating Change Conference, Luis Freddy Molano, Renato Barucco, Centers for Disease Control and Prevention, University of California at San Francisco, serosorting, Bill & Melinda Gates Foundation

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  comments 1 - 15 (of 50 total)     next > >>

Robert, Palmdale, 2013-09-06 14:11:51
Hmm, my wife and I have condomless sex... What's the problem here ??

Bentley Ball, Toronto, 2013-09-05 21:51:32
For my part, I would far rather my unnatural acts as natural as possible, but I fret about things like super-infection by treatment resistant strains and that "undetectable" might not equal "untransmissable". One of the good things about the eighties was that we didn't have those silly disclosure laws that imagine criminalization a new form of latex. Today, we need the freedom to talk about the sex we have, not just that we're instructed to have. Otherwise, we're only voicing our PC fantasies.

Richard Wilson, Chicago, 2013-09-05 21:21:39
I'm at the point in my disease where I absolutely don't care about kids infecting themselves as long as I get my medication first. Screw 'em. I know other people are thinking the same thing -- don't be afraid to stand up to this horrifying propaganda.

Jeton Ademaj, Harlem, NYC, 2013-08-26 17:45:36
BOB, Condomless sex is the REALEST sex, period. no other std is as bad as HIV, n suppressed HIV in blood leads to suppressed HIV in semen within 6 months for most n within 3 years for all. the Media and Healthcare industries are catching onto the fact that NO ONE CARES ABOUT A "COMMANDMENT" TO USE RUBBER...not from you, or M. Weinstein, or Simon Watney, or ANYONE else. Most want to avoid disease BUT have a FULL sex life. Truth always wins out, no matter the motive of those who try to obscure it.

bobcrem, , 2013-08-25 21:47:22
Why would anyone consider condomless sex? You want to measure risk? What about risk of Hep C, syphilis, gonorrhea, and parasites? ... And "non-detectable" means non-detectable in your bloodstream. Who says there is a "non-detectable" amount of virus in your semen. This is an idiotic conversation and I don't understand why is there even a discussion about this. How self-centered and foolish can you possibly be? ... USE CONDOMS. Period.

Jeton Ademaj, Harlem, NYC, 2013-08-19 12:58:34
YES, barebacking can be safer sex. often MUCH safer. sometimes the safEST of all, save for outright abstinence. the voices of the sexually neurotic (Jones, Adnum, Weinstein, etc)can no longer block the recognition of these facts in the medical and activist communities...and they NEVER could block this knowledge from the sexually active community. HIV+ people should be able to accurately and reliably ADVERTISE their virological control 2 partners...especially if they wish to BAREBACK MORE SAFELY.

Daniel Moen, Georgetown KY, 2013-08-17 20:10:22
Fantastic article!Quite educational, meaningful and should be required reading. I came out in 1985 in the middle of dire times. I had BB sex quite often until I educated myself and those that I chose to have sex with. I believe as a gay man that lived through those devastating years should consider myself an example for younger men. We need to provide more education and be open in urging them to play safe. I think that BB sex is a very selfish act. How many more lives need be cut short?

andy, central pa, 2013-08-07 17:08:36
Is is true, Or not, that two poz guys bearbacking (yes i read the arcitle) are potentially exposing each other to strains of the virus they they may not have , thus making it harder and harder to treat?

MATSTRAZZ, BOSTON, MA, USA, 2013-08-07 15:27:02
Unprotected sex, is not safe. non latex"(plastic) condoms, let heat threw, with crisco you can not tell the dif. done it to many guys who wanted bareback, slipped on the polyeurothane condom, and popped some crisco in their ass. After asked them was i bare or with condom, they all thought i was bare. ditch the latex, and go up a notch to better condoms. then the bareback question, just fades away. Why do people think latex is the only way to go. "plastoc condoms are stronger, n let heat threw.

Charles Lee, New Rochelle, 2013-07-17 21:46:33
If I am in non detectable status is barabacking is not good for same sex men? If not what is?

chcltbny2, Washington DC, 2013-07-17 12:57:24
So some of this is way it is so prevelant today. I am wondering why so many guys on the websites are promoting and advertising RAW and BB sex. I've been poz for 20+ yrs now and many guys today have been although I have had my day when I would sex with out protection I have moved more toward protecting ME and those that I sleep with. I had one of the two tests for syphillis to come back positive meaning that I had been exposed but had not contracted the disease, I guess. . I'm hoping.

Nachy, Santiago, 2013-07-14 09:41:43
Oh, how I wish STI, Pep, PrEP, and Tasp were everyday terms in gay communities, in health departments and even in congress. It's all been so retrograde up till now. Hurry up social administrators!

MiddleAgeLesbian, , 2013-07-13 07:33:38
Wear a condom. It's that simple. My sister is bi and in a relationship. As a couple, they often swing. Never does she NOT use condoms when she's in contact with outsiders. Either with intercourse or orally. Would it be more enjoyable without one? Of course, but she doesn't want disease. Only forgo it if you're monog, which you can do within timeframes (4 mos, 6 mos, etc.). Set some home rules.

compassion, , 2013-07-13 07:21:36
bareback has always, to me, brought about thoughts of violence, which i have never found to be sexy. also the conversation about STI need to be opened up. HPV and Herpes can cause horrific and deadly issues for everyone, especially Poz folks and I speak from my personal situation. Neither of these STI"s can be prevented by having safe sex so how does one Really proceed w/out the knowledge that you may bring significant harm to your partner? Again, this feels more like violence than sex to me

Jeton Ademaj, Harlem, NYC, 2013-07-12 23:58:43
Ajax, thanks for bringing the sexual neuroses, it has informed so much safer sex campaigning that if u hadn't shown up, i'd have had to make u up. The anus and rectum are delightful examples of Nature's parsimony, ably serving multiple purposes. in men, that includes erotic stimulation from being penetrated via a penis stimulating a man's prostate gland. furthermore, as many a well-hung top can tell u, once u successfully and gently breach past the rectum, things r ably self-lubricating! U FAIL.

comments 1 - 15 (of 50 total)     next > >>

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