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Safer sex maintenance among gay men: are we moving in the right direction?

AIDS, 1993, 7: 279-280.

Authors: PM Davies

Editorial comment - full text

Kippax et al. [1] adds a crucial dimension to what is perhaps the most immediate and pressing current debate in AIDS prevention among gay men: the failure to maintain behavioural change or, as it is sometimes termed, ‘relapse’ [2, 3]. The use of the term relapse has been the focus of a great deal of criticism [4 - 6], but to dismiss this as semantic fastidiousness, as indicated by Ekstrand [7] is to sidestep the substantial issues of interpretation and understanding that lie at the very heart of this debate.

Kippax et al., [1] have recognised that confining anal intercourse to a regular relationship represents one way of responding to the threat of HIV transmission, while satisfying the desire for the unique feelings about anal intercourse among gay [8]; some find it immensely satisfying, while others find it entirely repulsive. Moreover, we have shown that a strategic regard for safety with respect to HIV transmission forms part of the rules that many gay couples develop to maintain their relationships, to keep them special [9].

While epidemiological modelling requires simple, unitary measures of unsafe sex, these cannot be used to clarify the complex responses of ordinary men who make momentous but increasingly routine decisions about safer sex from day to day. Unprotected anal intercourse is clearly an unsafe activity, but it is not always and in every circumstance equally unsafe. However, to suggest that all couples' strategies are equally safe is misguided and dangerous. Table 1 shows a logical list of possible behavioural strategies employed by couples. In principle, all couples can be described, at any one time as employing one of the strategies on the list. In most cases, strategies 3,4,5,6 and 9 count as instances of unsafe behaviour, with putative need for intervention. Yet it is clear that strategy 4 is far safer than strategy 3, at the individual level, in that the uncertainty over sero-status is less and can be minimised by, for example, mutual testing.

Table 1. Possible behavioural strategies employed by couples.

Strategy Regular Partner Casual Partner
1 No anal intercourse No AI
2 No anal intercourse AI with condom
3 No anal intercourse AI without condom
4 AI without condom No AI
5 AI without condom AI with condom
6 AI without condom AI without condom
7 AI with condom No AI
8 AI with condom AI with condom
9 AI with condom AI without condom

AI, anal intercourse Nevertheless, it must be noted that strategy 4 is not entirely safe; much will depend on the knowledge, the honesty and the trust of the individuals involved. However, we suggest that the existence of a theoretical risk is not sufficient reason for this approach to be rejected. Human beings do not work on certainties but on probabilities using heuristic guidelines. Risk minimisation rather than risk elimination is the aim of most individuals and couples and should be the focus of programmes. Working on heuristic rules about the world is a deeply embedded feature of human interaction and should be encouraged, not condemned. The importance of the work of Kippax et al. in highlighting the existence of these risk-reduction strategies confirms our own data analysis, which strongly suggests that a very high proportion of the increase in 'unsafe sex' is due to strategies of 'negotiated safety'. Three recommendations follow from this analysis. First, we should be wary of translating epidemiological markers into prescriptions for individual behaviour. Second, we must try to reflect the complexity of what is happening in our study populations in our epidemiological categories and third, we should recognise the robust humanity of the men we study rather than seek out their weaknesses. In particular, we need to encourage and facilitate the emergent strategies of 'negotiated safety' rather than condemn them as irresponsible. The implicit goal of eradicating unsafe sex is unrealistic. It is neither a sustainable strategy, nor an epidemiological necessity. But rather an unnecessary restriction on desire and action. Many couples are working towards creating a sustainable combination of safety and pleasure and the goal of research should be to recognise, encourage and enable both couples and individuals to work towards a strategic understanding of safer sex, rather than the erection of monolithic, unrealistic criteria of unsafe behaviour.

References

1. Kippax S, Crawford J, Davis M, Rodden P, Dowsett G: Sustaining safe sex: A longitudinal study of homosexual men. AIDS 1993, 7:257-263.

2. Adib SM, Joseph JG, Ostrow DG, Tal M, Schwartz SA: Relapse in sexual behaviour among homosexual men: a 2-year follow-up from the Chicago MACS/CCS. AIDS 1991, 5: 757-60.

3. Stall R, Ekstrand M, Pollack L, McKusick L, Coates TJ: Relapse from safer sex: the next challenge for AIDS prevention efforts. J Acquire Immune Defic Syndr 1990, 3: 1181-7.

4. Davies PM: On relapse: recidivism or rational response. In AIDS: Rights, Risk and Reason. Edited by Aggleton P, Davies PM, Hart G. London, Falmer Press; 1992.

5. Baxter D: Maintenance of safe sex norms in the gay community. Paper presented at the IV Australian National AIDS Conference. Canberra, 1990.

6. Hart G: Relapse to unsafe sexual behaviour amongst gay men: a critique of recent behavioural HIV/AIDS research. Sociol Health Illness 1992, 14: 216-32

7. Ekstrand M: Safer sex maintenance among gay men: Are we making any progress? AIDS 1992, 6 875-877.

8. Hickson FCI, Weatherburn P, Davies PM, Hunt AJ, Coxon APM, McManus TJ: Why do gay men engage in anal intercourse? VIII International Conference on AIDS/ III World STD Congress, Amsterdam, July 1992 [abstract PoD5185].

9. Hickson FCI, Davies PM, Hunt AJ, Weatherburn P, McManus TJ, Coxon APM Maintenance of open gay relationships: Some strategies for protection against HIV. AIDS Care 1993 (in press).

Sponsorship: The research described in this paper was funded by the UK Medical Research Council and the UK Department of Health.

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