Transcript Research on HIV risk among gay and bisexual men: 2006

Research on HIV risk
among gay, bisexual, and other
men who have sex with men
Barry D Adam
University Professor
Senior Scientist & Director of Prevention
Research
Conceptualizing HIV risk
•
Epidemiology
•
•
•
Postulating MSM category
Identifying general trends
Risk factor analysis:
•
•
•
Search for pathological causal factors, often
abstracted from context
Rational man compromised by intervening variables
Biomedical or psychological individualism




The “calculating, rational, self-interested
subject” (Smart 2003:7), the
paradigmatic subject of contemporary
neoliberalism
contract-making citizen
choice-making consumer (Habermas,
1987)
in health research,

the rational, conscious, informed calculator of
risk
Health research models



Theory of reasoned action, health belief model
Subjects, “portrayed as free actors who are
constrained only by their ignorance about the
threat to which they may be exposed or their
lack of self-efficacy” (Lupton, 1999, p. 23)
Or as an “audience of thoughtful, actuarial
subjects, gathering data and acting on the basis
of ‘fact’” (Davis, 2002, p. 281)
Socio-cultural analysis
•
•
•
•
How to cope with an unwanted health threat while
searching for human connection
How to find pleasure and love while navigating
sometimes conflicting sources of risk and opportunity
Cultural resources/discourses available to make sense
of risk, choice & health
How social environment (state, capital, social
institutions) shape cultural resources




What Are The Numbers?
At the end of 2006, MSM accounted for
76.1% of cumulative reported AIDS
cases among adult males.
Since 1985, MSM accounted for 68.8% of
positive HIV test reports among adult
males.
In 2005, MSM accounted for an
estimated 45% of all new infections in
Canada.
http://www.phac-aspc.gc.ca/aids-sida/populations-eng.php#men
Public Health Agency of Canada. HIV/AIDS Epi Updates,
November 2007, Surveillance and Risk Assessment Division,
Centre for Infectious Disease Prevention and Control, Public
Health Agency of Canada, 2007.


An estimated 2,300 to 4,500 new HIV
infections occurred in 2005, and MSM
accounted for the greatest number of
these new infections, 1,100 to 2,000
27% of the estimated number of
Canadians living with HIV infection at the
end of 2005 are unaware they are HIV+
http://www.phac-aspc.gc.ca/aids-sida/publication/epi/pdf/epi2007_e.pdf
Ontario


HIV prevalence: 16% (but varies by
region: 6 -21%)
Translates to >800 new HIV infections
annually

Robert S. Remis and Juan Liu. 2007. Epidemiologic trends in HIV
infection among men who have sex with men in Ontario.
http://www.phs.utoronto.ca/ohemu/doc/MSM_Sept_2007.pdf

Highest infection rates among men, 2050
Risk context
physiology
age, identity,
social class
ethno-cultural
socio-cultural
psychology
sexual communication
settings
drug use
circuits
Psychological factors




Sex abuse
Sensation seeking
Personal disruption, stress & depression
Social isolation
Sex abuse




Men reporting unprotected anal
intercourse (UAI) more likely to report
childhood sexual abuse
HIV+ men report more childhood abuse
than HIV- men
Domestic abuse more common among
men with UAI
Also a predictor of drug use, more sex
partners, sex work
Sex abuse



Social context: “Young Latino boys who
are gay or effeminate may be at greater
risk for CSA than those who are not.”
(Arreola & Díaz 2002)
Difficulty asserting condom use with an
abusive partner
“Depression, confusion and uneasiness
about sex, and even loss of control over
their love lives, make meaningful selfprotection more difficult.” (Dorais
2004:119)
Sensation seeking


= e.g. bungee jumping, skiing fast, known
as a risk taker, fast driving, easily bored
Personality trait and/or expression of
sexual exploration & youthful party-hard
experience?
Personal disruption,
stress & depression



Low-grade depression & UAI
Major stressors, i.e. job loss, moving,
death of partner, etc
When life is worth living

Planning for a healthy future
Social isolation



Lack of social support, loneliness & UAI
Fatalism & UAI
"To the extent that persons do not hold
positive views for their future, and to the
extent that life is currently lacking
satisfaction, motivation to initiate and
maintain risk reduction changes in likely to
be weaker." (Kalichman et al. 1997:545)
Drug use
UAI & “club drugs”
 Alcohol with or without drugs
 Poppers
 Drug use & condom breakage
 Drug use & recent seroconversion

Drug use causal?



Does drug use cause UAI, therefore we
should campaign against it, or is drug use
a way of dealing with several problems?
Drug use + “sexual escape expectancies”
"in only three cases was this [drug use]
stated in isolation, the rest feel that
emotional issues had resulted in the use of
drugs/alcohol as a means of
release/escapism" (Gilbart et al. 2000)

“Risky sex does not result from the simple
exposure to drugs or alcohol before or
during sexual behaviours, but rather
depends on mitigating factors such as the
personal convictions of the individual, as
well as the decision-making processes that
occur well throughout the sexual act.”
(Myers et al. 2004:225)
Crystal meth

“three main patterns to respondents’
motivations to use crystal: escaping
loneliness, dealing with feelings of sexual
unattractiveness, and lowering sexual
inhibitions. In a more general sense, these
problems appeared to stem from deepseated feelings of being unloved and
unlovable.” (Kurtz 2005:65)
Circuit parties &

“tribalism,” “esprit de corps,” and sense of
communion associated with club drugs
Sexual communication



Couples
Trade offs
Disclosure
Becoming a couple
Condoms dropped over time as sign
of trust
 “Negotiated safety” vs tacit move

“Sero-discordant” couples


Not wanting to stigmatize a HIV+ partner
“In the context of relationships where one
partner is HIV positive, unprotected sex
can be considered to communicate
feelings of ‘love’ and ‘commitment’ in even
more powerful ways than would be the
case if both partners were negative.”
Rhodes 1997:215
Setting

“rules of engagement” in quick sex
environments:
 Low disclosure
 Low sense of obligation to partners

i.e. market rules; buyer beware
Disclosure


Cuerrier & disclosure
Greater with better-known partners; less
with casual



Safer sex practised more often with casual
partners anyway
Disclosure is not associated with higher
rates of protected sex
Those who decide, encounter to
encounter, whether to disclose or not, and
who then disclose inconsistently have
higher rates of UAI
Circuits & microcultures
Internet & more UAI but internet
users no more likely to have UAI with
partners met on-line than off
 Barebacking and “rhetoric of
individualism, personal responsibility,
consenting adults, and contractual
interaction.” (Adam 2005)

Bareback circuit
“Participants tacitly signed onto the social contract
that states the primary responsibility to disclose
HIV status is placed on the sexual partner. Many
claimed to operate from the assumption that
people are responsible for their own bodies, and
that feelings of responsibility toward another are
not obligatory. The participants referred to an
‘unspoken rule’ that men in public sex
environments who did not initiate a discussion
on disclosure were either HIV-infected or did not
care about their health.” Reback et al 2004:94
Condoms vs erections
Condom-avoidance rationales:





desensitizing
symbolic value of insemination
Intimacy
Erectile difficulties more common in older
men and men on HAART
Viagra & UAI
HIV optimism





Low endorsement among gay men
Cause or post hoc rationalization?
Rarely arises in narratives about UAI
Same as “undetectable” viral load?
Indicator of bareback circuit?
Socio-demographics




Youth
Bisexual men
Lower education & income
Migration & cultural assumptions

Men of colour & culturally appropriate
communication
Trade offs

scenarios where men who feel
disadvantaged in some way—be it age,
ethnicity, or attractiveness—fear to offend
a desirable partner and trade away safe
sex lest it prove an obstacle to sexual
interaction
 Insufficient study of institutional sources of HIV
information
 Schools, mass media, churches/mosques, biomedicine
 Inadequate mapping of popular understanding of
HIV technologies and messages
 For example, claim that gay men are complacent
because of ARVs–widely propagated, poorly
documented
 How does treatment=prevention mantra propounded
by biomedical “experts” translate into everyday risk
management?
 Insufficient ethnography of most vulnerable subsets of at-risk
populations.
 Not “behaviour,” but practices embedded in exigencies and choices
of everyday life
 Not “inadequate uptake” or failure to be rational, but discourses
available for making sense of risk
 In short, it’s about social networks, and sexual and drug cultures