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Negotiating Risks in Context: A Perspective on Unprotected Anal Intercourse and Barebacking Among Men Who Have Sex with Men—Where Do We Go from Here?

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Abstract

Recently, an alarming trend toward unprotected anal intercourse has emerged in men who have sex with men. A highly dangerous form of unprotected anal intercourse, barebacking—the deliberate and conscious choice to engage in anal sex without condoms knowing that there are risks involved—has received much attention in the gay press. This trend poses new challenges for HIV prevention. As the target population changes, prevention interventions must also evolve to remain effective. A review of the scientific literature on risk behaviors and the popular literature and websites devoted to barebacking suggests that many contextual factors influence the decision to engage in unprotected anal intercourse. This review examines the most salient contextual factors affecting risk behavior in gay/bisexual men. It also identifies four main cohorts and predominant contextual factors that appear to motivate unprotected anal intercourse in each. In answering the question “where do we go from here,” we conclude that contextual issues must be addressed in hybrid prevention interventions that include harm reduction, motivational interviewing, and traditional approaches.

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REFERENCES

  • AIDS Alert (1999). Behavior change model promotes HIV drug compliance, safe sex practices. AIDS Alert 14: 49.

    Google Scholar 

  • Barroso, P. F., Schechter, M., Gupta, P., Melo, M. F., Vieira, M., Murta, F. C., Souza, Y., and Harrison, L. H. (2000). Effect of antiretroviral therapy on shedding in semen. Ann. Int. Med. 133(4): 280-284.

    Google Scholar 

  • Centers for Disease Control (1997, September 26). Gonorrhea among men who have sex with menselected sexually transmitted disease clinics, 1993-1996. Morb. Mort. Week. Rep. 46: 889-892.

    Google Scholar 

  • Centers for Disease Control (1999a, January 29). Increases in unsafe sex and rectal gonorrhea among men who have sex with men-San Francisco, California, 1994-1997. Morb. Mort. Week. Rep. 48: 45-48.

    Google Scholar 

  • Centers for Disease Control (1999b, September 10). Resurgent bacterial sexually transmitted disease among men who have sex with men-King County,Washington, 1997-1999. Morb. Mort. Week. Rep. 48: 773-776.

    Google Scholar 

  • Centers for Disease Control (2000, June 23). Gonorrhea-United States, 1998. Morb. Mort. Week. Rep. 48: 538-542.

    Google Scholar 

  • Chiranni, A., Perna, E., Liuzzi, G., D'Abbraccio, M., Bonadies, G., Paone, G., Foggia, M., Patricelli, V., and Piazza, M. (1992, Abstract No. PoC4530). Absence of anti-HIV seroconversion in heterosexual partners of HIV patients treated with zidovudine. Paper presented at the XI International Conference on AIDS.

  • Cochran, S. D., and Mays, V. M. (1990). Sex, lies, and HIV. N. Engl. J. Med. 322: 774-775.

    Google Scholar 

  • Cook, R. L., and Rosenberg, M. J. (1998). Do spermicides containing nonoxynol-9 prevent sexually transmitted infections? A meta-analysis. Sex Transm. Dis. 25: 144-150.

    Google Scholar 

  • Denning, P. (1998). Therapeutic interventions for individuals with substance use, HIV, and personality disorders: Harm reduction as a unifying approach. In Session 4: 37-52.

    Google Scholar 

  • Dilley, J. W., Woods, W. J., and McFarland, W. (1997). Are advances in treatment changing views about high-risk sex? N. Engl. J. Med. 337: 501-502.

    Google Scholar 

  • Ekstrand, M., and Coates, T. J. (1990). Maintenance of safer sex behaviors as predictors of risky sex. Am. J. Pub. Health 80: 973-977.

    Google Scholar 

  • Ekstrand, M., Stall, R., Kegeles, S., Hays, R., DeMayo, M., and Coates, T. (1993). Safer sex among gay men: What is the ultimate goal. AIDS 7: 281-282.

    Google Scholar 

  • Elford, J., Bolding, G., Maguire, M., and Sherr, L. (2000). Combination therapies for HIV and sexual risk behavior among gay men. J. Acq. Imm. Defic. Syndr. 23: 266-271.

    Google Scholar 

  • Eron, J. J., Smeaton, L. M., Fiscus, S. A., Gulick, R. M., Currier, J. S., Lennox, J. L., D'Aquila, R. T., Rogers, M. D., Tung, R., and Murphy, R. I. (2000). The effects of protease inhibitors therapy on Human Immunodeficiency Virus Type 1 levels in semen (AIDS Clinical Trials Group Protocol 850). J. Infect. Dis. 181(5): 1622-1628.

    Google Scholar 

  • Fiore, J. R., Zhang, Y. J., Bjorndal, A., Di Stefano, M., Angarano, G., Pastore, G., and Fenyon, E. M. (1997). Biological correlates of HIV-1 heterosexual transmission. J. Acq. Imm. Defic. Syndr. 11: 1089-1094.

    Google Scholar 

  • Gerhart, K. (1999, June). Beyond Barebacking: The complacency crisis. Genre 7: 47-51.

    Google Scholar 

  • Gold, R. (1995). Why we need to rethink AIDS education for gay men. AIDS Care 7: S11-S19.

    Google Scholar 

  • Gold, R. S., Skinner, M. J., Grant, P. J., and Plummer, D. C. (1990). Situational factors and thought processes associated with unprotected intercourse in gay men. Psychol. Health 5: 259-278.

    Google Scholar 

  • Gunther-Grey, C., Lyles, C., Sumartojo, K. H., Choi, K. H., Clark, L., Collens, C., Lin, L., O'Donnell, L., and Remafedi, G. (2000). Knowledge of partners HIV serostatus among men who have sex with men. Paper presented at the XIII International Conference on AIDS.

  • Gupta, P., Mellors, J., Kingsley, L., Riddler, S., Singh, M. K., Schreiber, S., Cronin, M., and Rinaldo, C. R. (1997). High viral load in semen of human immunodeficiency virus type 1-infected men at all stages of disease and its reduction by therapy with protease and nonnucleoside reverse transcriptase inhibitors. J. Virol. 71: 6271-6275.

    Google Scholar 

  • Hecht, F. M., Grant, R. M., Petropoulos, C. J., Dillon, B., Chesney, M. A., Tian, H., Hellmann, N. S., Bandrapalli, N. I., Digilio, L., Branson, B., and Kahn, J. O. (1998). Sexual transmission of an HIV-1 variant resistant to multiple reverse-transcriptase and protease inhibitors. N. Engl. J. Med. 339: 307-311.

    Google Scholar 

  • Hort, H. K. (2000). Barebacking domino. Paper presented at the XIII International Conference on AIDS.

  • Kafka, M. P. (2000). The paraphilia-related disorders: Nonparaphilic hypersexuality and sexual compulsivity/addiction. In Lieblum, S., and Rosen, R. C. (eds.), Principles and Practice of Sex Therapy, 3rd Ed., Guilford Press, New York, pp. 471-503.

    Google Scholar 

  • Kalichman, S. C. (1998). Understanding AIDS: Advances in Research and Treatment, 2nd Ed., American Psychological Association, Washington, DC.

    Google Scholar 

  • Kalichman, S. C., Greenberg, J., and Abel, G. G. (1997). HIV-seropositive men who engage in highrisk behaviour: Psychological characteristics and implications for prevention. AIDS Care 9: 441-450.

    Google Scholar 

  • Kalichman, S. C., Nachimson, D., Cherry, C., and Williams, E. (1998). AIDS treatment advances and behavioral prevention setbacks: Preliminary assessment of reduced perceived threat of HIV-AIDS. Health Psychol. 17: 546-550.

    Google Scholar 

  • Kelly, J. A., Hoffman, R. G., Rompa, D., and Gray, M. (1998). Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex. AIDS 12: F91-F95.

    Google Scholar 

  • Kelly, J. A., and Kalichman, S. C. (1998). Reinforcement value of unsafe sex as a predictor of condom use and continued HIV/AIDS behavior among gay and bisexual men. Health Psychol. 17: 328-335.

    Google Scholar 

  • Kelly, J. A., Otto-Salaj, L. L., Sikkema, K. J., Pinkerton, S. D., and Bloom, F. R. (1998). Implications of HIV treatment advances for behavioral research on AIDS: Protease inhibitors and new challenges in HIV secondary prevention. Health Psychol. 17: 310-319.

    Google Scholar 

  • Kippax, S., Crawford, J., Davis, M., Rodden, P., and Dowssett, G. (1993). Sustaining safe sex: A longitudinal study of a sample of homosexual men. AIDS 7: 257-263.

    Google Scholar 

  • Kippax, S., Noble, J., Prestage, G., Crawford, J. M., Campbell, D., Baxter, D., and Cooper, D. (1996). Sexual Negotiation in the AIDS era: Negotiated safety revisited. AIDS 11: 191-197.

    Google Scholar 

  • Lee, T. H., Sakahara, N., Fiebig, E., Busch, M. P., O'Brien, T. R., and Herman, S. A. (1996). Correlations of HIV-1 RNA levels in plasma and heterosexual transmission of HIV-1 from infected transfusion recipients. J. Acq. Imm. Defic. Syndr. 12: 427-428.

    Google Scholar 

  • McKirnan, D. J., Ostrow, D. G., and Hope, B. (1996). Sex, drugs and escape: A psychological model of HIV-risk sexual behaviors. AIDS Care 8: 665-669.

    Google Scholar 

  • Murphy, S. T., Miller, L. C., Appleby, P. R., Marks, G., and Mansergh, G. (1999). Antiretroviral Drugs and Sexual Behavior in Gay and Bisexual Men: When Optimism Enhances Risk. Paper presented at the National Prevention Conference.

  • Musicco, M., Lazzarin, A., Nicolosi, A., Gasparini, M., Costigliola, P., Arici, C., and Saracco, A. (1994). Antiretroviral treatment for men infected with human immunodeficiency virus type 1 reduces the incidence of heterosexual transmission. Arch. Int. Med. 154: 1971-1976.

    Google Scholar 

  • NASTAD (1999, September). Negotiated safety, barebacking, and more. HIV Prevent. Update 5: 1-9.

    Google Scholar 

  • Odets, W. W. (1994). AIDS education and harm reduction do gay men: Psychological approaches for the 21st century. AIDS Pub. Pol. J. 9: 1-15.

    Google Scholar 

  • Odets, W. W. (1996). Risk appraisals and HIV prevention. Focus 11: 1-4.

    Google Scholar 

  • Ostrow, D. G., Fox, K., Chmiel, J. S., Silvestre, A., Visscher, B. R., Vanable, P., Jacobson, L. P., and Strathdee, S. A. (2000). Attitudes towards highly active antiretroviral therapy predict sexual risk-taking among HIV-infected and uninfected gay men in the Multicenter AIDS cohort Study (MACS). Paper presented at the XIII International Conference on AIDS.

  • Pinkerton, S. D., and Abramson, P. R. (1992). Is risky sex rationale? J. Sex Res. 29: 561-568.

    Google Scholar 

  • Pinkerton, S. D., and Abramson, P. R. (1996). Occasional condom use and HIV risk reduction. J. Acq. Imm. Defic. Syndr. 13: 456-460.

    Google Scholar 

  • Pinkerton, S. D., and Holtgrave, D. (1999). Combination antiretroviral therapies for HIV: Some economic considerations. In Ostrow, D. G., and Kalichman, S. C. (eds.), Psychosocial and Public Health Impacts of New HIV Therapies, Kluwer Academic, New York, (pp. 83-107).

    Google Scholar 

  • Prestage, G., Grulich, A., Campbell, D., Kaldor, J., and Kippax, S. (1997, Abstract No. IS 113). Unprotected intercourse among HIV-positive men: The influence of combination therapies. Paper presented at the Annual Conference of the Australas Society of HIV Med.

  • Purcell, D. W., DeGroff, A. S., and Wolitski, R. J. (1998). HIV prevention case management: Current practice and future directions. Health Soc. Work 23: 282.

    Google Scholar 

  • Quinn, T. C., Wawer, M. J., Sewankambo, N., Serwadda, D., Li, C., Wabwire-Mangen, F., Meehan, M. O., Lutalo. T., and Gray, R. H. (2000). Viral load and heterosexual transmission of human immunodeficiency virus type 1. N. Engl. J. Med. 342: 921-929.

    Google Scholar 

  • Rabkin, J., and Chesney, M. (1999). Combination antiretroviral therapies for HIV: Some economic considerations. In Ostrow, D. G., and Kalichman, S. C. (eds.), Psychosocial and Public Health Impacts of New HIV Therapies, Kluwer Academic, New York, pp. 61-79.

    Google Scholar 

  • Ragni, M. V., Faruki, H., and Kingsley, L. A. (1998). Heterosexual HIV-1 transmission and viral load in hemophilic patients. J. Acq. Imm. Defic. Syndr. 17: 42-45.

    Google Scholar 

  • Remien, R. H., Wagner, G., Carballo-Dieguez, A., and Dolezal, C. (1998). Who may be engaging in high-risk sex due to medical treatment advances? AIDS 12: 1560-1561.

    Google Scholar 

  • Rowatt, W. C., Cunningham, M. R., and Druen, P. B. (1999). Lying to get a date: The effects of facial physical attractiveness on the willingness to deceive prospective dating partners. J. Soc. Per. Rel. 16(2): 209-233.

    Google Scholar 

  • Royce, R. A., Sena, A., Cates, W., and Cohen, M. S. (1997). Sexual transmission of HIV. N. Engl. J. Med. 336: 1072-1078.

    Google Scholar 

  • San Francisco Department of Public Health (2000). The San Francisco Department of Public Health and AIDS Research Institute/UCSF Response to the Updated Estimates of HIV infection in San Francisco, 2000. Retrieved March 30, 1999 from the World Wide Web: http://hivinsite.ucsf. edu/

  • Scarce, M. (1999, February). A Ride on the Wild Side. POZ.

  • Schechter, M., Strathdee, S. A., Martindale, S. L., Miller, M. L., Hogg, R. S., Woodfall, B., Sestak, P., and Schechter, M. T. (1998). Evidence of elevated HIV incidence and relapse to unsafer sex among young men having sex with men (MSM) in Vancouver, Canada. Paper presented at the XII International Conference AIDS.

  • Seal, D. W., Kelly, J. A., Bloom, F. R., Stevenson, L. Y., Coley, B. I., and Broyles, L. A. (2000). HIV prevention with young men who have sex with men: What young men themselves say is needed. AIDS Care 12: 5-26.

    Google Scholar 

  • Sogolow, E., Peersman, G., Semaan, S., Strouse, D., Lyles, C., and the Prevention Research Synthesis Team (in press). CDC's HIV AIDS Prevention Research Synthesis Project: Development, initial results, and future directions. J. Acq. Imm. Defic. Syndr.

  • Suarez, T., and Kauth, M. R. (in press). HIV risk assessments in men who have sex with men. In Sessions.

  • Suarez, T., Kelly, J. A., Pinkerton, S. D., Stevenson, Y. L., Hayat, M. J., Smith, M. D., and Ertl, T. (2000). The influence of a partner's HIV serostatus and viral load on perceptions of sexual risk behavior in a community sample of gay and bisexual men. Manuscript under review.

  • Suarez, T., O'Leary, A., and Morganstern, J. (in press). Selective serotonin reuptake inhibitors: Can the play a role in HIV prevention? In O'Leary, A. (ed.), Beyond Condoms, Kluwer Academic.

  • Valleroy, L., MacKellar, D. A., Rosen, D., and Secura, G. (1998). Prevalence and predictors of unprotected receptive anal intercourse for 15-22-year old men who have sex with men in seven urban areas. Paper presented at the XII International Conference on AIDS, Geneva.

  • Vanable, P. A., Ostrow, D. G., McKirnan, D. J., Taywaditep, K. J., and Hope, B. A. (2000). Impact of combination therapies on HIV risk perceptions and sexual risk among HIV-positive and HIVnegative gay and bisexual men. Health Psychol. 19: 134-145.

    Google Scholar 

  • van de Ven, P., Campbell, D., Kippax, S., Knox, S., Prestage, G., Crawford, J., Kinder, P., and Cooper, D. (1998). Gay men who engage repeatedly in unprotected anal intercourse with casual partners: The Sydney Men and Sexual Health Study. Int. J. STD AIDS 9: 336-340.

    Google Scholar 

  • Vernazza, P. L., Troiani, L., Flepp, M. J., Cone, R. W., Schock, J., Roth, F., Boggian, K., Cohen, M. S., Fiscus, S. A., Eron, J. J., the Swiss cohort study (2000). Potent antiretroviral treatment of HIV-infection results in suppression of the seminal shedding of HIV. AIDS 14: 117-121.

    Google Scholar 

  • Voelker, R. (2000). HIV drug resistance. JAMA 12: 169.

    Google Scholar 

  • Wagner, G. J., Remien, R. H., and Carballo-Dieguez, A. (1998). “Extramarital” sex: Is there an increased risk for HIV transmission? A study of male couples of mixed HIV status. AIDS Educ. Prev. 10: 245-256.

    Google Scholar 

  • Wainberg, M. A., and Friedland, G. (1998). Public health implications of antiretroviral therapy and HIV drug resistance. JAMA 279: 1977-1983.

    Google Scholar 

  • Wittkowski, K. M., Susser, E., and Dietz, K. (1998). The protective effects of condoms and nonoxynol-9 against HIV infection. Am. J. Pub. Health 88: 590-596.

    Google Scholar 

  • Wolitski, R. J., Reitmeijer, C. A. M., Goldbaum, G. M., and Wilson, R. M. (1998). HIV serostatus disclosures among gay and bisexual men in four American Cities: General pattern and relation to sexual practices. AIDS Care 10: 599-610.

    Google Scholar 

  • Wolitski, R., Valdiserri, R., Denning, P., and Levine, W. C. (in press). Are we headed for a resurgence in the epidemic among men who have sex with men? Am. J. Pub. Health.

  • Wulfert, E., Safren, S. A., Brown, I., and Wan, C. K. (1999). Cognitive, behavioral, and personality correlates of HIV-positive persons' unsafe sexual behavior. J. Appl. Soc. Psychol. 29: 223-244.

    Google Scholar 

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  1. Center for AIDS Intervention Research, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Wisconsin

    Troy Suarez & Jeffrey Miller

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Suarez, T., Miller, J. Negotiating Risks in Context: A Perspective on Unprotected Anal Intercourse and Barebacking Among Men Who Have Sex with Men—Where Do We Go from Here?. Arch Sex Behav 30, 287–300 (2001). https://doi.org/10.1023/A:1002700130455

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