Safe sex after post-exposure prophylaxis for HIV: intentions, challenges and ambivalences in narratives of gay men

This paper draws on findings from an on-going prospective cohort study, with a quantitative and a qualitative arm, to monitor the implementation of non-occupational post-exposure prophylaxis (PEP) in Australia. The aim of the qualitative arm was to explore in-depth details of exposures to HIV and participants' understanding of 'risk'. Of the 328 patients who were enrolled in the study from March 1999 to July 2001, 88 (27%) participated in the qualitative arm. Interviews were conducted in a semi-structured style and explored the event that precipitated the request for PEP, participants' understanding of safe sex, their physical and psychological experience of the treatment and the impact that the availability of PEP may have on their sexual practices in the future. One theme running through the interviews was a determination to either maintain existing high levels of safe sex or to increase safe sex practices in those men who perceived PEP as 'a wake up call'. This determination was motivated by the experience of taking combination therapies and reflection on a potentially HIV-positive future. However, there were also tensions and ambivalences in the narratives. PEP was promoted as an adjunct to safe sex, not as an alternative. This is how PEP was understood by the men in this study.     

'The black dog just came and sat on my face and built a kennel': Gay men making sense of 'depression'

This article reports on in-depth interviews with gay men about their experiences and understanding of depression. It is a key outcome of the collaboration between social researchers, general practitioners and community partners to investigate the management of depression in gay men in primary care settings. As part of the qualitative arm of the project in-depth interviews were conducted with 40 gay men in Sydney and Adelaide (Australia). The approach to discourse analysis is informed by Hallidayan systemic functional linguistics. Six constructions of depression were identified: (1) depression as a constellation of symptoms; (2) symptoms constructed as experience; (3) depression as agent; (4) depression as mental processes; (5) not meeting social expectations; and (6) engaging with psychiatric discourse: constructing alternative positions. Gay men draw on the biomedical model of depression as low mood and loss of pleasure as well as on constructions of depression in terms of social experience. The biomedical model of depression is, however, not positioned as unproblematic. Rather, gay men align or disalign with this discourse according to their own experience, thereby enacting diverse masculinities. Gay men's discourses of depression are inextricably linked to the community activism of gay men and their community organizations in the context of the HIV epidemic, as well as a synergy between gay men and their doctors.     

Two sides to the HIV prevention coin: efficacy and effectiveness

In the context of the current concern about HIV prevention efforts, this article addresses the issues of efficacy and effectiveness. We argue that the success of treatments and associated increasing dominance of biomedicine has meant that far too little attention has been paid to effectiveness, that is, to the impact an HIV prevention program or intervention achieves in the real world, under resource constraints, in entire populations. Although biomedicine has, appropriately, investigated the efficacy of a number of new prevention technologies and modeled the impact of "test and treat," issues relating to the provision, acceptability, adoption, and sustained use of prevention technologies, both old and new, have not been fully addressed. As HIV is a profoundly social disease with its causes and consequences deeply embedded in social, cultural and political processes, social scientists need to be heard and work with biomedical scientists to ensure the success of HIV prevention.     

How has the sexual behaviour of gay men changed since the onset of AIDS: 1986-2003

OBJECTIVE: To report changes in sexual behaviour among gay men in Sydney from 1986 to 2003. METHODS: Baseline data from four studies of gay men in Sydney were used: the Social Aspects of the Prevention of AIDS study (1986/87: 91 HIV-positive and 444 HIV-negative men); the Sydney Men and Sexual Health cohort (1993-95: 237 HIV-positive and 910 HIV-negative men); the Health in Men cohort of HIV-negative gay men (2001-03: 1,148 men); the Positive Health cohort of HIV-positive gay men (2001/02: 237 men). Each sample was recruited and interviewed using similar methods. RESULTS: Fewer HIV-positive men had sex with casual partners over time (76.9% in 1986/87 to 63.7% in 2001/02; p = 0.001), but more HIV-negative men had sex with 10 or more casual partners in the previous six months (27.7% in 1986/87 to 37.7% in 2001-03; p = 0.012). The proportions engaging in particular sex practices with casual partners changed over time: anal intercourse without condoms that included ejaculation in the rectum fell from 29.4% among HIV-positive men and 32.4% among other men in 1986/87 to 17.8% and 10.0% respectively in 1993-95 (p = 0.034 and p < 0.001 respectively), but increased to 37.7% and 18.4% respectively in 2001-03 (p-values < 0.001); rimming one's partner increased from 36.8% among HIV-positive men and 17.6% among other men in 1986/87 to 63.6% and 52.3% respectively in 2001-03 (p = 0.001 and p < 0.001 respectively). CONCLUSION: Gay men's sexual behaviour with casual partners has changed over time, perhaps partly in response to HIV and partly as a general expansion of sexual repertoires. These changes have implications for gay men's health.     

Prevalence and risk factors of hepatitis C in HIV-negative homosexual men in Sydney, Australia

OBJECTIVE: To determine the prevalence and risk factors for hepatitis C (HCV) in HIV-negative homosexual men in Sydney. METHODS: A cohort study was conducted in a sample of community-based, HIV-negative, homosexual men in Sydney. Participants underwent a face-to-face interview regarding sexual behaviour, sexually transmissible infections, and injecting drug use (IDU). RESULTS: Eight hundred and twenty-four men consented to HCV testing, and the prevalence was 0.85% (95% CI 0.34-1.74). HCV seropositivity was strongly associated with a history of IDU (OR = 60.43, 95% CI 6.70-544.79). All HCV seropositive individuals reported a history of either IDU or other means by which they may have had parenteral exposure to HCV. There was no evidence of an independent association between sexual behaviour and HCV infection. CONCLUSION: The prevalence of HCV in this cohort was about the same as in the general population in Australia, and there was no evidence for sexual transmission in this population.     

It's not just condoms: Social contexts of unsafe sex in gay men's narratives of post-exposure prophylaxis for HIV

This paper draws on findings from an ongoing prospective cohort study with a quantitative and a qualitative arm to monitor the implementation of guidelines for non-occupational post-exposure prophylaxis in Australia. The aim of the qualitative arm was to explore in-depth details of exposures and participants' understanding of ‘risk’. This paper documents the physical, social and emotional contexts in which unsafe sex leading to post-exposure prophylaxis occurred. It will be argued that unsafe sex happened in spite of participants' knowledge about safe sex and as a consequence of a temporary absence of control. Five themes characterising the social contexts of unsafe sex can be identified in the narratives: issues relating to past, current and potential future relationships, drugs and alcohol, public and private social spaces, stress, and adventure. These contextual categories are not always neatly separated but interact with each other in various ways. Findings suggest that disseminating knowledge of safe sex practices based on condom use alone is not enough. Safe sex messages need to be contextualised to make links between sexual practices and the everyday experiences of those for whom they are intended.     

Demographic predictors of circumcision status in a community-based sample of homosexual men in Sydney, Australia

Male circumcision may reduce the risk of HIV acquisition in heterosexual men. In observational studies, confounding by demographic factors could produce spurious associations between circumcision and HIV risk. To assess this possibility, cross-sectional data on self-reported circumcision status and demographic factors were collected at baseline as part of the Health in Men study. Two-thirds of 1426 subjects were circumcised, mostly in the neonatal period. In multivariate analyses, age, ethnicity and country of birth were independently associated with circumcision status. Confounding by these demographic factors must be considered in future epidemiological studies addressing circumcision and HIV acquisition.