Sustaining safe practice: twenty years on

This paper examines the ways in which populations at risk of HIV in the developed world have enculturated the knowledges and technologies of both the medical and the social sciences. By revisiting a number of review papers and by reviewing findings from a range of studies, we argue that gay men have appropriated information that has enabled them to sustain safe practices while they have eschewed information that has made maintenance difficult.The paper describes a range of risk reduction strategies and compares the responses of populations at risk of HIV in the years before the advent of highly active antiviral therapy (HAART) with their responses after the introduction of HAART in 1996. We concentrate our argument on the changing responses to HIV risk of gay men, although occasionally illustrate our argument with reference to the responses of injecting drug users. The responses of gay men to risk post-HAART--particularly those who reside in Australia--speak to the adoption of a range of considered strategies, not altogether safe, to reduce harm.We argue that such strategies need to be understood and addressed within a 'new' social public health, that is, a public health that takes what social analysis has to say seriously. The paper examines the differences between the traditional, the 'modern' epidemiological/clinical and the 'new' social or socio-cultural public healths and describes the tensions between the medical and the social science disciplines in their efforts to inform public health. Key concepts provided by social science such as agency (including individual and collective agency), alongside its methodological reflexivity are key to effective public health. The risk avoidance strategies adopted by gay men suggest a way forward by turning our attention to the ways in which medicine is taken in(to) their practice.     

Structural influence of cohesive mixtures of salbutamol sulphate and lactose on aerosolisation and de-agglomeration behaviour under dynamic conditions

PurposeThe purpose of this study was to understand the behaviour of cohesive powder mixtures of salbutamol sulphate (SS) and micronized lactose (LH300) at ratios of SS:LH300 of 1:1, 1:2, 1:4 and 1:8 under varying air flow conditions.MethodsAerosolisation of particles less than 5.4 μm at air flow rates from 30 to 180 l min^?1 was investigated by determining particle size distributions of the aerosolised particles using laser diffraction and fine particle fractions of SS using the twin stage impinger modified for different air flow rates using a Rotahaler^®. The de-agglomeration data were best fitted by a 3-parameter sigmoidal equation using non-linear least squares regression and characterised by the estimated parameters.ResultsDe-agglomeration air flow rate profiles showed that SS:LH300 mixtures with increased lactose content (1:4 and 1:8) improved powder aerosolisation, but lactose had negligible effect on SS aerosolisation at the higher and lower limits of air flow rates studied. De-agglomeration flow rate profiles of SS–LH300 mixtures with increased lactose content (1:4 and 1:8) were greater than theoretically expected based on weighted individual SS and LH300 profiles. This indicated that interactions between the cohesive components led to enhanced de-agglomeration. The composition of the aerosol plume changed with air flow rate.ConclusionThis approach to characterising aerosolisation behaviour has significant applications in understanding powder structures and in formulation design for optimal aerosolisation properties.     

Differences between HIV-positive gay men who 'frequently', 'sometimes' or 'never' engage in unprotected anal intercourse with serononconcordant casual partners: positive Health cohort, Australia

By measuring the actual number of risk acts engaged in by HIV-positive men participating in the Positive Health (PH) cohort study, this paper sets out to document the distribution of risk acts, to report on the proportion of acts of unprotected anal intercourse with casual (UAIC) partners that occurred between HIV-positive men (i.e. seroconcordant positive) and to examine the factors that differentiated men who 'frequently' compared with 'sometimes' or 'never' engaged in unsafe UAIC (i.e. UAIC with serononconcordant partners: partners who have not tested positive for HIV). The findings show that 42.6% of all UAIC acts occurred between seroconcordant HIV-positive partners, posing no risk of HIV infection to an HIV-negative person. A minority of participants (10%) accounted for the majority (70.7%) of the unsafe acts of UAIC. The HIV-positive men who 'sometimes' engaged in unsafe UAIC had higher treatment optimism scores and were more likely to use Viagra in comparison with those who did not engage in such risk. Those who reported 'frequent' engagement in unsafe UAIC were more likely to engage in a range of esoteric sexual practices, be slightly less well educated and be taking antiretroviral therapy compared with HIV-positive men who 'sometimes' engaged in unsafe UAIC. As such, taking ART but not viral load, predicted frequent unsafe UAIC. When considered alongside earlier studies, these results suggest that HIV-negative men who engage in esoteric sexual practices may be at increased risk of HIV transmission, not necessarily because they engage in esoteric sex practices but because of the sub-cultural milieu in which esoteric sex is occurring. The findings from this study also endorse the measurement of UAIC acts as a useful gauge of risk.     

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study

OBJECTIVE: The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney. STUDY DESIGN: The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected. RESULTS: Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039). CONCLUSIONS: Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.     

A public health dilemma: a testing question

The current moves to provide access to antiretroviral therapy (ART) to all in need has led to a push to HIV test. In particular, there have been policy moves endorsed by the World Heath Organization and UNAIDS to introduce routine 'opt out' HIV testing in countries with high prevalence. A number of claims have been made with regard to the benefits of increasing the numbers of people on antiretroviral therapy. Two of these claims are disputed here. Treatment roll-out and the associated push for routine testing raise questions of concern to public health and human rights. While it is claimed that treatment roll-out will reduce stigma and discrimination, there is little evidence to support the claim. It is also claimed that treatment uptake will reduce the likelihood of HIV transmission and that thus treatments themselves have a preventive effect. This direct effect of treatment uptake on prevention is augmented, it is claimed, if use is made of the voluntary counselling and testing (VCT) encounter and people counselled to act safely. Again there is little evidence to support the claims made. In addressing the evidence for these two claims, the paper cautions against the large scale adoption of routine 'opt out' or, as it is sometimes called, 'provider-initiated' testing.     

Negotiating risk and social relations in the context of post-exposure prophylaxis for HIV: Narratives of gay men

This paper draws on findings from a study to monitor the implementation of non-occupational post-exposure prophylaxis (PEP) in Australia. It focuses on the study's qualitative arm, which explores in-depth details of possible exposures to HIV, participants' understanding of risk and their physical and psychosocial experience of the treatment. Results indicate that, in addition to taking antiretroviral treatment after unsafe sex, PEP requires the negotiation of a multitude of social relations in order to reduce the possibility of HIV infection. For the participants this meant: assessing the risk; engaging their social networks in the search for possible prophylaxis; negotiating with health professionals when deciding whether to take PEP; and negotiating disclosure of PEP and the sexual risk which necessitated it, to people in their social networks. For the participants in this study, PEP did not undermine safe sex messages. It was used as an additional line of defence when condoms and other risk reduction strategies had failed. Participants presented themselves in their narratives in accordance with the public health discourse of safe sex, which foregrounds agency and rational decision making, in relation to all aspects of PEP: sexual practices, treatment decision and disclosure.     

A STUDY OF HLA-A,B, DR and Bf5 BEARING HAPLOTYPES DERIVED FROM 304 FAMILIES RESIDENT IN THE NORTH WEST OF ENGLAND

We report here haplotype frequencies for class I (HLA-A, B), class III (HLA-DR) and class III (Bf) gene products of the major histocompatibility complex (MHC) of man. As in other studies (Bertrams & Baur, 1979; Grange et al., 1981), we have chosen to document all families typed for HLA antigens and Bf phenotypes irrespective of ascertainment. We obtained 1,094 haplotypes from 304 families resident in the North West of England, of which 34·1% had been fully typed for HLA-A,B,DR and Bf polymorphisms. We have been able to find both positive and negative linkage disequilibria for two and three locus haplotypes and have listed the most commonly occuring four locus haplotypes. Our data confirms the position of the complement group between HLA-B and HLA-DR, and we have looked for evidence of segregation distortion of MHC haplotypes.     

Trends in Agreements Between Regular Partners Among Gay Men in Sydney,Melbourne and Brisbane,Australia

Between 1998 and 2007, 51,449 Gay Community Periodic Survey questionnaires were completed in Sydney, Melbourne and Brisbane, Australia. These included 23,424 where the respondents reported currently being in a relationship with a regular male partner. About 90% of men with a regular partner had been tested for HIV, and about three quarters had tested HIV-negative. Between 1998 and 2007 there was an increase in the proportion of men in HIV-negative seroconcordant relationships. About three quarters of men with a regular partner had negotiated an agreement about sex within their relationship. There was little change over time in the likelihood of having negotiated such agreements. There were, however, changes over time in the nature of these negotiated agreements: Over time, more men in HIV-discordant relationships permitted unprotected anal intercourse with their regular partners (P-trend < .001); among men in HIV-negative concordant relationships, an increasing proportion required a monogamous arrangement with their regular partner (P-trend < .001); and over time, fewer men in general required consistent condom use with casual partners (P-trend < .001). Some of these changes in negotiated agreements represent an increase in the potential risk of HIV transmission.     

HIV treatments optimism is associated with unprotected anal intercourse with regular and with casual partners among Australian gay and homosexually active men

We examined HIV optimism and unprotected anal intercourse (UAI) in a nationwide sample of gay and homosexually active men. Questionnaires were distributed throughout Australia through pornographic catalogues. 1832 men responded, 1181 (64.5%) classified as gay community attached (GCA) and 651 (35.5%) as non-GCA (NGCA). Mean HIV optimism scores tended toward scepticism rather than optimism, with no significant difference between GCA and NGCA men. Men who had UAI with regular partners were significantly more optimistic than men who did not (P<0.001). There was a significant UAI-casual/GCA interaction (P<0.001). GCA men who engaged in UAI-casual were significantly more optimistic than GCA men who did not (P<0.001). Likewise, NGCA men who had UAI-casual were significantly more optimistic than NGCA men who did not (P<0.001). These findings corroborate earlier evidence that gay men's UAI is associated with - not necessarily caused by - HIV optimism. Importantly, these data come from a broad national sample rather than one drawn from within a 'gay precinct'.