by Stephen J. Fallon, PhD -
Special to the SGN
These days, everything is about the selfie. We listen to our personalized music playlists on our phones, binge-watch entire seasons of our favorite program on demand, and target our social media shout outs to specific people on our friends list.
So it's no surprise that you can now customize your strategy for staying safe from HIV. Choice is empowering. Yet too many new choices can be confusing. So here's the new menu of choices for staying safe. Create your safer selfie.
Condoms: Lots of guys use condoms when they hook up with someone who looks like he gets around, but then skip the rubbers when they meet a 'quality' guy. Even quality guys may have had playful pasts, and many are telling the truth when they say they don't think that they're infected ... even though they haven't tested in years. So how well do condoms protect you?
" Best case: If a condom appears intact after use, you've lowered by 125,000 times your chance of catching HIV. Condoms also offer this undeniable benefit: you can check to see if the other guy is really wearing one right now.
" No guarantees: Condoms only work when someone is wearing them. Gay guys who claim to use condoms all the time reduced their HIV risks by 70%. Rule out the guys who seem to be forgetting the nights they skipped the condoms, and protection is much higher. Condoms break or slip off in as few as 0.4% to 0.6% of uses, and that's because these numbers include the people who fumble with them drunk or use wildly inappropriate lubricants. Still, if you just can't stand using condoms, there are other choices.
PrEP: Never heard of it? You will. With PrEP, an HIV-negative guy takes the anti-HIV combination medicine that people living with HIV take. The difference is that he takes it every day before a possible exposure to HIV. That's the 'pre' in PrEP.
" Best case: PrEP can offer almost complete protection from an HIV exposure. In the largest studies conducted, none of the guys who took at least most of their PrEP medications became infected. PrEP does take advance planning, though. You can't start taking PrEP the day you're planning to have sex (it takes about a week to build up in the body).
" No guarantees: Truth is, in the largest PrEP study, new HIV infections were only reduced by 44%, mainly because some people who said they were going to start PrEP never did, or they only took a few of their pills. So just like condoms, you have to use it to get the benefits.
Treatment as Prevention: If your HIV+ partner is taking anti-HIV medications, that helps him and protects you. Less virus in his bloodstream makes him far less contagious. The first large study said that the risk of catching HIV from a treated person drops 96%. There were some holes in the study: nearly everyone in the study was heterosexual and married, so would the results translate for Gay men? In this year's newer PARTNER study, about a third of the people living with HIV were Gay men, and none of their partners got infected either.
" Best case: taking anti-HIV treatment is something many positive guys are already doing.
" No guarantees: there's no way to see if the other guy is taking his treatment the way you could check for a condom. Once they're off the meds, the drugs start draining out of their system, and that means you're not protected anymore.
Test twice, Talk, and Trust: This is not the same as only hooking up with guys you think are HIV-negative. Here, you take an HIV test with your partner, and discuss whether you're both comfortable having a 'closed' relationship (or open only with protection). If you both are, you test again to confirm neither had a new HIV infection that the first test missed, and then you may choose to take the condoms off.
" Best case: Many guys have been using this strategy for years (including me), and it appears to work for those who follow all the steps.
" No guarantees: If you do allow 'playing,' remember that condoms protect better against HIV than against some other STDs that are easier to transmit. Also, once you're in the habit of condomless sex at home, it may be harder to stick to your pledge of protected playing outside.
PEP: Whichever safer selfie method you choose, if something goes wrong and you realize you've been exposed to HIV, there's one more option. If you get on a six-week prescription of anti-HIV medicines right away ('post-exposure'), you can often stop the virus from 'latching on.'
" Best case: Officially, you have 72 hours to start treatment, and your odds of becoming HIV+ drop by about three-quarters.
" No guarantees: Don't take the deadline too literally, and wait the whole weekend. The same studies show that the earlier you start PEP, the better the protection.
Why choose any option? Maybe you just don't consider staying HIV-free that important anymore. If and when you catch it, you'll just take a pill a day, and live forever. Well, you're not entirely wrong, but there's more to it than that.
" Best case: If you keep to your doctor's appointments and take your medicines faithfully, you can live a long life these days with HIV. Some studies predict that people can live with HIV for three or four decades, or even up to 53 years. I've never been as hopeful for my friends and community as I am these days.
" No guarantees: HIV treatments still cause side effects, from the unpleasant and common ones (diarrhea, fatigue, sleeplessness) to the silent bodily changes that can add up over time to cause other serious health problems in some people to trigger cardiac events, kidney failure, liver failure, and bone fractures. Then there's our community's dirty little secret of stigma: some guys still act as if HIV makes you sexually radioactive. If you're HIV-negative now, life's probably easier if you can stay that way.
Whichever safer option you choose, the best thing you can do is just to make a choice. Condomless sex is up 20% amongst Gay men over the past five years. HIV is still causing the equivalent of five 9-11s in U.S. deaths each year. Almost all new HIV infections are happening to guys who aren't following any of these strategies. So pick one, stick to it, and make a safer selfie.
© 2014 Stephen J. Fallon
Stephen Fallon is the President of Skills4, a healthcare consulting firm that provides services to CDC and HRSA funded providers, primarily Gay- or minority-based agencies and clinics. www.skills4.org
Reprinted courtesy of Stephen Fallon
125,000x reduction in HIV transmission if condom intact; low rates of condom breakage or condoms that slip off:
National Institutes of Health. Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention. [Workshop summary report] July 20, 2001.
Overall 70% reduction in HIV risk long term amongst 'consistent' condom users:
D Smith, J Herbst, X Zhang, and C Rose. Condom Efficacy by Consistency of Use among Men Who Have Sex with Men: US. 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013). Atlanta, March 3-6, 2013. Abstract 32.
No transmissions in PARTNER study by gay HIV+ men who were successfully treated (viral load <200) having unprotected sex with HIV- partners:
Rodger A et al. HIV transmission risk through condomless sex if HIV+ partner on suppressive ART: PARTNER study. 21st Conference on Retroviruses and Opportunistic Infections, Boston, abstract 153LB, 2014.
Monogamy not protective from HIV if not preceded by HIV testing:
Stephen J. Fallon, David W. Forrest. Unexamined Challenges to Applying the Treatment as Prevention Model Among Men Who Have Sex With Men in the United States: A Community Public Health Perspective AIDS and Behavior. 2012;16(7):1739-1742.
Gay men can become infected by primary partners, but longer relationships, and monogamy seem to rule out risk:
Patrick S. Sullivan, Laura Salazar, Susan Buchbinder and Travis H. Sanchez. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities AIDS 2009 Jun 1;23(9):1153-62.
Long life expectancy potential for PLWH today:
van Sighem Gras L, et al, and ATHENA Natl Observational Cohort Study. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. 17th CROI. February 16-19, 2010. San Francisco. Abstract 526.
Lohse N, et al. 'Survival of Persons with and without HIV Infection in Denmark, 1995-2005.' Annals of Internal Medicine 16 January 2007, 146;2: 87-95.
VD Lima, RS Hogg, PR Harrigan, et al. 'Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy.' AIDS 21(6): 685-692. March 30, 2007.
Lewden C, et al. HIV-infected adults with CD4 cell count above 500/mm3 on long term combination antiretroviral therapy reach same mortality rates as the general population. JAIDS 2007;46(1):72-7.
Post-Exposure Prophylaxis efficacy:
CDC. Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States. Morbidity and Mortality Weekly Report. January 21, 2005 / 54(RR02);1-20.
Roland ME et al. Seroconversion following nonoccupational postexposure prophylaxis against HIV. Clin Infect Dis 2005 Nov 15; 41:1507-13.
Gay condomless sex up 20%:
CDC. HIV Testing and Risk Behaviors Among Gay, Bisexual, and Other Men Who Have Sex with Men - United States. Morbidity and Mortality Weekly Report, November 29, 2013 / 62(47); 958-962.
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