NAPWA

Negotiating the complex terrain of sexual negotiation and disclosure remains a key challenge for people living with HIV/AIDS. At a time when HIV infections appear to be on the rise, it’s appropriate that we stop and take stock of our place in an epidemic that seems to be here to stay.

Sex has not been easy for a lot of HIV-positive people. Most of us have had to engage with the process of disclosure of status and safe sex negotiation; we’ve probably been rejected a few times because of our positive status and maybe wondered whether sex is really worth it. Unless you’ve managed to find yourself a relationship with another positive person (or a very understanding HIV-negative one) celibacy, maybe becoming a Buddhist monk or a nun, may not have seemed such a stupid idea.

Paula is a positive woman in her twenties. “The biggest difficulty for me,” she told me, “was about when to tell your new sexual partner. I found a lot of guys don’t have a problem with condoms when I asked them to use them. But I didn’t enjoy the sex, not knowing what they might think if they find out I’m HIV-positive. Did I tell them before we have sex or after a couple of nights together? I met a guy who was shocked when I told him before we’d had sex but he took it on board. He went and did a bit of reading up on the subject and asked his doctor about the possibility of transmission. He came back and was fine to have a sexual relationship with me and two years later, we are still together.”

The issue of disclosure is the same in some ways for positive gay men. We have all wondered when to tell a partner about our status: before we sleep with them, straight afterwards, after things are getting serious, when? Some of my friends take the brave option, like Paula, and tell them before any sex happens. They figure if the person can’t cope then, they never really will in the future.

I’m not so sure it’s as straightforward as that with all people and I find it really difficult to be so upfront with somebody I hardly know. I have had too many ugly episodes of rejection when I have done “the brave thing” and told them first. So I tread warily and hope the right time presents itself.

With much greater opportunities for casual sex, particularly for quick liaisons in sex-on-premises venues or beats, many gay men face additional difficulties around disclosure and safe sex negotiation. It can be difficult, sometimes nigh on impossible, to talk about HIV status or condom use in these fast and furious encounters — although I am not saying that there is any real excuse for people not being prepared with condoms when they go looking for sex and then using them.

There would be very few sexually active people who have not had unsafe sex at least once — no one is perfect all the time and in every situation. A report titled Touchwood, everything will be OK, released several years ago by the National Centre in HIV Social Research, found that in situations where condoms are not available positive people often try to minimise the chance of HIV transmission by taking the bottom position in anal sex even if that is not their preferred position. The report also suggested that positive people are likely to refrain from anal sex — or at least avoid ejaculating inside a partner — if their recent viral loadA measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma. counts are high.

This is a responsible approach to risk reduction by positive people although it is hardly a foolproof recipe for preventing transmission; low viral load counts do not mean the sex is safe. And many of us know of exclusive tops who have become positive in recent times.

Doctors I have talked to are also concerned about the current high rates of sexually transmissible infections (STIs[Sexually Transmissible (or Transmitted) Infection] Infections spread by the transfer of organisms from person to person during sexual contact. Also called venereal disease (VD) (an older public health term) or sexually transmitted diseases (STDs). ) such as gonorrhoea and chlamydia in gay men in many capital cities. The presence of an STI during anal sex can greatly increase the chances of passing on HIV. It is a little-known fact that chlamydia (an STI which can be present without symptoms and which people may not be aware of having) can cause anal bleeding which can significantly increase the risk of HIV infection.

The Touchwood report also suggests that there are different views between positive and negative guys around what “shared responsibility” (a concept advanced by AIDS Councils as a sharing of responsibility for safe sex between all people regardless of HIV status) really means. A significant percentage of negative guys thought it meant positive guys should always wear a condom. Some of the positive guys they interviewed thought “shared responsibility” meant taking the receptive position during unprotected sex. They also thought that taking part in sex without condoms, without status being established, is consensual and therefore a sharing of responsibility.

I have some doubts about how widely shared these views are as those of us who were bombarded by AIDS Council campaigns on this concept can hardly have forgotten them that quickly. Of course some younger people may not been exposed to them. I have had some challenging conversations with positive guys of late though, about this topic. Here is an example of a conversation I had with a positive guy, whom we’ll call Nigel, which went something like this:

Nigel: If a guy comes to me wanting to fuck me without a condom, I figure he’s made a choice in his head. He must know that I could be positive, so he’s either positive himself or he’s prepared to take the risk.

David: But he doesn’t know your status. Do you think you owe him that information?

Nigel: It’s ridiculous to even talk about telling someone your status in a backroom. It’s not only going to destroy the moment sexually, people are just not prepared to break the silence in those spaces to share any information.

David: You can communicate though: you can give him a condom if he wants to top or roll one on yourself. You could refuse to have penetrative sex.

Nigel: I don’t think I should have to take the sole responsibility for the other person in this situation. Each person is in charge of their body and makes their own choices and their own mistakes. I’m not responsible for their conscience.

Therein lies a major ethical dilemma for positive guys. I know many share Nigel’s view on this, particularly around the other individual having already made a choice to have unsafe sex by not introducing a condom into the scenario. There are many people who make assumptions about status based on this behaviour and just “go with the flow.”

“There are many people who make assumptions about status and just go with the flow.”

I wonder about people’s consciences after this has all happened. I doubt if Nigel really thinks his perspective is totally OK and that he would be so happy with it if he learned that someone was infected after having sex with him. Of course in these situations you are unlikely to see the individual again, you probably didn’t get a good look at him in the dark room and the chance of that reality ever slapping you in the face is small.

I know plenty of positive people who have major difficulties around “occasional slip-ups” in maintaining safe sex. They talk about the great pressure to have unsafe sex and wish they had more discipline to insist on a condom and not put their partner at risk. They are terrified about the possibility that they will end up with an STI and have to face the reproach of their doctor who will then make the assumption they have been having loads of unsafe sex. I’m told there is almost a “black market” in ciprofloxacin (an antibiotic used to treat gonorrhoea) in some places so that individuals will not have to front their doctors with the fact that they have an STD.

Some positive guys worry that contact tracers from the health department will arrive at their door and give them the “third degree” for having unsafe sex with a negative guy who reports them. Others have told me that they fear talking to counsellors about their behaviour for fear they will report them to the contact tracers. Whether these fears are rational or not, they feel quite trapped and that they have nowhere to go.

So what can be done to alleviate their fears? Clearly AIDS Councils and other agencies who counsel positive people need to make it clear that they will not report individuals who are genuinely trying to do the right thing and not spread HIV. They need to know that their concerns will be listened to in an understanding and non-judgmental way. In my interview with contact tracers in the last issue of Positive Living I was heartened to hear the Melbourne contact tracers state that they do not take a “police-like” attitude to the work they do and are not interested in pursuing those who have had the occasional “slip-up” in their safe sex behaviour.

More to the point though, positive people need safe spaces to talk to other positive people about their anxieties around unsafe sex. I think initiatives like the PLWHA NSW “Barebacking and Nail-Biting” forum held in the lead up to Mardi Gras this year are a great way to thrash these issues out. More PLWHA groups could follow this path — hopefully making the events as entertaining as possible (like using a compere like Vanessa Wagner) to help to bring crowds who might not normally attend such a function. Positive peer support groups need to be looking at these pressures as I hope many already are.

I know some positive guys are solving their anxieties on this issue by only having sex with other positive guys; stating their preferences for “HIV+ only” in personals pages or, for the more adventurous, going onto bareback sites or attending positive-only sex parties. For some this is about the joys of condom-less sex and maybe finding a long-term positive partner but for others it is getting away from the hassles of having to get your negative sex partner to wear a condom for his own sake. As increasing transmission figures (in some states) and many positive people can attest, this is proving to be an increasingly difficult task.

David Menadue is the President of NAPWA; the views expressed in this article are his own and do not necessarily represent the views of NAPWA.