A pair of gay cowboys promoting condom use were the surprise hit of this year’s AIDS Impact Conference. DAVID MENADUE reports from Milan.
Two horseback riders dressed in cowboy gear, one Asian and one African American, were the pin-up boys for a very successful Canadian HIV prevention campaign, the audience was told at the Sixth International AIDS Impact Conference, held in Milan in July.
Using the slogan “Welcome to Condom Country,” this controversial campaign of billboard posters and television advertisements incurred the wrath of cigarette producer Phillip Morris for its unashamed take-off of their Marlboro ads, and shook up middle-class Canada with its homoerotic cross-cultural message, but succeeded in getting noticed by more than 80 percent of 5000 gay men surveyed in Ontario.
This campaign, by the AIDS Committee of Toronto, was one of the few stand-out success stories in a social research conference which focused heavily on the question of why gay men (in particular) are using condoms in decreasing numbers and why transmissions are rising in the predominantly Western countries represented at the meeting.
Ted Myers from the University of Toronto HIV Prevention Unit, reporting on the Condom Country campaign, said that after viewing the campaign and taking in its messages (HIV rates are on the rise and you should use condoms) 41.2 percent of respondents said that they were more likely to practice safer sex. Whether they did or not is a moot point, but there would be few other condom campaigns around which could claim to have had that penetration of the audience and supposed change of attitude. Maybe the take-home message for those HIV agencies struggling to make an impact with their message is to do something controversial and in-your-face (and risk the wrath of your funders!)
Not surprisingly, condom use was a major topic at this conference. We heard from Barry Adam, of the University of Windsor in Canada, that difficulty in using condoms is an increasing issue, particularly for older HIV-positive men. This is related to erectile difficulties caused by use of antivirals and low self esteem caused by depression and changes in body image due to lipodystrophy. Adams spoke of men having insertive anal sex and delaying putting on condoms until ejaculation to try to cope with this problem. We need to look at the use of Viagra and other erection-enhancing techniques to help these men to be able to use condoms, he argued. Interestingly, Adams claims that younger people are more likely to have a positive association with condoms.
A challenge was thrown down to AIDS educators by Nigel Dickson from the University of Otago in New Zealand. His sample of 812 participants compared three age groups — under 30, 30 to 39, and 40 years and older — and found that the younger group were much more likely to like condoms, more likely to test and to say that their sex was not as safe as they might like it to be than the older age groups. Dickson’s point to the audience was that AIDS educators are often people in older age groups who have already gone through extensive condom prevention campaigns. “We have to remind ourselves that there are new generations of young gay men arriving on the scene all the time who have not received these messages like us,” he said.
Dickson feels that it is fine to say “Condoms every time” to these young people and that risk reduction messages could be confusing to them. This provoked a lively debate at question time, with one woman saying: “Young people who have never had sex before will think having it with condoms is pretty good, no matter what. We should remember this.” Food for thought, but of course the other side of the debate is about what can be done with those who are tired of condoms and require new messages and strategies.
The “risk-reductionists” — educators who believe that you have to work with the more risky behaviours which some gay men have chosen to take (some of the time) and try to improve them — copped some criticism for supposedly abandoning the mantra of condoms every time.
But analysing the risks showed some interesting results. Susan Keine from the University of Connecticut in the US reported that 50 percent of people in discordant relationships in her cohort of MSMs reported not using condoms some of the time. But June Crawford, from Australia’s National Centre in HIV Social Research, reporting on the HIM study of negative men, said that of the 20 percent of her sample who did have unprotected sex, most of them did not ejaculate, had only one or two partners in a six-month period and were aware of risk modifying practices (such as taking the top position if you were negative or passive role if you were positive).
In other words even the risk-takers were, in many cases, taking steps to minimise their exposure to HIV.
Graham Hart, from the University of Glasgow, gave an interesting summary of why he thought new infections are occurring. “While I’m not saying to write the obituary for the condom yet — they do work — there are significant changes happening in some gay men’s sexual cultures in many cities around the world. There are sexual micro-cultures developing where there is less sense of a gay community as we have come to know it and more sense that an individual has to look after their own risk as their own responsibility,” he said.
This is the ethos of barebacking clubs and the world of the internet for some. Hart suggested that a major way forward is to look at meeting the sexual health needs of positive men, including their counselling needs, as a part of the prevention effort. He singled out the presentation given by Antony Nicholas from PLWHA NSW that looked at a sexual health and HIV prevention campaign for positive people in NSW. This is the type of innovation, involving positive people in prevention, that other agencies should follow, said Hart.
Quite a few researchers looked at the internet and barebacking sites to see if they could find answers for the increases. Jonathan Elford from the City University in London compared a cohort of people interviewed on the internet with a paper questionnaire delivered to gay male attendees at nine gyms. He found the internet cohort were younger, had lower education qualifications, were less likely to describe themselves as gay, were less likely to have tested — and were more likely to have had unprotected anal sex.
Elford feels that education campaigns on the internet are a necessity; Udi Davidovich from the Amsterdam Municipal Health Service has tried just that. Davidovich had been concerned that figures had shown 67 percent of new infections occurred in his city in men in new relationships. He had two cohorts of couples in new relationships (under three months), one on the internet, and a control group of non-internet users. After a concerted campaign around negotiated safety he reported an improved willingness on the part of the internet group to be safer with their partners.
We also had research on barebacking in New York City (Bimbi et al) that showed 12 percent of respondents — 9 percent of the negative men and 33 percent of the positive men — described themselves as barebackers. Bimbi went on to talk about how barebackers had a higher score in Kalichman’s measure of Sexual Compulsivity (whatever that is!)
The issue of sexual compulsiveness was also raised by Jeffrey Parsons from Mount Sinai in the US. He spoke of self-help groups being set up in the States which used a “twelve-step” model, like Alcoholics Anonymous, to treat people who just couldn’t stop thinking about sex.
What makes you a sexual compulsive? Forty-five orgasms a week, more than 15 hours a week on internet sex sites, excessive time spent fantasising about sex (and interfering with your work, for instance) were some of the symptoms Parsons described. He asked me later on if we had such groups in Australia, which I thought we didn’t — our view of someone who had too much sex was anyone who was having more than you, I said jokingly. But he was deadly serious, arguing that perhaps we should look at this problem more closely in Australia.
The conference also looked at sexual dysfunction amongst positive people. Mandalia Sundhiya from London’s Chelsea Hospital reported that 33 percent of positive men had severe/moderate erectile dysfunction. Of those, more were likely to report problems after their HIV diagnosis than after they had started taking antivirals, suggesting the psychological issues associated with diagnosis are important contributing factors. Among men who took antivirals, the likelihood of problems increased if they had taken at least three protease inhibitors, if they had peripheral neuropathy, or if they were older. She found no significant correlations with IDU status, smoking, testosterone levels or blood glucose levels.
Among positive women, Robert Colebunders from Chelsea Hospital reported similar findings in relation to sexual desire. Positive women were more likely to lose interest in sex related to their diagnosis than to taking antivirals. In fact taking an NNRTI-containing regimen seemed to increase some women’s satisfaction with their sex lives, if it resulted in improved general health (Rita Murri from Catholic University in Rome).
Italy in summer is a lovely place to have an AIDS Conference but it is not such a great place to be a positive person on benefits, it seems. Italian PLWHAs have to wait up to two years to qualify for disability benefits, and even then they only receive about 200 euros (A$345) a month. Many have to rely on friends and families to survive, although at least their health system provides them with treatments. Italy has the third highest incidence of HIV/AIDS in Europe, its epidemic having been largely fuelled by injecting drug use in the early days. With needle and syringe exchanges, this is less of a problem now and transmission through sex (both heterosexual and homosexual) is a major issue. With the dominating influence of the Roman Catholic Church and the relatively closeted nature of the Italian gay scene, I can’t imagine a Condom Country campaign like the one in Toronto will ever hit the billboards there!
*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.
