BHIVA: Recent gay seroconverters explain why they became HIV-infected

Gay men are extremely aware of the HIV risks associated with receptive unprotected anal intercourse (UAI) but still do not practice safer sex for a multitude of psychosocial reasons, according to qualitative data from the INSIGHT study presented to the Twelfth Annual Conference of the British HIV Association (BHIVA) in Brighton on March 31^st. These require a diverse portfolio of interventions which include: providing more information on the risks of insertive UAI; changing perceptions that HIV infection only happens to promiscuous men; and addressing issues of depression and low self-esteem.

Although heterosexuals who acquired their infection outside of the United Kingdom are now being diagnosed with HIV more often than gay and bisexual men, it is the latter who are most at risk of contracting HIV in the UK, accounting for at least 80% of all new UK-acquired HIV. The latest figures for 2005 suggest that up to 2500 gay and bisexual men were diagnosed with HIV for the first time, the highest number since records began, although this may represent an increase in HIV testing as well as incidence.

Data from the most recent London gay men's sex survey suggest that the number of gay men practising UAI with a casual partner has remained steady since 2002, although more men are still reporting UAI now than in 1998, when the survey began. Other data suggest, however, that the greatest risk of HIV acquisition is not with casual partners, but within relationships, or with regular partners.

INSIGHT is a collaborative research project funded by the Medical Research Council investigating risk factors for HIV seroconversion in gay and bisexual men who undergo HIV testing at sexual health clinics in England and Wales. There are three parts to the study: a clinic-based survey; a case-control study; and a qualitative study.

Gillian Elam reported on the qualitative study on behalf of her colleagues at the Health Protection Agency (HPA), Sigma Research and London's Royal Free and University College Medical School. This comprised in-depth interviews with 48 participants in the case-control study from seven sexual health clinics in London, Brighton and Manchester and explored the social, behavioural and emotional contexts of seroconversion in order to identify factors contributing to gay men's sexual health and lifestyles. Data presented at BHIVA focused on the 26 cases that took part in the qualitative study.

HIV happens to other people

A common theme was that the type of UAI that the recent seroconverters practised was low risk. This may have been because it was insertive rather than receptive; gentle rather than hard; well-lubricated rather than not; or too brief, or infrequent to pose a risk.

Another factor informing perceptions of risk was that the men felt that they were somehow removed from HIV and not the type of person to acquire the virus: they were not 'promiscuous' and didn't use drugs, or were not part of the gay scene. “It shouldn't have really been me," said one recent seroconverter. "My friends go out on the scene a lot, they're quite frivolous sexually, have lots of sexual partners, lots of proper anal sex and different partners and take drugs … I'm the most reserved out of the people I know.”

Consequently, when looking for casual partners, young, inexperienced men, who were not on the gay scene were not regarded as an HIV risk, and the same often applied to well-groomed and fit men.

A desire for love, trust and intimacy greater than fear of HIV

The INSIGHT researchers found that decisions not to use condoms both within relationships and with casual encounters were informed by a perception that condoms were a barrier to intimacy, trust and spontaneity, "it just feels like a long way from each other," said one of the men interviewed.

This was true both within relationships, and also for the men looking for love during casual encounters. Some men expressed the idea that not using condoms meant they trusted their casual partner, and that this represented the hope that this casual encounter would lead to love.

In serodiscordant relationships, the researchers found that the HIV-negative partner could find that condom use within the relationship represented a lack of intimacy. Some HIV-negative men chose to have UAI with their HIV-positive partner in an attempt to redress that imbalance.

HIV is not the worse thing that can happen to me

Although many studies have examined so-called highly active antiretroviral therapy (HAART) optimism - the concept that lack of visible AIDS deaths and the impact of highly active antiretroviral therapy on life-expectancy has resulted in the notion that HIV is a chronic, manageable condition and not to be feared - it was thought that this phenomen was happening more with younger gay men.

However, the INSIGHT researchers found that older men perceived HIV to be less of threat not only due to HAART optimism, but also because of ambivalent feelings about ageing. One recent seroconverter placed the threat of HIV into the context of the threat of cardiovascular and Alzheimer's disease in an ageing population. “It (UAI) felt better and in the end you think life is so much easier if you just go with it…It doesn't mean I am going to die tomorrow…I'm 43, so I might not die until I'm 60, so do I really want to die with dementia, incontinence, stroke, heart disease and all the rest of it.”

Repeated negative HIV tests confirm sense of immunity

The investigators found that recent seroconverters did not always expect to become HIV-positive despite engaging in high-risk sex. Prior HIV-negative test results were regarded as evidence of immunity from HIV infection and/or that their harm-reduction practises (like being the insertive rather than receptive partner during UAI) were working.

Suggested interventions

The INSIGHT researchers concluded by suggesting that gay men's HIV prevention work needs to target diverse needs.

These include addressing the following:

• The perception that insertive UAI is not a risk.
• The feeling that condom use does not remove anxiety about HIV transmission.
• The perception among older men that HIV has a low impact on health.
• The perception that prior HIV-negative tests suggest immunity from HIV.
• The impact of depression, bereavement and low self-esteem on efficacy of harm-reduction practises.

Depression, low self-esteem, lack of control, often lead to unplanned UAI

When the INSIGHT researchers talked to the recent seroconverters who wanted to practise safer sex but didn't, it was their loss of control due to low self-esteem or depression - often leading to alcohol or drug use that affected their ability to make safer sex choices - that was the dominant theme. “It [depression] really influenced my sexual behaviour," said one man. "You go out, you want to be abused almost… you might as well let anybody do what they want to do to you.”