Barebacking: A Harm Reduction Approach

1. Barebacking: A Harm Reduction Approach Paul Quick, M.D. Tom Waddell Health Center San Francisco Department of Public Health paul.quick@sfdph.org

2. Why “Harm reduction”? • The principles of harm reduction stem from the ethical obligations of physicians and other caregivers, namely • The duty to respect autonomy, and • The duty of beneficence. • Our goal is to help patients improve and protect health.

3. Is HIV incidence falling? • San Francisco incidence appears to have fallen from 2.2-2.5% to 1.2% over 3-6 years MMWR. June 24, 2005 / 54(24);597-601

4. Harm reduction in HIV+ MSM • Reduced numbers of UIA with HIV- partners • Serosorting, Strategic positioning, Pulling out • The HIV/STD paradox • Gay press reports: large decline in expected new cases based on mathematical modeling; EtOH more associated with UIA than meth.

5. Harm reduction in HIV- MSM • Negotiated safety • Decrease in URA with positive/unkown partners • BUT, words of caution…

6. Negotiated safety can fail • Of 38 men in negotiated safety relationships, 22% violated agreement in prior 3 mos; 18% had STI in prior year • But 61% adhered • (Guzman R, Colfax GN, et al.J Acquir Immune Defic Syndr. 2005 Jan 1;38(1):82-6.)

7. HIVNET data • 3257 MSMs, 1995-1997 • Independent risk factors for seroconversion: • Increased # reported neg partners (AOR 1.14, PAR 28%) • URA, partner status unknown (AOR 2.7, PAR 15%) • URA, partner HIV+ (AOR 3.4, PAR 12%) • PRA, partner HIV+ (AOR 2.2, PAR 7%) • Receptive oral with ejaculation, partner HIV+(AOR 3.8, PAR 7%)

8. The Great Oral Sex Controversy • Hecht et al reported at CROI VII in 2000 that HIV seroconversion was attributed to “oral sex” in 8 of 122 incident cases of HIV. • All cases involved ejaculation, but this was not reported in the popular press. • Anecdotally, gay men reported that they were “giving up” on safer sex. “If oral sex is unsafe, why bother?” • In fact, this study confirmed 15+ years of advice: oral sex without ejaculation is low risk, with ejaculation is higher risk.

9. From Science to Response--what MSMs can do • Use a condom every time for every encounter (the ultimate harm reduction) • Serosort • Get tested. Talk about status before you bring him home. Post it in profiles online. • Ration anal intercourse and barebacking • Strategically position • Pull out--for anal and oral

10. From Science to Response--what MSMs can do • Know the signs of acute HIV infection; see a doctor right away if you have them • Get tested for STDs every 3-6 mos. • Consider HAART if positive. • Ask “Am I as safe as I want to be?”

11. From Science to Response--what medical providers can do • Ask “Are you as safe as you want to be?” • See patients every 3 months • GC/CT testing of rectum and urethra, GC of throat, RPR q year (more if increased SA) • Review sx of Acute retroviral syndrome

12. From Science to Response--what medical providers can do • Viral load and antibody test for suspected ARS. • Screen and immunize for hep A and B, screen for hep C. • Screen and treat mental illness, with caution and counseling (improvement from depression or induction of mania might increase risky sex).

13. From Science to Response--what medical providers can do • Evaluate for domestic violence • Refer for vocational rehab or benefits advocacy as appropriate • Ask, “what do you like about drinking/using crack/speed/heroin/poppers/Ecstasy,etc. • Opiate addiction therapy

14. Future directions • Need FDA approval of rectal/pharyngeal NAAT testing for GC/CT • Improve case finding of early HIV infection. • Early HIV infection occurs in clusters (Pao D et al.. AIDS. 2005;19:85-90.) • Addition of batched viral load testing to antibody screening is cost-effective • Will we need to move back away from rapid and anonymous testing? • Clinical trials of acyclovir, tenofovir for primary prevention • Rectal/oral virucides

15. Future directions • Clinical trials of acyclovir, tenofovir for primary prevention • Rectal/oral virucides • Stimulant replacement/blocking therapy