Until now safe sex has been synonymous with condom use. But condoms, it seems, are failing. Or rather, condom use is failing. So the AIDS prevention industry is gearing up for a new approach, in the process redefining protected sex.
Condoms are not popular. Condoms feel unnatural. People are tempted – especially when their guard is lowered by lust, alcohol or drugs – to take the risks of unprotected sex.
The prevention industry has tried to address this by setting out conditions under which unprotected sex might be negotiated between partners. If you know each others HIV status, the story goes, are ‘seroconcordant’ – both HIV negative, or both positive – and have a monogamous relationship of absolute trust, then the risks are small.
That still leaves a lot of people for whom condoms remain the only safe bet. If you are not a monogamous couple, even if you’re both pos, you still need to use condoms when you’re having sex with other people. Not just to avoid passing on HIV, but also to avoid picking up some other sexual disease like syphilis or gonorrhoea. And if you are ‘serodiscordant’ – one pos, one neg – condoms are your only safe option. In addition, HIV positive people are often reluctant to disclose their status, especially to casual partners, for fear of rejection.
Unfortunately, complex – or as the industry likes to say, ‘nuanced’ – safe sex messages are apt to get ignored, or garbled, or misinterpreted. People often hear only the part they want to hear, or interpret the message in ways that suit their desires rather than the facts. Whatever the reasons, condom use is falling, unprotected sex is on the rise, and governments are worried. A new strategy, and a new definition of safe sex, is required.
The TAXI-KAB study questionnaire makes it plain changes are on the way, and what those changes might be:
The TAXI-KAB Study is designed to measure the Knowledge, Attitudes, and Beliefs (KAB) of gay men in Australia when they Think About eXposure to Infection (TAXI) to HIV. Gay men are going to experience many changes in the way healthcare is presented to them in the next few months. We are seeking information from these men in order to inform the progress of the “Treatments as Prevention” revolution that is occurring in Australian health care, right now.
Working through the questionnaire the scope of the coming changes becomes clear. We are about to see the AIDS Councils and their equivalents embrace two new tools in the fight to stop more people becoming infected.
The first is the use of antiretroviral drugs, not to control HIV in those who are already infected, but to prevent people becoming infected in the first place.
There are two ways to do this: by taking the drugs for a period of time BEFORE you have unprotected sex (PReP – Pre-Exposure Prophylaxis) or AFTER (PeP – Post Exposure Prophylaxis).
This immediately raises a lot of questions. For how long before sex must you take the drugs in order for them to give you adequate protection? And/or for how long after? Does this not imply that sexually active men should be on anti-retrovirals more or less continuously?
We have all heard that it’s very important for people on anti-retrovirals to stick strictly to their treatment regimes. Just how strictly will people who are not sick adhere to a preventative regime? And what happens if they are careless? Could casual anti-retroviral use create resistant strains of HIV?
And who will pay for the drugs? WIll they be free, or subsidised, or full-price? What happens if someone decides they can’t afford a pack this week, and goes ahead with that big weekend trusting to the residual protection from their previous intake?
What about the long-term health impacts of the drugs themselves? What are they, and who will pay for their treatment? Whoever pays, this could be an absolute bonanza for drug companies: to what extent are they driving this change? We all know how unscrupulous they can be, and how corrupting their influence is on some doctors.
I will watch developments with interest, but I can’t say I like the idea – or the cost – of medicating people who are not actually ill. On the other hand, if we do nothing, will the epidemic – and the cost of treating it – spiral out of control? There is no simple answer.
The other change on the horizon is faster testing. At this point no rapid testing methods are used in Australia. Everyone agrees that it is vital to know your HIV status. Overseas, rapid testing and home testing have been introduced, and the pressure is on to bring them to Australia, too. These reduce the agony of waiting for results, but also reduce the opportunity for counselling and support.
In the US, six rapid HIV tests with a claimed accuracy greater than 99% have been approved by the Food and Drug Administration. Results come back in about 20 minutes. Positive results must be confirmed by another test, which may take anything from a few days to a few weeks. There have been concerns about false positives on some types of tests.
Only one home testing kit, the Home Access HIV-1 Test System, has been approved. Users collect finger prick samples at home, send them to a laboratory for testing and get the results back in about a week. Other home tests exist which claim to give an answer in ten minutes at home, but their reliability is questioned.
[There’s an update on home testing here on the Advocate.]
Most rapid tests, which are also used in the EU and UK, only test for HIV antibodies, which are generally reckoned to be produced between 2-8 weeks after exposure. The tests currently in use in Australia can detect an infection sooner as they also detect an antigen produced in the early stages of HIV infection.
Given that politics will inevitably make its own demands on the decision-makers, I expect any new HIV prevention messages will continue to advocate condoms alongside whatever new methods are approved. The AIDS Councils are in for an interesting time. Watch this space.
The TAXI-KAB study was conducted in partnership with state AIDS Councils of NSW and Victoria, NAPWA (National Association of People Living with AIDS), ARCSHS (Australian Research Centre in Sex, Health and Society) and in conjunction with AFAO (Australian Federation of AIDS Organisations), Positive Life NSW and National Centre in HIV Social Research (NCHSR). This study is led and funded by the HIV Epidemiology and Prevention Program at the Kirby Institute.