HIV risk reduction strategies and practices among gay men: is our understanding of them in disarray?
Issues: The rates of unprotected anal intercourse and HIV incidence among gay men are increasing worldwide. A review of risk reduction practices adopted by gay men is timely.
Description: Gay men’s prevention of HIV transmission has not been limited to condom use. A variety of strategies have been adopted. In regular relationships, regular testing, commitment to monogamy, reduction in number of partners, negotiated safety (a form of serosorting), different types of agreements, strategic positioning, and withdrawal before ejaculation have been described. Strategies such as reduction in number of partners, regular testing, serosorting, strategic positioning and withdrawal have been used in casual encounters as well. Often, a combination of strategies has been described depending on the context of the sexual encounter. Changes in risk reduction are also related to men’s changing perceptions of risk. A growing concern is the role of HIV testing and disclosure in risk reduction strategies.
Lessons learned: Although there is a body of literature about HIV-risk reduction among gay men, this review highlights confusion regarding the discrepancy between risk reduction strategies and observed patterns of practice. Changing perceptions of HIV risk and the utility of HIV disclosure have been under scrutiny. Seroguessing rather than explicit disclosure and the reliability of explicit disclosure are growing concerns. Risk reduction practices built on inadequate foundations cannot be effective and may indeed be counterproductive. Growing HIV incidence worldwide may be an evidence that some of these strategies are in disarray.
Next steps: Current ineffectiveness of HIV prevention to cope with growing HIV rates is rooted in our lagging understanding of the changing perceptions of risk and of the resulting changes in the application of risk reduction in practice. This review is important for HIV prevention.
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