Risk reduction strategies:definitions, assumptions and

the difference between concept and practice

Martin Holt

Jeanne Ellard

Some definitions

What are risk reduction strategies?

A working definition:

Ways of having anal intercourse without condoms that are intended to reduce or limit the risk of HIV transmission

Most well-known strategies (in the literature):

Negotiated safety – agreement to have UAIR and not UAIC

Strategic positioning – HIV+/receptive, HIV-/insertive for UAI

Withdrawal – withdrawing before ejaculation during UAI

Undetectable viral load – UAI when HIV+ partner has UVL

Serosorting – UAIC with concordant partners only

Some assumptions

Risk reduction strategies are typically practices engaged in by some gay men which are subsequently recognised (& named) in research and education

Identifying strategies may be informed by qualitative research, but strategies more typically inferred from survey data

We often have to make assumptions about:

men’s intentions

how well they understand what they are doing

how ‘strategies’ are implemented in practice

And strategies are not used consistently in the field...

Conceptual variation

Concepts are not always used in the same way in the field e.g. strategic positioning

Strategic positioning defined as

Rosengarten, Race & Kippax (2000)

‘Folk belief’ that HIV+/receptive, HIV-/insertive pattern less risky during UAI

Van de Ven et al (2002) HIV+/receptive, HIV-/insertive pattern for UAIR and UAIC

Kalichman et al (2007) HIV+/receptive, HIV-/insertive pattern for UAIR and UAIC and oral sex

Dodge, Jeffries & Sandfort (2008)

Avoiding unprotected sex and practising withdrawal (a case of not reading the literature?)

Jin et al (2009) HIV-negative men always taking the insertive position for UAI (no reference to status of partner)

Conceptual variation

Serosorting

Serosorting defined as

Suarez & Miller (2001) HIV disclosure/discussion and then UAI only with concordant partners

Truong et al (2006) Unprotected sex only with concordant partners (disclosure/discussion not specified)

Elford (2006) HIV-positive men having concordant UAI (HIV-negative men excluded)

Parsons et al (2006) Actual serosorting (HIV status is known) and perceived serosorting (status is assumed)

Xia et al (2006) Concordant UAIC and UAIR (confusing serosorting with negotiated safety)

Zablotska et al (2009) Serosorting for UAIC (as Suarez & Miller) and seroguessing (similar to Parsons et al’s perceived serosorting)

What’s in a name?

Risk reduction strategies are often given quite grand names

The names are useful shortcuts (& help researchers get published) but...

They often bear no relation to the way that gay men talk about what they do e.g. strategic positioning:‘sometimes a person who is negative will still have unprotected sex with a person who is positive as long as the person who is negative is on the top.’ (p. 2115, Sheon & Crosby, 2004)

They also give the impression of sophisticated, well thought out and effectively practised strategies (understandable, given arguments about ‘complacency’)

The gap between concept and practice

Research often presents an ideal case... which may obscure the messy reality

Take strategic positioning... the ideal case:

Partners know their own status (testing)Partners know each other’s HIV status (disclosure)Serodiscordance established/recognisedPartners want to have UAI but want to minimise HIV transmission riskPartners understand HIV+/receptive, HIV-/insertive pattern is saferPartners only engage in HIV+/receptive, HIV-/insertive pattern (& may reinforce with UVL, withdrawal)

Assumptions of the ideal case

The ideal case for risk reduction assumes that men:

know their status/are recently tested

think about type of sex they want beforehand

are comfortable disclosing

act rationally based on disclosure

are concerned about reducing HIV risk (a priority before/during sex)

know how to minimise risk (which strategy to use and when)

stick to what they planned/agreed

don’t undermine the strategy by other behaviour

use condoms/change strategy if ideal conditions not met

Messy reality

In reality men may:

not know their status/not be recently tested

not disclose HIV status, partially disclose or assume/guess

not respond effectively/positively to disclosure

act spontaneously (no planning)

not have HIV uppermost in mind

not understand ways to minimise risk

change what they planned as they go along

engage in other forms of risk practice during same occasion e.g. swap positions

The challenge

The messiness of real life has always been hidden by impressive names for risk reduction practices

Despite this, men can and do get it right consistently enough to protect themselves

Jin et al (2009) found that:

any risk reduction strategy is better than nothing, if practised consistently

negotiated safety and strategic positioning as good as not having UAI, if practised consistently

A challenge is to work out which skills need to be strengthened/changed to make effective risk reduction more likely... and without unreasonable demands

Take HIV disclosure...

Example: responding to HIV disclosure

Protected AI Unprotected AI

No disclosure 60% 40%

Incidental disclosure – not concordant

82% 18%

Incidental disclosure – concordant

29% 71%

Sero-seeking, disclosure – not concordant

n=1 n=0

Sero-seeking, disclosure – concordant

6% 94%

Total 52% 48%

HIV-positive men, last occasion of anal intercourse with casual partner,e-male 2008

Example: responding to HIV disclosure

Protected AI Unprotected AI

No disclosure 72% 28%

Incidental disclosure – not concordant

54% 46%

Incidental disclosure – concordant

55% 45%

Sero-seeking, disclosure – not concordant

n=0 n=1

Sero-seeking, disclosure – concordant

61% 39%

Total 65% 35%

HIV-negative men, last occasion of anal intercourse with casual partner,e-male 2008

HIV disclosure

Most risk reduction strategies rely on HIV disclosure, if negotiation around status is expected

From e-male, HIV-positive men seem more practiced at:

using disclosure to seek/negotiate concordant UAI

responding to disclosure and having safe sex if dis/noncordance revealed

HIV-negative men appear to:

use disclosure differently, seeking concordant partners for safe sex more often than UAI

not respond well to incidental disclosure, being more likely to have UAI than usual if dis/nonconcordance revealed

HIV disclosure

Summary:

HIV-positive men appear to use HIV disclosure more effectively for serosorting than HIV-negative men

HIV-negative men tend to have safe sex when they seek partners on the basis of HIV status... (not serosorting for UAI)

...but respond poorly to incidental HIV disclosure (just as likely to have unsafe UAI as concordant UAI)

We do not know how common rejection is as a result of disclosure

Suggests an important area to improve is HIV-negative men’s preparedness for partners’ HIV disclosure.

Summary/questions

The description of risk reduction strategies implies a lot more coherence than may really exist

Assuming coherent strategies may mask the continuing range of influences over unprotected sex

Recognising more of the messy and partial ways in which risk reduction is practised helps us to:

Remember the limits of ‘ideal’ concepts

Focus on what we asking men to do in the ideal version of events (& assess whether this is practical)

Identify practices we can encourage and strengthen (like responses to HIV disclosure) that are critical for effective risk reduction and safe sex.