Barebacking: A Harm Reduction Approach Paul Quick, M.D. Tom Waddell Health Center San Francisco Department of Public Health

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.

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

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.

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

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 Jan 1;38(1):82-6.)

HIVNET data 3257 MSMs, 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%)

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.

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

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?”

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

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).

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

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: ) 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

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