By PAIGE PARKER, The Oregonian
The Oregonian, Saturday, October 13, 2007 — More than two decades after the first warnings that condoms prevent the spread of HIV, an increasing number of gay men are instead betting their lives on vague conversations and verbal assurances from their partner before having unprotected sex.
The Centers for Disease Control and Prevention reports that nationally, the number of HIV and AIDS diagnoses among men who have sex with men increased 11 percent from 2001 to 2005. Researchers in Oregon and elsewhere say one reason could be that men attempt to sort themselves. HIV-positive men limit their partners to others with HIV; those without the disease avoid sex with those who have it. But some experts say it's more of a guessing game because too few men directly ask or answer, "Do you have HIV?"
"People make a lot of assumptions," says Michael Anderson-Nathe, prevention services manager for Cascade AIDS Project. "They say, 'Well, if he didn't ask me to use a condom, he must be negative.' Or, 'If he was positive, he would have said something.' "
The rate of new infections among gay men in Oregon remains flat at 70 percent. However, last month, an Oregon State University behavioral researcher reported an increasing reliance on "serosorting" and other risky behavior in San Francisco, along with a 40 percent increase in reported HIV infection.
The researcher, Joe Catania, says there's reason to assume that the same pattern could be unfolding in other major cities, including Portland. In a 2002 survey, Multnomah County Health Department workers found that 1 in 10 men who were not in a monogamous relationship had unprotected sex with a man of different or unknown HIV status inthe past year, considered the riskiest sexual behavior.
Serosorting is a shaky prevention strategy for healthy men, not so much because men lie to their sexual partners — most don't, especially not those who are HIV positive. Instead, HIV prevention specialists say, men afraid of rejection or who are embarrassed to talk about sex dance around the topic, behavior also seen in heterosexuals. Gay and bisexual men might drop hints about taking medication, for example, and hope their partner understands they mean HIV medications.
Some men, aware that anal sex is riskiest for the receptive partner, assume it's that person's responsibility to ask for a condom. Other men who say they're negative cite outdated HIV test results. And 1 in 4 people infected with HIV doesn't know it.
Complicating prevention efforts, new drugs extend the lives of HIV patients, allowing them to potentially spread the disease to more partners. And, as with heterosexuals, alcohol and drug use can cloud the judgment and communication skills of the most prevention-minded.
"If it was working for HIV-negative men who have sex with men to ask, 'Are you negative,' and hear 'Yes,'… then they wouldn't be testing positive a year later," says Kim Toevs, a health educator in the county health department's STD prevention and treatment program.
OSU's Catania found that 18- to 29-year-olds — men who missed the early days of the AIDS epidemic — were most likely to have unprotected sex with someone of the same HIV status, though the practice was on the increase with all age groups.
"The bottom line is, most gay men do not want to get infected," Catania says. "It's like economics, where most people make rational decisions, but some don't. It's also true with sex, where there are enough people making irrational decisions to keep an epidemic going."
Andrew Tweedie was a 28-year-old professional living in Denver when he learned his boyfriend had given him HIV. The two never discussed HIV before having unprotected sex, and Tweedie's partner didn't know he was infected.
It was 1998. "By then, the panic had gone away. AIDS wasn't in the forefront of our thoughts," Tweedie now of Portland says.
AIDS has cast a shadow for 26 years, and it's difficult to tell whether some men are less afraid of it today. The Centers for Disease Control and Prevention says some men's optimism about the effectiveness of HIV treatments might make them more willing to have unprotected sex.
"It used to be a great predictor of condom use whether you knew somebody who has AIDS," Catania says. Now, "Very few people are showing symptoms. They don't have lesions on their face. They're not gaunt. That kind of visible proof really makes people stop and think and change their behavior."
Then again, Catania adds, "The human brain is great at suppressing negative information."
Tweedie wishes antiretroviral ads depicting vigorous men climbing mountains would instead show the side effects.
"I hear people say it's the new diabetes," he says, "but it's not."
Ten years after his diagnosis, Tweedie is adamant that everyone must know every prospective partner's HIV status, but sticking to that principle has meant facing rejection.
Whenever he starts to feel attracted to a man, Tweedie tells him, "I'm HIV positive. If that's a deal-breaker, I understand.' When you're standing in a bar and you're connecting with someone and having a good time, the last thing you want to do is, errrrch, put on the breaks. But it has to happen."
According to the CDC, like Tweedie, many people change their behavior after learning they're infected. While they don't endorse serosorting as an effective prevention tool, health workers say they must teach men how to talk about HIV. Behavioral change usually happens in stages.
Portlander Sergio Perez was once diligent about getting annual HIV tests — until he started shooting meth. The drug wiped away his sexual inhibitions, and the Internet made casual hookups easy. He went two years between HIV tests, a time when he had many partners. Cascade AIDS Project recommends men who have sex with men get tested every three months.
"I was a prude about sex until my mid- to late-30s, and then I figured I was missing out," says Perez, now 44 and sober. "I just really had lost all self-worth. I went gung-ho into the drug thing because I thought it was fun. And I ended up where I am."
Diagnosed with HIV a year ago, Perez immediately posted his status on the Internet, along with an apology. He continues to have unprotected sex, but only with HIV-positive partners.
Paul Homan, a 29-year-old diagnosed four years ago, says he also posts his status on his Internet profiles, "just because I don't like dealing with that uncomfortable conversation." If he meets a man on the Internet, he doesn't bring up the subject again in person.
Homan of Portland says it has been several months since he had sex with an HIV-negative man. He uses condoms. "It amazes me how kind of blindly trusting people can be, and these aren't really trusting people in other areas of their life," he says.
Anderson-Nathe of the Cascade AIDS Project says everyone, including those who don't have the disease, is responsible for disclosing their HIV status to sex partners.
In December, Cascade began offering CDC-funded classes designed to teach HIV-positive men how to tell friends, family and others they're infected. The goal is to get men comfortable telling their sexual partners, says Josh Ferrer, the program's coordinator.
So far, 52 men have participated. Cascade AIDS will survey them about their behavior after the classes and evaluate the program's effectiveness. The next session begins Oct. 22.
Though he's told many people since his diagnosis, Tweedie attended the classes to learn new skills.
"Every time you tell," he says, "it gets a little bit easier."
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