The Resonance Project

What we heard from gay men and their service providers about: Risk Calculation 

What we heard from gay men and their service providers about:

Participants described how they formulated personal strategies for HIV risk reduction that worked for them, based on balancing their knowledge and fears/anxieties. In general, HIV-positive men felt an extra burden of responsibility for risk reduction. How gay men understood risk, and how service providers helped gay men to assess their risk, depended on the nature of the relationship and the type of sexual encounter. Service providers had the impression that gay men sought reassurance, often after a sexual encounter.

Personal rules and strategies for managing risk

Several gay men described the rules and strategies they had devised for managing risk, and how they made an informed choice about the level of risk they were willing to take according to circumstances. Some referred to the influence of their closest peers within their social circle in terms of setting the norms for risk tolerance. Some participants pointed out that there was risk in any sexual activity, that some of that risk was due to chance, and that there was a great deal of subjectivity in how individuals perceived and mitigated  risk. As part of their risk calculations, gay men often compared  HIV prevention strategies (condoms, serosorting, seropositioning, PrEP, undetectability) to each other, weighing the pros and cons and relative efficacy of those strategies. Some described the challenge and frustration of having so many mixed messages about HIV risk.

I don’t think [if someone was on PrEP] would change my opinion either way. I’d still insist on playing safely whether they were on it or not. It would be non-data to me. Neg, 35-49, VAN2

As a young man…I’d get testing on a regular basis. The tests get back a negative result and then I kind of put everything that I’ve done into the category: ‘well that was reasonably safe’ and carry on. Neg, 50+, VAN2

Discourse: analogies, code words and numbers

Several types of discourse circulated in the focus groups: 1) making sense of various prevention strategies by comparing HIV risk to everyday experiences of risk such as driving a car, getting on a plane, stepping out of the house or winning the lottery; 2) deciphering, critiquing or defining code words commonly used in hookup sites and apps, such as “clean,” “DDF”, “undetectable”, “PNP”, the “+” symbol, and “UB2”; and, 3) discussing risk and effectiveness of various prevention strategies in terms of numbers and percentages.

A couple years back growing up on my little island, I used Craigslist and I didn’t know the internet lingo and I didn’t know the jargons that they used. So ‘undetectable’ back in my earlier days, I may have mistaken that for oh I’m on DL. No one can tell I’m gay. [group laughter] … I still don’t even know what PNP stands for. Neg, <35, TO1

Well we’re talking about acceptable risks right. I would say the risk is acceptable. If you put it in line with, for example, someone like me getting behind the wheel of a car, it’s probably far less dangerous than that. Pos, 50+, VAN2

Negotiating risk in the heat of the moment

Gay men discussed many factors at play in risk negotiation, often weighed “in the heat of the moment”: balancing emotional factors (fear and worry, desire and intimacy, horniness and impulses)  with rational decision-making, and risk calculation; negotiating whether or not sex occurs, condom use and positioning with their sex partners, based on discussions of HIV/STI status, testing patterns, and drug use; figuring out their partners’ HIV status, the awkwardness of asking the questions, and the extent to which their answers could be trusted. Some men pointed out that not everyone is on an equal playing field when it comes to HIV prevention. The ability to protect oneself and one’s partner is dependent upon factors like self-esteem, self-efficacy, sexual positioning, power dynamics, whether options truly are available, and broader structural issues like the legal context of criminalization.

I think I already know what my preference would be in the encounter; like you know big guy, I think I want him to top me. That’s probably going through my head and then it’s what’s the risk, what am I willing to tolerate in terms of risk with this guy. So that’s when the decision would be is it undetectable and bareback versus condom…I guess it is possible, but rare, that the negotiation of position comes up after the undetectable conversation. Neg, 50+, VAN2

Influence of relationship status

Several gay men and service providers described how risk management strategies and acceptable levels of risk vary based on partner type (regular or long-term; occasional; one-time/anonymous), relationship status (open/closed, dating, seroconcordant/discordant) and how  men met (online; in saunas, parks, bars). For others, their strategies remained immutable, regardless of the partner or their relationship status. Some gay men specifically addressed the risks of anonymous sex, particularly in relation to not knowing the partner’s HIV status, and the constraints around negotiating risk. According to some participants, one of the benefits of meeting through online hookup sites was that some negotiation and information sharing happened upfront (e.g., preferences re top/bottom, HIV status, viral load, etc).

But in terms of this situation, it’s the emotional bond that makes it a little bit harder to think about transmission within the relationship. Today what we both do external to the relationship, it’s almost it doesn’t matter as much, as long as we kind of protect each other. And quite frankly I like condomless sex. But with him, because of the love and the bond that we share, I can’t see myself shaking a condom. I think I would do everything I could. Pos, 35-49, TO2

Risk elasticity

Service providers noted that tolerance for risk varied by person, and that there was often a mismatch between a given level of risk and the level of worry felt by gay men. As a result, service providers described the paradox of trying to instil a greater sense of risk in some clients while trying to quell a sense of fear in others, often for the same behaviour. Service providers discussed the phenomenon of gay men having "flexible" perceptions of risk, or “stretching” their risk practices to fit an expanding repertoire of behaviours and prevention strategies.

With the presence of PEP and PrEP, gay men can stretch their risk…So in my head, are we seeing risk like a rubber band that we can stretch as far as possible until it…? SP, 35-49, CBO, TO

Bottom line, you have to be comfortable having sex with people. You have to be comfortable taking a certain amount of risk when you have sex. It’s an interesting challenge. People want absolutes… So you have to figure out how can you do this to be comfortable so that it doesn’t cause you great anxiety.’ It’s amazing because some people are taking huge risk and they seem to have no anxiety around it where there are other people that have no risk or very small risk and have huge anxiety around it. It’s really interesting to kind of deal with those two extremes. SP, 35-49, PH, VAN

Extra burden of responsibility on positive gay men

Some gay men living with HIV described the paradoxical feeling of liberation in learning of their HIV status, and realizing that they no longer had to be preoccupied with the risk of becoming HIV-positive. They also talked about serosorting for other HIV-positive men, and their strong fears around passing HIV to their partners.

I’m actually motivated now to take my medications and adhere to them because I don’t want to be anything other than undetectable because my partner is HIV-negative. I’d like to keep it that way. that’s a relationship. that’s not just sex. so i mean when negotiating sex and negotiating your relationship, it’s two totally separate things. Pos, 35-49, TO1

Seeking reassurance, after the fact

Service providers explained that they helped gay men to understand the risks associated with certain sexual practices, but that gay men often sought this advice after a risky behaviour had already occurred. They noted that questions were often driven by the need for reassurance, and that discussions about HIV were generally avoided unless the clients were driven by fear to raise the issue.

I just got a question from a client. ‘How safe I am if I have sex with someone positive and using a condom?’ Immediately I thought like ‘oh my God this is another dumb question’ because as a service provider you get so sick and tired of being asked. This is basic HIV 101. It’s like ‘yeah, it’s safe.’ And I realize what he was asking wasn’t the safety. There is that stigma of HIV-positive people. He’s just afraid of having sex behind that question. SP, 35-49, CBO, TO

Patten S, LeBlanc MA, Jackson E, Adam B (2016). The Resonance Project Community Report: Emerging biomedical discourses on HIV among gay men and their service providers.