Reconsidering “Unprotected” and HIV Risk in the Twenty-First Century

Citation: Kelly BC (2016) Reconsidering " Unprotected " and HIV Risk in the Twenty-First Century. A commentary on " Any condomless anal intercourse " is no longer an accurate measure of HIV sexual risk behavior in gay and other men who have sex with men Conceptualizations of HIV risk have changed over the 35 years since the identification of a cluster of mortality among gay men in Los Angeles (1). From these early days, condoms have served as a critical primary prevention tool. The entrenchment of condom use as the central prevention strategy during the ensuing years left a legacy by which it remained the focal point in considerations of risk. Yet, increasingly during the intervening years, concerns arose about the absence of condoms as a marker of risk. Men increasingly questioned a " one size fits all " approach to defining risk and the impact that had on their lives. Jin and colleagues (2) have provided us with useful empirical evidence for conversations about the nature of risk in the sexual encounters of men who have sex with other men, and such approaches are more feasible with methodological advances facilitating refined data collection. The pattern of sexual partnering described in their results explains why they assert " any condomless anal intercourse is no longer an accurate measure of HIV sexual risk behavior. " Simply put, risk reduction efforts are widespread during episodes of condomless anal sex among these men. In response to the desire to provide alternative strategies to condom use, numerous harm reduction practices emerged over time. Serosorting, negotiated safety, strategic positioning, and withdrawal before ejaculation all became incorporated into the sexual routines of gay men and other MSM even prior to the more recent biomedical approaches, such as PrEP and viral load sorting. Importantly, many of these risk reduction methods emerged in a bottom-up fashion and serve as a reminder of the critical role that communities themselves play in public health promotion. The evidence provided by Jin and colleagues affords an understanding of how HIV-negative men approach sexual encounters with respect to the range of risk reduction options available to them. Among the HIV-negative men they followed over the course of several years, six out of seven episodes of condomless anal intercourse occurred with a regular HIV-negative partner. This critically underscores that most condomless anal sex occurs within the context of a regular sexual relationship with someone …