Important New HIV Risk Study

Bill Weintraub

Bill Weintraub

Important New HIV Risk Study


An important new study of MSM ("men who have sex with men") HIV risk behavior is now out:

Sexual Risk, Nitrite Inhalant Use, and Lack of Circumcision Associated With HIV Seroconversion in Men Who Have Sex With Men in the United States


Susan P. Buchbinder, MD, Eric Vittinghoff, PhD, Patrick J. Heagerty, MD, Connie L. Celum, MD, MPH, George R. Seage, III, DSc, MPH, Franklyn N. Judson, MD, David McKirnan, PhD, Kenneth H. Mayer, MD, and Beryl A. Koblin, PhD

Those who read AIDS research papers will recognize many of those names -- it's an impressive group.

The official reference is:

Buchbinder et al J Acquir Immune Defic Syndr Volume 39, Number 1, May 1 2005

The study's conclusions are striking in a number of areas, and they're well worth looking at.

Because they overwhelmingly support what we've said and what we do.

Indeed, one AIDS researcher was so excited by the study that he sent me and Chuck Tarver copies -- and you'll see why.

Let's start with the study's summary -- I've left in the statistical jargon for those who understand it, but if you don't, you can easily read through it:

Summary: Men who have sex with men (MSM) continue to account for the largest number of new HIV infections in the United States, but limited data exist on independent risk factors for infection beyond the early 1990s. The HIV Network for Prevention Trials Vaccine Preparedness Study enrolled 3257 MSM in 6 US cities from 1995 to 1997. HIV seroincidence was 1.55 per 100 person-years (95% confidence interval: 1.23-1.95) over 18 months of follow-up.

On multi-variable analysis using time-dependent covariates, independent risk factors for HIV seroconversion were increased number of reported HIV-negative male sex partners (adjusted odds ratio (AOR) = 1.14 per partner, population attributable risk (PAR) = 28%), nitrite inhalant use (AOR = 2.2, PAR = 28%), unprotected receptive anal sex with an HIV unknown serostatus partner (AOR = 2.7, PAR = 15%) or HIV-positive partner (AOR = 3.4, PAR = 12%), protected receptive anal sex with an HIV-positive partner (AOR = 2.2, PAR = 11%), lack of circumcision (AOR = 2.0, PAR = 10%), and receptive oral sex to ejaculation with an HIV-positive partner (AOR =3.8, PAR = 7%). Having a large number of male sex partners, nitrite inhalant use, and engaging in receptive anal sex explained the majority of infections in this cohort and should be targeted in prevention strategies for MSM.

"Having a large number of male sex partners, nitrite inhalant use, and engaging in receptive anal sex explained the majority of infections in this cohort and should be targeted in prevention strategies for MSM."

Once again:

"...engaging in receptive anal sex...should be targeted in prevention strategies for MSM."

That's what we do.

We tell men not to engage in anal.

At the same time providing them with a far more pleasurable and far safer alternative.

Let's take a closer look at some of these risk factors.

1. "Increased number of reported HIV-negative male sex partners"

At first glance, that sounds counter-intuitive, but it should serve as a warning.

Although many counseling messages aimed at HIV negative persons focus on unsafe sexual activity with HIV positive sex partners or those of unknown HIV serostatus, our study suggested that more than one quarter of new infections arose from men having HIV-''negative'' partners. This probably reflects error in presumed partner serostatus, particularly among men with multiple partners, as well as residual confounding by factors such as partner infectiousness and level of sexual trauma. There is an increasing literature on the importance of understanding patterns of sexual mixing on HIV spread, because the rate of sexual partner change is an important variable in the equation of epidemic spread of infectious diseases. Recent data suggest that as many as 25% of the HIV-infected population in the United States and up to 77% of young HIV-infected MSM are unaware of their HIV serostatus and that 42% of MSM failed to disclose HIV serostatus with at least 1 partner, particularly in non exclusive partnerships.

Notice that:

"the rate of sexual partner change is an important variable"; and, that "up to 77% of young HIV-infected MSM are unaware of their HIV serostatus and ... 42% of MSM failed to disclose HIV serostatus with at least 1 partner, particularly in nonexclusive partnerships."

So: the more partners you have, the greater the risk; and many guys routinely lie about their antibody status, particularly during hook-ups and in other promiscuous settings.

While other guys simply don't know they're positive.

Notice also the reference to "level of sexual trauma."

"Sexual trauma" is a direct consequence of being penetrated anally; given the anatomy of the anus and rectum, some trauma is inevitable, but obviously the more violent and brutal the act, the greater the potential for trauma.

2. Unprotected Receptive Anal (URA) vs Protected Receptive Anal (PRA)

Many studies have demonstrated that receptive anal sex is most strongly associated with prevalent and incident HIV infection in MSM and carries the highest per-contact risk of acquiring HIV. This study found that that URA with either HIV-positive or unknown serostatus partners explained one quarter of new infections in this cohort. Surprisingly, we also found an independent increase in the risk of HIV seroconversion among men reporting PRA with an HIV-positive partner. This finding likely represents a combination of overreporting of condom use and unrecognized condom failure by the receptive partner. Condom failure rates are particularly increased among MSM who use condoms infrequently, substance users, and those failing to use appropriate lubricants.

Let's look at these two factors: "overreporting of condom use and unrecognized condom failure by the receptive partner"

Overreporting of condom use

This is a consequence of the un-connected and un-intimate nature of anal penetration, and the relative lack of sensitivity of the anus and rectum.

Most anal penetration is performed with the receptive partner, the so-called bottom, in a prone -- that is, face down, stomach down, on all fours, doggie-style -- position.

In that position he can't see if the insertive partner, the so-called top, is wearing a condom, and his anus and rectum aren't sensitive enough to feel whether the insertor's penis is sheathed or not.

So it's easy for the top to mislead the bottom, either by lying to him outright, or by putting on a condom and removing it just before entry.

Of course if the bottom is befuddled by drugs, it's even easier to fool him.

And the top has a lot of incentive to do so, since condoms markedly reduce his pleasure.

In addition, and as we saw in the message thread titled It's the anal, the emphasis in AIDS prevention on protecting oneself rather than protecting others creates around anal and MSM sex in general an amoral atmosphere, in which it's easy for a sexual actor to regard someone else as responsible, rather than himself.

You hear this sentiment time and again: "If he didn't bother to ask, I wasn't going to bother to tell him."

And that attitude is a direct outgrowth of decisions made in the early 1980s, well-intentioned to be sure, to protect HIV+ gay men by freeing them of responsibility for their status.

The result has been however that we've ended up underwriting what is without question bad and indeed dangerous behavior in the gay male community and thus made that community significantly more dysfunctional.

We need to be very clear about this:

Not only has the MSM HIV prevention paradigm of the 1980s failed, but it's become a form of negative social engineering which props up and supports the very two behaviors pinpointed by this study and every other -- anal penetration and promiscuity -- which are directly responsible for the MSM AIDS epidemic, while fostering an ethos of moral irresponsibility among gay and bi men.

The result, not surprisingly, has been and will continue to be a public health disaster and an anomic, dysphoric, community.

"unrecognized condom failure"

We have long argued -- see, for example, our Man2Man Alliance policy paper Do Condoms Work? -- that condoms are far less effective than the AIDS Service Organizations claim in their incessant propaganda.

In particular, I've suggested that because "lapses" in condom use are so common, we don't really know how many seroconversions are due to condomless or unprotected anal -- so-called barebacking; and how many are actually due to condom failure.

In other words, if a guy has condomless anal "sex" on Monday; and "protected anal" on Wednesday, during which, unbeknownst to him, the condom breaks and he's infected; he'll, quite naturally, attribute the infection to the condomless event on Monday.

Because he doesn't know that the condom broke or that his partner didn't use one; he'll just assume that the infection occurred during his "lapse."

The importance of this finding by Buchbinder et al is that even "protected receptive anal" -- that is, getting anally penetrated by a guy wearing a condom -- is a RISK FACTOR.



Condoms reduce risk, but they CANNOT ELIMINATE RISK.

And Buchbinder proves it.

Which is why the Summary I quoted above says "Having a large number of male sex partners, nitrite inhalant use, and engaging in receptive anal sex explained the majority of infections in this cohort and should be targeted in prevention strategies for MSM."

"...engaging in receptive anal sex...should be targeted in prevention strategies for MSM."

Once again, that's exactly what we do.

We tell MSM to stop doing anal.

Now guys, for those of you who like to debate this sort of thing in chat rooms and on message boards, don't expect your average "man into anal" to believe you when you say that even with a condom there's still significant risk.

He's been told over and over and over and over and over again that a condom will protect him.

Nevertheless, you can refer him to: Buchbinder et al J Acquir Immune Defic Syndr Volume 39, Number 1, May 1 2005

and let him draw his own conclusions.

3. Nitrites aka "poppers"

This one should be a no-brainer, but, remarkably, I still get guys trying to post in Frot Club about using poppers.

So let's see what Buchbinder and her peers have to say:

Nitrite inhalers have long been reported as associated with prevalent HIV infection and high-risk sexual practices and were suspected of being the causal agent of AIDS in the early years of the epidemic. Although the independent contribution of nitrite inhalants to incident infection has been inconsistent across studies, our study and others found a significant association of nitrite inhalants with prospectively identified HIV infection. Recently, nitrite inhalants have also been found to be independently associated with Kaposi sarcoma-associated herpesvirus (KSHV) infection acquisition. The pathway by which nitrite inhalants lead to HIV or KSHV infection are not clear. Nitrites inhalants cause peripheral vasodilatation and are believed to decrease anal sphincter tone, potentially leading to more traumatic sexual intercourse or more direct exposure to blood cells. ... There are also limited animal and human data suggesting that nitrite inhalants may cause transient immunosuppression or alter cytokine profiles, which could enhance transmission HIV or KSHV transmission across mucosal barriers. The high prevalence of nitrite inhalant use among high risk MSM, recently reported by 37% of MSM enrolled in a large multisite behavioral intervention and in 16% to 21% of a multisite household-based sample of urban MSM, reinforces the need to develop prevention strategies to decrease nitrite inhalant use....

In sum, poppers are linked not just to HIV infection, but to KSHV -- Kaposi's Sarcoma -- as well, and to "transient" immunosuppression.

Still think they're cool?

4. Male circumcision (MC).

Always a crowd pleaser.

Whenever I post about MC being protective against HIV, I get email from the anti-circumcision fanatics.

Who are about as reasonable as the Flat Earthers and the Holocaust deniers and the HIV denialists.

Guys, the earth is not flat, the Holocaust happened, HIV causes AIDS, and male circumcision is protective against HIV.

Like Woody Allen says, I didn't invent the cosmos, I just explain it.

So, if you're upset with the fact that being uncircumcised puts you at greater risk for HIV infection -- yell at God.

Don't yell at me, cause I didn't make it that way.

All I'm doing is reporting a scientific finding, which I have a responsibility to do.

Does that finding mean that it's BAD to be uncircumcised?


But it does mean two things:

1. If you're uncircumcised, you have to factor that in to your assessments of risk when you have sex.

2. The gay male embrace of non-circumcision, like the gay male embrace of anal and promiscuity, was a bad choice based on what was at best a very poor understanding of the science of disease transmission, and, in my view, a lot of wishful thinking.

So: In the 1970s, gay men managed to enshrine at the center of their sexual culture the very three practices which would put them at greatest risk for at least one fatal sexually transmitted disease.

That's a fact, and we need to learn from it.

Cause, like the guy says, if we don't learn from it, we'll be doomed to relive it.

Over and over again.

Here's what Buchbinder et alia say -- once again, if it bothers you, write to Buchbinder -- not to me, cause I didn't say it, Buchbinder et al said it:

Although 2 meta-analyses of the role of circumcision in sub-Saharan Africa have demonstrated a reduced risk of HIV infection in circumcised heterosexual men, there have only been 2 studies published to date evaluating the association of circumcision with male-to-male HIV acquisition.

One, a multivariate analysis, found that lack of circumcision was independently associated with a 2-fold increased risk of prevalent infection, whereas the other found no association between circumcision and recent infection (but without controlling for behavioral risk). Our study found a doubling of the risk of HIV acquisition associated with lack of circumcision, although the PAR in our population was relatively low. There is substantial biologic plausibility supporting our finding of decreased risk of HIV acquisition in circumcised MSM, despite our inability to identify the mechanism by which this occurred. Foreskin mucosa contains an abundance of CD4+ T cells and Langerhans cells, and these cells are further increased in men with recent sexually transmitted diseases. Foreskin epithelium from uncircumcised men is more susceptible to infection with CXCR5 viruses than cervical mucosa or keratinized foreskin tissue from circumcised men. Intact foreskin has also been associated with an increased incidence of ulcerative sexually transmitted diseases, and recent studies demonstrate that herpes simplex virus 2 (HSV-2) is associated with an increased risk of HIV acquisition among MSM. The advisability of promoting circumcision among high-risk adult men is uncertain, because circumcision after puberty may be less protective. A randomized controlled trial of this prevention strategy is being planned for heterosexual men in Africa, where the PAR for HIV infection arising from lack of circumcision appears to be substantially higher than in MSM.

5. Unprotected Oral with Ejaculation (UOE).

Again, this should be a no-brainer, but there are still guys out there who "take cum."

Usually they hedge it though by saying something like, I only take cum if I've known the guy awhile -- like maybe five minutes; or if there's some other seemingly mitigating factor.

For example, I had a guy write to me that he took cum, but only from married men.

I wrote back that he shouldn't let men, no matter how married, ejaculate in his mouth.

He never answered my email.

But, maybe, he'll read this post.

Although there have been a number of well-documented case reports of HIV acquisition likely as a result of receptive oral sex and a number of studies demonstrating an epidemiologic association of receptive oral sex with HIV infection, most studies have failed to find an independent contribution of oral sex to HIV seroconversion after controlling for receptive anal sex, which carries a much higher per-contact risk. Our study found a substantial elevated risk independently associated with receptive oral sex with ejaculation with positive partners, however, after controlling for receptive and insertive anal sex practices. The plausibility of oral transmission of HIV comes from animal studies and studies indicating that tonsillar tissue is rich in dendritic cells and M cells, both capable of antigen transport to lymphoid tissue in the absence of trauma or inflammation. A longitudinal study of MSM found the per-contact risk of receptive oral sex to be comparable to that of insertive anal sex, and several studies of newly infected persons document a substantial minority of newly infected persons reporting only this risk behavior despite repeated questioning. The fact that other types of contact were reported in our study by seroconverters who also reported receptive oral sex with an HIV-positive partner makes it less likely that our finding is a result of underreporting of stigmatized higher risk behaviors; furthermore, the finding persisted in alternative models in which numbers of contacts were taken into account. Our study was also able to address the independent contribution of unprotected oral sex among MSM engaging in multiple types of risk; studies of persons whose only exposure is to oral sex may not be generalizable to populations engaging in both anal and oral sex. Nevertheless, it is impossible to determine definitively whether the independent association of oral sex with ejaculation in our study represents true transmission by this route or instead may be a marker of riskier sexual practices in general or of unmeasured confounders. Other studies attempting to evaluate the role of oral sex in transmission are difficult to interpret because of the limited number of persons with exposure to known HIV-positive partners or because of a focus on serodiscordant couples, a group in which the risk of transmission by any route is already likely to be lower than in persons newly entering relationships or persons with multiple partners. Data from our study and reports of newly infected individuals suggest that approximately 5% to 10% of new HIV infections in MSM are attributable to receptive oral sex. Public health efforts should focus on reducing the total number of partners and receptive anal sex contacts; however, individual counseling should include messages about the potential for HIV acquisition to occur by means of oral exposure to infected semen.

Let's repeat that last sentence:

"Public health efforts should focus on reducing the total number of partners and receptive anal sex contacts; however, individual counseling should include messages about the potential for HIV acquisition to occur by means of oral exposure to infected semen."

"Public health efforts should focus on reducing the total number of partners and receptive anal sex contacts..."

For five years, I've called for "accurate and realistic assessments of pleasure and risk in the various sex acts available to men who have sex with men."

And I've said that if you make those assessments, you'll conclude that anal is highest risk, oral middling, and Frot lowest.

And that promiscuity is a problem.

What this study concluded was:

Don't be promiscuous.

Don't do anal.

Watch out for oral.

I've been publicly pilloried and attacked repeatedly in the most foul and vicious manner for saying exactly that.

Guess what?


My critics -- every single one of them -- are wrong.

That's the significance of Buchbinder et al.

Anyone seeking to debate me or any one of us in the public arena should take note that the FACTS are on our side.



Our critics do not have a leg to stand on.

They know it, and that's why they resort to personal attacks.

They're liars and knaves who've put their sexual practice ahead of the lives of their fellow gay and bi men.

And then tried to cover their tracks by defaming men advocating safe, pleasurable and responsible practices for the community.

That's sickening, and they deserve nothing but our contempt.

To read Buchbinder et al is to understand that we're telling the truth.

Anal is the problem, anal has always been the problem, and throwing condoms at anal while supporting promiscuity is not the solution -- it has not worked and it will never work.

Bill Weintraub

May 29, 2005

Bill Weintraub

Re: Important New HIV Risk Study


Now, in terms of risk behaviors:

As we just saw, in any epidemic, one risk behavior usually predominates.

That's the case for the HIV epidemic among MSM.

As I made clear in the post titled It's the anal, anal penetration is the pre-eminent risk behavior among MSM.

It's not cruising the internet, it's not using meth, it's not suffering from depression or low self-esteem or homophobia.

It's the anal.

Protected or unprotected, with a condom or without, whether your partner says he's poz or neg, doing anal puts you at significant risk for HIV.

And large numbers of guys doing anal, particularly in groups, in group settings like bath-houses and sex clubs and circuit parties, and with concurrent partners, is what created and is sustaining the epidemic.

"Unprotected oral with ejaculation" -- UOE -- puts you at some risk; but, had gay men stayed with oral in the 1970s, it's extremely unlikely that we would have had an epidemic.

Because HIV is a difficult virus to get, and oral is not the major MSM vector.

Anal is.

Get rid of the anal, and the epidemic will go away.

Buchbinder et al did find that using poppers, taking cum, and being uncut were risk factors.

But the pre-eminent risk behavior is anal.

Reduce the prevalence of anal, and you reduce the prevalence of HIV.

During that email colloquy on the Philippines I mentioned in "It's the anal," I asked the man who, I believe, is widely regarded as the world's leading AIDS epidemiologist, whether a 10% reduction in the prevalence of anal among MSM would produce a 10% reduction in new MSM HIV infections.

He said yes.

He said the relationship was simple and direct.

Let's repeat that:

Were we to reduce the prevalence of anal by 10%, we would reduce new MSM HIV infections by 10%.

20%, 20%.

50%, 50%.

Why does this idea meet with so much opposition?


The numbers of men we're talking about are not small.

Every year more than 20,000 American gay and bi men are infected with HIV.

Were we to reduce the prevalence of anal penetration by 50%, we'd reduce the number of new HIV infections by 10,000.

That's a lot of men.

Furthermore, every man who does NOT get infected is a man who CANNOT infect anyone else.

The virus is contained.

In this context, anal penetration needs to be seen for what it is: an act of collaboration with a virus which is killing gay and bi men.

This same epidemiologist told me that he's long wanted to advocate what he calls "mutual masturbation" as an alternative practice which would reduce HIV infection, but that he cannot because doing so would cost him his funding.

Funding, that is, from the federal government.

So he won't do it.

Because in sexual matters, the religious right controls the executive, legislative, and, increasingly, judicial branches of the federal government.

And many state governments as well.

And epidemiologists can't operate without federal funds.

Once again, we're the only people around who are both willing and able to speak truth to power on this issue.

We've challenged the analists, who believe that sex between men must be anal.

We've told the analists that in reality anal is a pale imitation of sex between a man and a woman, and that because anal is not mutually genital, it's not truly sex.

Rather it's an act of domination and control centering on two politically-coerced roles which have nothing to do with authentic masculinity.

And, as Robert Lorspir and Joel Aurifero have so ably pointed out, men need their masculinity.

And all people not only deserve but need to have sex which is both genital and safe.

Yet what does analism do?

It deprives men of their masculinity and their genitality, and offers them a Hobson's choice of either deadly disease or numbing their penises with latex.

Then, to add insult to injury, the multipartnered pansexualists combine the emphasis on anal penetration and effeminacy with a ringing cultural endorsement of promiscuity, thus depriving gay men of stability in their most important relationships.

Is it any wonder that there's so much substance abuse, and depression, and "low self-esteem," among gay men?

Or that so much of gay male sexuality is suicidal?

We speak truth to analist power.

We've told the analists that a community built on raunch, kink, and sleaze, on sex which isn't sex and men who aren't men and relationships which aren't relationships, cannot stand.

And we've said there's a better way.

One which is Phallic, Faithful, and unabashedly Masculine.

We've also challenged the religious right, who believe that all homosex is sin.

We've told them that it is not.

That while one can argue that anal penetration is a sin, Scripture makes plain that the love of man for man is not sinful, but is, rather, something "wonderful to behold."

And that the religious right's focus on the issue of homosex to the exclusion of virtually all others has nothing to do with Christ and is indeed a mockery of the Christian Faith worthy, in evangelical terms, of one entity, and one entity only: the adversary.

In evangelical terms that's what they're doing: the devil's work.

Take a look at some of these megachurches.

They're not Christian.

Nor are they Judaic.

What they are in reality is crudely Americanist.

They replace God and Christ with free enterprise and market capitalism and, last but not least, chauvinism.

They are crass materialists who seek to nail all mankind to a cross of gold.

And an American cross at that.

They can call themselves "Christians," but neither their doctrines nor their actions have anything to do with the Christian Faith.

This is not Christianity.

This is a partisan, political, "religion."

And that needs to be said over and over again:

That just as analism has nothing to do with sex, so the religious right, though its beliefs may be interpreted as "religious" in the most narrow doctrinal sense of the word, has nothing to do with Faith.

Those are our opponents.

Those are the people the rest of America is afraid to challenge.

We're not.


This site is a call to action.

You need to answer that call.

Because action is affirmation.

Every time you act, you affirm your lives and your manhood, and you grow stronger.

Every time you speak up for who and what you are, you make yourself stronger.

Every time you donate to or otherwise help a cause you believe in, you make yourself stronger.

Every time you train at a fight school, such as a martial arts academy, you make yourself stronger too.

The opposite is true as well.

When Masculinity is mocked, Frot denigrated, and Fidelity dishonored, yet you stay silent -- you make yourself weaker.

When you know a cause needs your help and you turn your back -- you make yourself weaker.

When, whether you're a person of Faith or secular, you fail to challenge the religious right, you weaken yourself.

As you do when you pass up the opportunity to train in a martial art in favor of going to the gym or a bar or sitting at home.

So it's in your power to grow as a Warrior;

or shrink as a man.

The analists and the religious right are a problem.

But until you metaphorically take up arms against them, you're part of the problem too.

Cockrub WARRIORS Rule.

Frot MEN Rock.

Donate guys.

Start looking into the Regional Chapters -- slowly but surely, Beagle is doing some great things in Oregon, and you could too, wherever you live.

And tell your friends and family and whoever else matters:

You don't do anal.

You're a Frot man.

We have the truth on our side if we're willing to speak it.

But we have to get that truth out.

For while there's no ally more powerful than truth, as Aldous Huxley observed, "Great is truth, but still greater, from a practical point of view, is silence about truth."

Oscar Moreno Vallejo

Re: Important New HIV Risk Study


Amen to that

Well said Bill!

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