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Barebacking: A Harm Reduction Approach. Paul Quick, M.D. Tom Waddell Health Center San Francisco Department of Public Health paul.quick@sfdph.org. Why “Harm reduction”?. The principles of harm reduction stem from the ethical obligations of physicians and other caregivers, namely

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barebacking a harm reduction approach

Barebacking: A Harm Reduction Approach

Paul Quick, M.D.

Tom Waddell Health Center

San Francisco Department of Public Health

paul.quick@sfdph.org

why harm reduction
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
Is HIV incidence falling?
  • San Francisco incidence appears to have fallen from 2.2-2.5% to 1.2% over 3-6 years

MMWR. June 24, 2005 / 54(24);597-601

harm reduction in hiv msm
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 msm5
Harm reduction in HIV- MSM
  • Negotiated safety
  • Decrease in URA with positive/unkown partners
  • BUT, words of caution…
negotiated safety can fail
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. 2005 Jan 1;38(1):82-6.)
hivnet data
HIVNET data
  • 3257 MSMs, 1995-1997
  • 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
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
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 do10
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
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 do12
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 do13
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
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;19:85-90.)
    • 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 directions15
Future directions
  • Clinical trials of acyclovir, tenofovir for primary prevention
  • Rectal/oral virucides
  • Stimulant replacement/blocking therapy