Positive prevention: Contemporary issues facing HIV positive people negotiating sex in the UK
Introduction
More than 40,000 people are now living with diagnosed HIV in the UK, the majority of whom are gay men (mostly white) and black African heterosexual men and women. (The UK Collaborative Group for HIV and STI Surveillance, 2005). Helping people with HIV to improve their health, maintain their emotional wellbeing, and avoid passing the infection to others have emerged as major priorities for public health. This approach has been coined ‘positive prevention’, i.e. primary and secondary prevention which targets people who are living with diagnosed HIV (International HIV/AIDS Alliance, 2003). As the number of people living with diagnosed HIV in the UK has risen substantially over the last five years, positive prevention has gained increasing importance.
Current approaches to preventing HIV transmission recognise that people make varying choices about the risks they are willing to take and that risk may be minimised yet not eliminated entirely (Bartos, McLeod, & Nott, 1993). Complex and sometimes contested discourses about HIV prevention have emerged as a consequence. People are required to make sense of their personal experience, varying circumstances and the proliferation of prevention approaches. The scope of these diverse approaches to risk include ‘serosorting’ for partners of the same HIV status for unprotected (vaginal and anal) sex (Elford, Bolding, Sherr, & Hart, 2007), and “strategic positioning” (a practice reported by some gay men where the HIV positive partner is receptive in anal sex and the HIV negative partner is insertive) (Elford, 2006).
Qualitative research has revealed narrative complexity in the way people assimilate HIV prevention messages and negotiate sex (Power, 1998). One finding to emerge is that real life sexual risk-taking and risk-reduction strategies are not well described by rational health models (Martin, 2006; Rhodes & Cusick, 2002). Indeed, people who take a ‘rational’ approach to sexual risk reduction may well under-estimate the importance of subjective experience and so be caught unawares when ‘irrational’ feelings such as intimacy and trust influence risk perceptions (Slavin, Richters, & Kippax, 2004). The accumulation of HIV narrative research over the years shows that a nuanced understanding of meanings, emotions, sexual dynamics and circumstance is essential for understanding HIV risk and prevention (Bartos et al., 1993; Davis, Hart, Bolding, Sherr, & Elford, 2006; Davis et al., 2002; Martin, 2006; Ridge, 2004; Rosenthal, Gifford, & Moore, 1998).
To date most research around HIV prevention in the UK among people living with—and at risk of—HIV has considered gay men and black African heterosexual men and women separately. For example, a considerable body of research has examined the reasons underpinning practices of risky sex among gay men including ‘ AIDS fatigue’ and ideas that infection is inevitable; the transgression of social rules including sexual safety; using sex to deal with difficult emotions; men making assumptions about the serostatus of other men rather than talking about it; and even the operation of a ‘death wish’ among gay men (Carballo-Dieguez, 2001; Crepaz, Hart, & Marks, 2004; Grov, 2004; Halkitis, Parsons, & Wilton, 2003; Martin, 2006; Rhodes & Cusick, 2002; Ridge, 2004) Furthermore, not all condomless sex presents a risk of HIV transmission. ‘Sero-sorting’ involves discussing your HIV status with potential partners and avoiding unprotected anal sex with those considered to have a different HIV status. Although a potential strategy for reducing HIV risk, there are concerns with this approach. For example, among people with diagnosed HIV, unprotected sex of this kind might result in ‘re-infection’ with more virulent or more drug resistant strains of HIV as well as other sexually transmitted infections (Halkitis & Parsons, 2003).
More recently researchers have examined sexual risk among Black African heterosexual men and women in the UK, many of whom were exposed to, and acquired HIV in Africa (The UK Collaborative Group for HIV and STI Surveillance, 2005). HIV prevention knowledge among Africans in the UK is still relatively poor, (Chinouya, Ssanyu-Sseruma, & Kwok, 2003), in marked contrast to certain parts of Africa, although even in Africa the knowledge base may be mixed with misinformation as well as elements of denial (Kalichman & Simbayi, 2003; Walker, Reid, & Cornell, 2004). Whether due to denial, insufficiently good knowledge or both, many African people in the UK mistakenly view themselves as being at low risk for HIV. Consequently, a diagnosis of HIV frequently comes as a shock, and is associated with isolation and depression (Anderson & Doyal, 2004; Burns & Fenton, 2006; Chinouya, Davidson, & Fenton, 2000; Flowers et al., 2006). Recent research among HIV positive black African men and women in London suggests that levels of risky sex are higher with regular partners than with casual partners (Elford, Ibrahim, Bukutu, & Anderson, 2007). And, as with gay men, some HIV positive Africans in the UK seek out HIV positive sexual partners as a risk reduction strategy (Chinouya et al., 2003; Elford, Ibrahim, Bukutu, & Anderson, 2007).
No study has specifically investigated the contemporary sexual risk and prevention challenges facing HIV positive people in the UK. In this paper, we used a modified grounded theory approach to investigate personal positive prevention approaches. We used the theme of ‘life journey’ in semi-structured in-depth interviews (and theme- clarifying focus groups) to identify the significant sexual issues recognised and prioritised by people themselves, rather than specifying these in advance. The key issues discussed in this paper include coping with threats posed by compromised mental health; protecting partners from HIV; and the challenges that negotiating sex poses to maintaining safe sex. The discussion investigates the broad perspectives and experiences of HIV positive people, highlighting how differing social circumstances and contexts are important for positive prevention.
Section snippets
Methods
In this article, we draw on data from audio and video recorded interviews that provided the foundation for the development of a Web site covering experiences of living with HIV (www.dipex.org/hiv), which was launched in November 2006. During 2005, the first author conducted 44 individual and three group interviews largely with gay men and black African heterosexual men and women who were living with diagnosed HIV. People were encouraged to tell their stories in their own words about their
Negotiating sex
For all participants, the negotiation of safe sex required a specialised body of skills and knowledge. This is because the negotiation of sex is essentially a complex social interaction where individual as well as partner dynamics need to be taken into account, along with the specifics of circumstance (Ridge, 2004). Of particular concern in accounts that cut across the interviews were sexual partners who appeared willing to engage in unprotected anal or vaginal sex. However, the reasons for
Discussion
This qualitative study is one of the first to thematically investigate ‘positive prevention’ among people living with HIV in the UK. While there has been an historic reluctance to design specific HIV prevention interventions for people living with HIV (van Kesteren, Hospers, Kok, & van Empelen, 2005), the current study shows that HIV positive people living in the UK do indeed have very specific prevention requirements because they are HIV positive. Additionally, HIV positive individuals
Acknowledgements
We are very grateful to the respondents for so thoughtfully sharing their experiences of living with HIV, and those who helped us to recruit them (see credits www.dipex.org/hiv for details). We would also like to thank the three anonymous reviewers whose constructive advice helped to improve the manuscript. The HIV module of DIPEx was funded by City University London, the Health Department, Gaydar, and the Terrence Higgins Trust. Damian Ridge & Jonathan Elford were funded by the City University
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