Objective-A range of risk reduction behaviours in which homosexual men practise unprotected anal intercourse (UAI) has been described. We aimed to assess the extent of any reduction in HIV risk associated with these behaviours.Design-A prospective cohort study of HIV-negative homosexual men in Sydney, Australia. Methods-Men were followed up with 6-monthly detailed behavioural interviews and annual testing for HIV. The four risk reduction behaviours (behaviourally defined) examined were serosorting, negotiated safety, strategic positioning, and withdrawal during receptive UAI (UAI-R).Results-In 88% of follow-up periods in which UAI was reported, it occurred in the context of consistent risk reduction behaviours. Compared with those who reported no UAI, the risk of HIV infection was not raised in negotiated safety [hazard ratio = 1.67, 95% confidence interval (CI) 0.59-4.76] and strategic positioning (hazard ratio = 1.54, 95% CI 0.45-5.26). Serosorting outside negotiated safety was associated with an intermediate rate of HIV infection (hazard ratio = 3.11, 95% CI 1.09-8.88). Withdrawal was associated with a higher risk than no UAI (hazard ratio = 5.00, 95% CI 1.94-12.92). Patterns of UAI differed greatly according to partner's serostatus. Men who reported serosorting were less likely to report either strategic positioning or withdrawal.Conclusion-Each behaviour examined was associated with an intermediate HIV incidence between the lowest and highest risk sexual behaviours. The inverse association between individual behaviours suggests that men who practise serosorting rely on this protection. The high prevalence of these behaviours demands that researchers address the contexts and risks associated with specific types of UAI.

Objective-To estimate per-contact probability of HIV transmission in homosexual men due to unprotected anal intercourse (UAI) in the era of highly active antiretroviral therapy (HAART).Design-Data were collected from a longitudinal cohort study of community-based HIV-negative homosexual men in Sydney, Australia.Methods-A total 1427 participants were recruited from June 2001 to December 2004. They were followed up with 6-monthly detailed behavioral interviews and annual testing for HIV till June 2007. Data were used in a bootstrapping method, coupled with a statistical analysis that optimized a likelihood function for estimating the per-exposure risks of HIV transmission due to various forms of UAI.Results-During the study, 53 HIV seroconversion cases were identified. The estimated per-contact probability of HIV transmission for receptive UAI was 1.43% (95% CI 0.48%-2.85%) if ejaculation occurred inside the rectum occurred, and it was 0.65% (95% CI 0.15%-1.53%) if withdrawal prior to ejaculation was involved. The estimated transmission rate for insertive UAI in participants who were circumcised was 0.11% (95% CI 0.02%-0.24%), and it was 0.62% (95% CI 0.07%-1.68%) in uncircumcised men. Thus, receptive UAI with ejaculation was found to be approximately twice as risky as receptive UAI with withdrawal or insertive UAI for uncircumcised men and over 10-times as risky as insertive UAI for circumcised men.Conclusion-Despite the fact that a high proportion of HIV-infected men are on antiretroviral treatment and have undetectable viral load, the per-contact probability of HIV transmission due to UAI is similar to estimates reported from developed country settings in the pre-HAART era. KeywordsHIV; per-contact probability; transmission risk; cohort study; homosexuality, male; Australia

This paper examines the ways in which populations at risk of HIV in the developed world have enculturated the knowledges and technologies of both the medical and the social sciences. By revisiting a number of review papers and by reviewing findings from a range of studies, we argue that gay men have appropriated information that has enabled them to sustain safe practices while they have eschewed information that has made maintenance difficult. The paper describes a range of risk reduction strategies and compares the responses of populations at risk of HIV in the years before the advent of highly active antiviral therapy (HAART) with their responses after the introduction of HAART in 1996. We concentrate our argument on the changing responses to HIV risk of gay men, although occasionally illustrate our argument with reference to the responses of injecting drug users. The responses of gay men to risk post-HAART--particularly those who reside in Australia--speak to the adoption of a range of considered strategies, not altogether safe, to reduce harm. We argue that such strategies need to be understood and addressed within a 'new' social public health, that is, a public health that takes what social analysis has to say seriously. The paper examines the differences between the traditional, the 'modern' epidemiological/clinical and the 'new' social or socio-cultural public healths and describes the tensions between the medical and the social science disciplines in their efforts to inform public health. Key concepts provided by social science such as agency (including individual and collective agency), alongside its methodological reflexivity are key to effective public health. The risk avoidance strategies adopted by gay men suggest a way forward by turning our attention to the ways in which medicine is taken in(to) their practice.