1. KEEPING GAY & BISEXUAL MEN
SAFE:
Adam Isaiah Green, Ph.D.
***
Simon Fraser University
Community-Based Research Centre
Beyond Behaviours
April 15, 2013

3. THE BUILDING BLOCKS OF
MSM HIV PREVENTION
1. Assumptions concerning the underlying
psychology of the sexual actor.
2. The relative importance of sexual pleasure
vs. risk containment.
3. Attributions of expertise: biomedical, social
scientific, or local/ indigenous?

4. GREEN’S TWO QUESTIONS:
1. What have we learned in thirty years
about why gay and bisexual men have
UAI?
2. What is the historical trajectory of
rates of HIV transmission among MSM in
North America, Western
Europe, Scandinavia and Australia?

6. HEALTH BELIEF MODEL
“In general, it is now believed that individuals will
take action to ward off, to screen for, or to control ill-
health conditions if they regard themselves as
susceptible to the condition. They will also take
action if they believe the health condition to have
potentially serious consequences; if they believe that
a course of action available to them would be
beneficial in reducing either their susceptibility to or
the severity of the condition; and if they believe that
the anticipated barriers to (or costs of) taking the
action are outweighed by its benefits” (8).
-Rosenstock, Irwin, Victor Strecher and Marshall Becker. 1994. “The Heath Belief Model and HIV
Risk Behavior Change,” Pp. 5-24 in DiClimente, Ralph and John Peterson (eds.), Preventing AIDS:
Theories and Methods of Behavioral Intervention. New York: Plenum Press.

7. BARRY ADAM et al. (2000)
“…(UAI is) associated with relatively
complex issues, such as participants’
sexual and affective preferences, the
nature of the relationship between
partners, ambiguities about what is truly
safe, and the influence of dominant
cultural values and discourse” (25).
-Barry D. Adam and Alan Sears, E. Glenn Schellenberg. “Accounting for
Unsafe Sex: Interviews With Men Who Have Sex With Men.” Journal of
Sex Research. 37:24-36.

8. TREVOR HART et al.
“Education, Black or White ethnicity, and
age were not associated with sexual risk
behavior…Findings of this study suggest a
relatively robust association between HIV
optimism and high-risk UAI that did not
vary by type of sexual position of the
participant, (or) HIV status of sexual
partner…” (441).
-Trevor A. Hart; Carolyn A. James; P. Hagan; Emilie Boucher. 2010. “HIV Optimism
and High-Risk Sexual Behavior in Two Cohorts of Men Who Have Sex With Men”.
Journal of the Association of Nurses in AIDS Care. 21:349-443.

9. GARY DOWSETT et al.
“There was no homogeneity that could
identify a clear point of intervention for
behavior change. Yet, the issue of the
pleasure and intimacy experienced having
condomless sex … was very frequently
present…as a potent force that men could
not or did not want to control” (S64).
- Alex Carballo-Dieguez, Ana Ventuneac, Gary W. Dowset, Ivan Blan, Jose Bauermeister,
Robert H. Remien, Curtis Dolezal, Rebecca Giguere, Marina Mabragana. 2011. “Sexual
Pleasure and Intimacy Among Men Who Engage in ‘Bareback Sex’”. AIDS Behavior. 14:S57-
S65.

10. ADAM ISAIAH GREEN
“…(S)exual decision-making is rarely a simple
unidimensional process but, rather, grows out
of a complex assemblage of emotional states
and meanings associated with identity and self-
worth…(A) low status partner may expand the
parameters of acceptable sexual risk in the
context of sexual exchange with men from a
higher status group” (447).
-Adam Isaiah Green. 2008. “Health and Sexual Status in an Urban Gay
Enclave: An Application of the Stress Process Model.” Journal of Health &
Social Behavior. 49:436-451.

11. GARY DOWSETT et al.
“There was no homogeneity that could
identify a clear point of intervention for
behavior change. Yet, the issue of the
pleasure and intimacy experienced having
condomless sex … was very frequently
present…as a potent force that men could
not or did not want to control” (S64).
- Alex Carballo-Dieguez, Ana Ventuneac, Gary W. Dowset, Ivan Blan, Jose Bauermeister,
Robert H. Remien, Curtis Dolezal, Rebecca Giguere, Marina Mabragana. 2011. “Sexual
Pleasure and Intimacy Among Men Who Engage in ‘Bareback Sex’”. AIDS Behavior. 14:S57-
S65.

12. BARRY ADAM et al. (2000)
“…(UAI is) associated with relatively
complex issues, such as participants’
sexual and affective preferences, the
nature of the relationship between
partners, ambiguities about what is truly
safe, and the influence of dominant
cultural values and discourse” (25).
-Barry D. Adam and Alan Sears, E. Glenn Schellenberg. “Accounting for
Unsafe Sex: Interviews With Men Who Have Sex With Men.” Journal of
Sex Research. 37:24-36.

13. ADAM ISAIAH GREEN
“…(S)exual decision-making is rarely a simple
unidimensional process but, rather, grows out
of a complex assemblage of emotional states
and meanings associated with identity and self-
worth…(A) low status partner may expand the
parameters of acceptable sexual risk in the
context of sexual exchange with men from a
higher status group” (447).
-Adam Isaiah Green. 2008. “Health and Sexual Status in an Urban Gay
Enclave: An Application of the Stress Process Model.” Journal of Health &
Social Behavior. 49:436-451.

14. GARY DOWSETT et al.
“There was no homogeneity that could
identify a clear point of intervention for
behavior change. Yet, the issue of the
pleasure and intimacy experienced having
condomless sex … was very frequently
present…as a potent force that men could
not or did not want to control” (S64).
- Alex Carballo-Dieguez, Ana Ventuneac, Gary W. Dowset, Ivan Blan, Jose
Bauermeister, Robert H. Remien, Curtis Dolezal, Rebecca Giguere, Marina Mabragana. 2011.
“Sexual Pleasure and Intimacy Among Men Who Engage in ‘Bareback Sex’”. AIDS Behavior.
14:S57-S65.

20. META-ANALYSIS of BEHAVIORAL
INTERVENTIONS FOR MSM
“Behavioral interventions have the strongest
evidence but have only slight effects on self-
reported behaviours, and no evidence shows a
reduction in the incidence of HIV infection…
Efficacy is generally slight, fidelity is of
concern, and few resources are available to
bring individual or multi-session approaches to
scale…Stand-alone behavioral interventions are
not sufficient to reduce HIV transmission in
MSM” (389).
-Patrick S. Sullivan et al., 2012. “HIV in Men Who Have Sex With Men: Successes and
Challenges of HIV Prevention in Men Who Have Sex With Men”. The Lancet. 380:388-399.

21. NEW HIV DIAGNOSES: BC MSM

22. New HIV Diagnoses: Canada MSM
(PHAC)

23. New HIV Diagnoses: US MSM
1994-2003

24. NEW HIV DIAGNOSES:
ENGLAND & WALES MSM
Paul Birrell and Sarika Desai. 2013. “HIV Incidence in Men Who Have
Sex With Men in England and Wales 2001-10. A Nationwide Population
Study”. The Lancet. Infectious Diseases, 13: 279-280
New
HIV
diagno
ses
1640 1780 1970 2240 2450 2440 2640 2470 2440 2550
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

25. NEW HIV DIAGNOSES: BELGIUM MSM

26. NEW HIV DIAGNOSES: NETHERLANDS
MSM

28. PITT MEN’S STUDY 1988
32% report occasional use of condoms when topping
28% report occasional use of condoms when bottoming
50% report NEVER using condoms when bottoming
(N=955 MSM)
-Valdiserri et al., 1988. “Variables Influencing Condom Use in a
Cohort of Gay and Bisexual Men.” AJPH Vol. 78