Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 14313-14316 245

Design: This study took place in Dhaka, with the help of a small new nongovernment organization dedicated to male sexual health. In-depth life history
interviews were collected.
Methods: 7 young men were selected and trained as qualitative interviewers.
They gained access to their informants through their own friendship networks
as well as simply meeting men on the street. Sampling aimed at maximizing
class, educational, age and situational variation. A total of 45 interviews were
tape recorded and translated from Bangla to English.
Results: Initiation into same sex activities prior to opposite-sex activities occurs
widely among male youth, especially in rural areas. This may occur as early as 8
or 9 years old, but the most appear to be in the 13-15 year old age group, with
initiating partners in the 17-24 year old group. These are often relatives, such as
brother-in-laws or cousins. In some cases, younger boys are raped by groups of
older boys. Gender roles vary widely and different life courses range from having
no further male to male sex to becoming a professional sex worker. Some move
toward transexual lifestyles, while others become bisexually active. Sex with boys
is seen as a safe substitute for sex with dangerous female sex workers. Most
men claim they do not use condoms or water-based lubricants. Nearly all of those
interviewed were married, or claim they will marry. Of greatest importance was
the necessity to keep their lives hidden from family members.
Conclusions: Early male to male sex poses serious risks, particularly when
the older males have also begun having intercourse with women. Risk increases
with age throughout young adulthood, particularly after moving to urban settings.
As disclosure is rarely possible, anal sex issues are best handled within general male sexual health clinic settings and well controlled venue-based outreach
programmes. Rural boys and men will be most difficult to reach, but using local
traditional healers is a possibility.
14313 Anal intercourse without ejaculation as a safe sex
strategy: Researching something that isn't there
Juliet Richters, S. Knox, H. Santana, S. Kippax. National Centre in HIV Social
Research, Sydney, NSW, Australia
Issues: Anal intercourse without condoms, but without ejaculation inside the
partner (withdrawal), is a common minority practice among gay men that alarms
HIV-prevention practitioners, as it is not an effective safe sex strategy. National
health promotion campaigns have been run to discourage its use by gay men.
Project: The Sydney Men and Sexual Health (SMASH) cohort study of gay
men has collected figures on withdrawal since 1993. Interviews from qualitative
studies of gay couples, of putative seroconversion events and of sex-on-premises
venues are also analysed.
Results: SMASH statistics reveal that the majority of 'withdrawers' are men
who commonly also practise unprotected intercourse with ejaculation. Withdrawal
as a deliberate practice is thus much less widespread than it appeared. Men who
withdraw but do not use condoms differ from men who have unsafe sex with
ejaculation and from condom users in their liking for anal and 'esoteric' sexual
practices and their attitudes to condoms.
Interview analyses reveal complex patterns of practice in which what has been
labelled 'withdrawal' by researchers and in health promotion campaigns is not defined in such terms by respondents. Important issues include dislike of condoms,
erectile difficulties, preferences for a variety of sexual practices, the emotional
connotations of ejaculation and of receiving semen, and differing understandings of the mechanism of HIV transmission. Results show the inadequacy of
notions of sex as negotiated between two people in other social circumstances
for comprehending sex as practised in sex-on-premises venues.
Lessons learned: Most men who sometimes have sex without ejaculation
inside the partner are not deliberately practising withdrawal. Concepts and assumptions from heterosexual practice and fertility control are inappropriate to
describe sexual practice in gay men. We need better ways of understanding how
sexual sensation is interpreted by the individual, and how the sexual partner's
behaviour is interpreted and influenced/controlled (or not) in order for the sexual
actor to gain his own pleasures.
14314 Sex is more than HIV risk: The many roles sex plays in
the lives of young gay men
Robert B. Hays, S.M. Kegeles, T. Slama, M. Chesney, T.J. Coates. UCSF Center
for AIDS Prevention Studies 74 New Montgomery San Francisco CA 94105, USA
Background: Interventions to change young gay men's sexual behavior must
recognize the profound significance sex has for them and the personal context
of their sexual acts. We identified the meanings sex has for young gay men and
examined men's subjective interpretations of why they engaged in unsafe sex.
Methods: 137 young gay men (age 18-27; 22% Black, 22% Latino, 36%
White, 18% Asian), recruited from bars, streets, community events and public
sex venues, participated in in-depth, semi-structured qualitative interviews which
examined the personal meanings sex had for them and the roles sex played in
their lives. They also described in detail their most recent safe and unsafe sexual
interactions and discussed factors which influenced how the acts transpired.

Interviews were transcribed and content-analyzed.
Results: The multi-layered functions sex serves for young men were striking;
73% identified at least 3 different meanings sex had for them. The physical
pleasures of sex were frequently cited (72%), but the interpersonal roles of sex
were equally prominent (69%), i.e., serving as a way to express affection (46%),
as a relationship-building tool - to get to know someone, make friends or test the
potential for a relationship (33%), and as a way to please a partner (7%). Sex

also served important psychological functions, i.e., alleviating loneliness (25%),
boosting self-esteem/validating one's desirability (23%), releasing stress (12%),
self-exploration (12%), gaining power over others (9%), sensation-seeking (6%),
spirituality (4%), and fulfilling a social norm (5%). 7% acquired money or other
material rewards from sex. 4% described sex as an addiction/compulsion. Frequently cited reasons for unsafe sex were: assuming the partner was "safe", i.e.,
HIV- or monogamous (39%), influence of drugs/alcohol (37%), physical enjoyment (24%), feeling invulnerable (22%), losing control in "heat of moment" (20%),
non-assertiveness (16%), desire to please partner (12%), pressure from partner
(10%), curiosity (10%), and no condoms available (10%). Most men knew their
behavior was risky for HIV, but felt their personal needs had overwhelmed their
health concerns.
Conclusions: To be effective, HIV prevention programs must respect the complex, multi-determined nature of sex for young gay men and understand their
personal meanings of sex. Helping men to identify their reasons for having sex
in particular situations, explore alternative means of filling those needs and/or
empower them to have sex safely may prove valuable. Focusing on the disease
transmissibility of sex should not overshadow an appreciation of the important
interpersonal and psychological roles sex serves for young gay men.
14315 Factors associated with sexual abstinence in the Chicago
Women's Interagency HIV Study (WIHS)
Alice Kim1, K. Weber1, M. Cohen1, J. Burke1, M. Santiago1, A. Dunmore2
1Cook County Hospital, 1900 W Polk St, 1246, Chicago, IL, 60612; Chicago, IL;
2Rush Presbyterian, St. Luke's Hospital, Chicago, USA
Objective: To determine the prevalence of and factors related to sexual abstinence in the Chicago WIHS.
Methods: The WIHS is a US multi-site longitudinal study of HIV disease in
women. Chicago data included Visit 1 (V1, n = 340) and 1,321 follow-up (f/u)
visits. Factors (psychosocial, sexual, and drug behaviors, disease stage and
therapies) were tested for association with abstinence by chi-square analysis at
V1 and two-year f/u (V5, n = 240). Abstinence was defined as reporting no sexual
encounter for six months prior to a visit. Reasons for and sequelae of abstinence
were determined through participant focus groups and newsletter submissions.
Results: Of 340, 185 women (54%, 164 HIV+, 21 HIV-) reported abstinence
at any visit. Analysis of the HIV+ cohort showed 92/279 (33%) were abstinent at
V1 and 72/189 (38%) were abstinent at V5. Women with CD4 < 200 were more
likely to be abstinent than those with CD4 > 200 (V1, 53.3% vs. 23.7%, p <.001).
Women reporting no current hard drug use were more likely to be abstinent than
those reporting current use (V1, 40.4% vs. 21.1%, p =.001). Women with detectable plasma viral loads were more likely to be abstinent than those with undetectable plasma viral loads (V1, 37.7% vs. 22.1%, p =.010; V5, 40.8% vs. 34.7%,
p =.400). Abstinence was associated with greater depression (V5, p =.036) and
poorer quality of life (V5, p =.001). Reasons for abstinence included anger at
men; fear of bad experiences; lack of opportunity or desire; and prevention of
pregnancy or disease. Alternative expressions for sexual energy included masturbation and fantasy; non-sexual intimacy and sensual experiences; spirituality and
activism. Feelings related to abstinence included empowerment, independence,
contentment, sexual dissatisfaction, low self-esteem and loneliness.
Conclusions: Sexual abstinence is a significant factor in the overall health
and feelings of well being among HIV+ women. Providers should be made aware
of the varied ways sexual abstinence impacts the lives of HIV+ women. Further
studies to determine specific reasons for sexual abstinence and its influence on
women's overall health may help in devising more holistic treatment.
14316 Promoting open discussions about sexuality to enable
behavior change among the youth in rural Uganda
Haruna Kharim1, S. Asuzi2, S. Tani2, P. Waka2, J.W. Idro2, J. Homsy3. 1Moyo
AIDS Control Initiative (MACI), Adjaumani; 2MACI, Adjumani; 3MSF-Switzerland,
Kampala, Uganda
Issues: Talking about AIDS, sex and the sexual organs is difficult in this remote
district of Uganda where Madi, our local language, is not direct when mentioning
the sexual organs. Penis and vagina are indirectly called "body" and sexual fluids
like semen and vaginal fluids are referred to as "urine".
Project: In order to promote open discussion of sexuality as a means to responsible behavior change and acceptance of condom use, separate workshops
for males and females have been organised for youth aged 15-25. The workshops aimed at making participants feel free to discuss among themselves about
sexual organs and their functions, stages in organ development, advantages and
disadvantages of sex, and the importance of protecting the body from the dangers
of infections.
Results: Twenty workshops of 1-day each were conducted for a total of 700
young men and 300 young women. Reported outcomes from participants and
project field staff after 1 year include:
(a) Changes in sexual behavior noted through reduction in number of pregnancies in schools

(b) Higher demand for condom and increased number of condom packages
seen dropped in discos
(c) Many new condom sales points opened through shops and clinics
Lessons learned: The youth have shown positive responses to receiving sex
education. Promoting behavior change among the sexual active youth using innovative/adapted approaches can give results even in a rural African community
not traditionally open to discussing sexual matters openly.