Risk behaviors for HIV infection. A review of emerging trends

Yasel Manuel Santiesteban Díaz Solon Alberto Orlando-Narváez Rafael Ballester-Arnal About the authors

Abstract

HIV infection, acquired with the conscious participation of the recipient, is a complex problem of international concern, especially among men who have sex with men. Behaviors emerge such as bareback (intentionally unprotected anal sex between men) and bugchasing (bareback sex when one participant is HIV+ and the other is not). A group of emerging risk behaviors for HIV infection was characterized. A review of the literature in the MEDLINE, Web of Science and regional SciELO databases was performed. HIV-related search terms such as unprotected sex, barebacking/bareback and bug chasing, were used. Bareback and bug chaser behaviors occur, among other factors, through social homonegativity, ART positive coverage, insufficient prevention campaigns, search for new sensations and attempts to strengthen the relationship with the HIV+ member. Unprotected sex is primarily associated with having HIV/AIDS diagnoses, physical violence due to sexual orientation, viewing homosexual sex sites, and having bought or sold sex. It is necessary to work with individual behaviors that draw individuals close to infection.

HIV; Behavior; Bareback; Risk; Sex

Introduction

The HIV/AIDS epidemic has been viewed from its social, economic and political realm and in its relationship with other Sexually Transmitted Infections (STIs). However, there are still some gaps in the knowledge of the individual’s role, such as being vulnerable to acquire the infection, which could be summarized in a dynamic process involving different factors (social, environmental and cultural)11. Gala González A, Berdasquera Corcho D, Pérez Avila J, Pinto Valluerca J, Suárez Valdéz J, Joanes Fiol J, Sánchez L, Aragonés Lopez C, Díaz González, M. Dinámica de adquisición del VIH en su dimensión social, ambiental y cultural. Rev Cubana Med Trop 2007; 59(2):90-97.. So far, no vaccine or therapeutic agent is capable of eliminating HIV. Thus, the response is prevention geared towards working with transmission routes and vulnerable groups.

Epidemiological trends since the mid-1990s suggest an alarming hike of unprotected sexual behaviors among men who have sex with men (MSM), a phenomenon found mainly in large homosexual communities22. Chen JL, Kodagoda D, Lawrence AM, Kerndt PR. Rapid public health interventions in response to an outbreak of syphilis in Los Angeles. Sex Transm Dis 2002; 29(5):277-284.,33. Wolitski RJ, Valdiserri RO, Denning PH, Levine WC. Are we headed for a resurgence in the HIV epidemic among men who have sex with men? Am J Public Health 2001; 91(6):883-888.. These data show a gradual increase in HIV infections in this population at the time44. Kellogg T, McFarland W, Katz M. Recent increase in HIV seroconversions among repeat anonymous testers in San Francisco. AIDS 1999; 13(16):2303-2304.,55. Van de Ven P, Prestage G, Crawford J, Grulich A, Kippax S. Gay men in Australia who do not have HIV test results. Int J STD AIDS 2000; 11(7):456-460., especially among young gay and bisexual men66. Koblin BA, Torian LV, Gulin V, Ren L, MacKellar DA, Valleroy LA. High prevalence of HIV infection among young men who have sex with men in New York City. AIDS 2000; 14(12):1793-1800.,77. Valleroy LA, MacKellar DA, Karon JM, Rosen DH, McFarland W, Shehan DA, Stoyanoff SR, LaLota M, Celentano DD, Koblin BA, Thiede H, Katz MH, Torian LV, Janssen RS. HIV prevalence and associated risks in young men who have sex with men. JAMA 2000; 284(2):198-204..

At present, these behaviors have diversified and become increasingly complex. We observe behaviors such as the so-called bareback 9 (performance of intentional unprotected anal sex between men who are not steady partners); bug chasing 10 (virus chasers), the act of performing bareback sex when one of the participants is HIV+ and the other is not; and gift giver 10 (the one giving a gift) (HIV+individuals who lend themselves to donate their virus to those who wish to receive it). Although media outlets have drawn attention to some trends that are unfavorable to epidemic control efforts, they have not yet been adequately addressed by scientific studies. In all health problems, as is undoubtedly HIV, it is necessary to study how the process of transmission of the disease occurs. Several models have been developed to explain the context and causes of HIV/AIDS, as well as to identify the impacts of the epidemic and its control strategies. The model proposed by Coreil et al.88. Coreil J, Whiteford L, Salazar D. The household ecology of disease transmission: Dengue fever in the Dominican Republic. Inhorn MC, Brown PJ, editors. The Anthropology of Infectious Disease: International Health Perspectives. Atlanta: Gordon and Breach Publishers; 2000. breaks down the three macro-environments where the determinants that influence the vulnerability of acquiring a transmissible disease develop: the social environment, the biophysical environment and the culture-based environment. Gala et al.11. Gala González A, Berdasquera Corcho D, Pérez Avila J, Pinto Valluerca J, Suárez Valdéz J, Joanes Fiol J, Sánchez L, Aragonés Lopez C, Díaz González, M. Dinámica de adquisición del VIH en su dimensión social, ambiental y cultural. Rev Cubana Med Trop 2007; 59(2):90-97. adapt this model to the issue of vulnerable behavior, and they identify three types of HIV infection-related behaviors: behaviors that increase exposure to HIV, behaviors that facilitate HIV infection, and behaviors that protect against HIV infection. Therefore, it is presumed that there are risk behaviors that increase the probability of acquiring the infection, and of specific protection that counteract the former and that can be identified to study them as measurement variables of the acquisition process11. Gala González A, Berdasquera Corcho D, Pérez Avila J, Pinto Valluerca J, Suárez Valdéz J, Joanes Fiol J, Sánchez L, Aragonés Lopez C, Díaz González, M. Dinámica de adquisición del VIH en su dimensión social, ambiental y cultural. Rev Cubana Med Trop 2007; 59(2):90-97.. Of those that increase the risk, the participation of the vulnerable individual in the dynamics of virus dissemination acquires a considerable value for the targeting of prevention strategies. This study aims to conduct a literature review to characterize some emerging risk behaviors towards HIV infection.

Methods

A bibliographic review was conducted by searching in the Medline, Web of Science and regional SciELO databases. Some HIV-related search terms used were unprotected sex, barebacking/bareback, and bug chasing. Search was conducted in Spanish and English, with no determination regarding the year the study was published. Only papers with one of the search terms reflecting in their title and which were available in the full-text version were selected. The reference lists of identified items were inspected to complement this process. The primary inclusion criterion was a substantial emphasis on intentional unprotected sex behaviors somehow related to HIV infection. Abstracts of congresses, letters to the editor and book reviews were excluded.

Results

A total of 90 papers were found under the search terms. Of these, 62 belong to the term unprotected sex-HIV, 26 belong to barebacking/bareback terms, and lastly, only two concern bug chaser. The results of the review of these terms will be described separately below.

Bareback

The phenomenon of barebacking has been examined from the perspective of sociology99. Shernoff M. Condomless Sex: Gay Men, Barebacking, and Harm Reduction. Social Work 2006; 51(2):106-113.

10. Silva, LA. Cybersexuality and online research: some reflections about the concept of barebacking. Interface (Botucatu) 2010;14(34):513-528.

11. Silva LA, Iriart JA. Practices and meanings of barebacking among HIV-positive men who have sex with men. Interface (Botucatu) 2010; 14(35):739-752.
-1212. Nuno N, Pamela V, Ana V, Emily M, Carballo AD. The Internet profiles of men who have sex with men within bareback websites. Cult Health Sex 2011; 13(9):1015-1029., psychology1313. Lewin EW, Leap L. Out in theory: The emergence of lesbian and gay anthropology. Chicago: University of Illinois Press; 2002.

14. Cole, GW. Barebacking: Transformations, dissociations, and the theatre of countertransference. Studies in Gender and Sexuality 2007; 8(1):49-68.

15. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS 2002; 16(4):653-659.

16. Berg RC. Barebacking: A Review of the Literature. Archives of Sexual Behavior 2009; 38(5):754-764.
-1717. Elford J, Bolding G, Davis M, Sherr L, Hart G. Barebacking among HIV-positive gay men in London. Sexually Transmitted Diseases 2007; 34(2):93-98., and public health1616. Berg RC. Barebacking: A Review of the Literature. Archives of Sexual Behavior 2009; 38(5):754-764.

17. Elford J, Bolding G, Davis M, Sherr L, Hart G. Barebacking among HIV-positive gay men in London. Sexually Transmitted Diseases 2007; 34(2):93-98.

18. Halkitis PN. Behavioral patterns, identity, and health characteristics of self-identified barebackers: Implications for HIV prevention andintervention. Journal of GLBT Health Research 2007; 3(1):37-48.

19. Cuadra-Hernández SM, Baruch-Domínguez R, César I, Granados-Cosme JA. Dame una pastilla”: los significados del VIH/sida en la práctica del bareback en la ciudad de México e implicaciones para la prevención. Salud Pública de México 2015; 57(2):113-118.

20. Bauermeister JA, Carballo-Diéguez A, Ventuneac A, Dolezal C. Assessing motivations to engage in intentional condomless anal intercourse in HIV-risk contexts (“bareback sex”) among men who have sex with men. AIDS Educ Prev 2009; 21(2):156-168.

21. Iván CB, Carballo-Diéguez A, Ventuneac A, Robert HR, Dolezal C, Ford J. HIV-negative Men-who-Have-Sex-with-Men who Bareback are Concerned about HIV Infection: Implications for HIV Risk Reduction Interventions. Arch Sex Behav 2013; 42(2):279-289

22. Frasca T, Ventuneac A, Balan I, Carballo-Diéguez A. Inner Contradictions Among Men Who Bareback. Qual Health Res 2012; 22(7):946-956.
-2323. Silva LA. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafios. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafíos. Psicología & Sociedade 2012; 24(2):327-336., among other sciences. Despite the disparate perspectives, most of these reports agree on addressing definitional issues and factors that may explain the popularity of unprotected barebacking sex.

The term bareback is an equestrian expression that means riding without a saddle. It was first introduced outside the equestrian terms by O’Hara2424. O’Hara S. Autopornography. New York: Haworth; 1997. in 1997. It was later defined by Goodroad et al.2525. Goodroad BK, Kirksey KM, Butensky E. Bareback sex and gay men: An HIV prevention failure. J Assoc Nurses AIDS Care 2000; 11(6):29-36. as the performance of intentionally unprotected anal sex between men who are not a steady couple. The term bareback, quoting Bazaldúa2626. Bazaldúa D. Evaluación actitudinal y conceptos asociados al Bareback en hombres que tienen sexo con otros hombres en la Ciudad de Mexico. Revista Salud & Sociedad 2010; 1(1):41-50., is also known as “bareback sex” or “natural sex” and can be differentiated from other risky sexual practices because of: 1) the intentionality and premeditation of performing the sexual act without adopting a barrier method such as condom in its multiple presentations; 2) the focus on anal sex practices among men; 3) the temporal and cultural reference after the emergence and spread of HIV/AIDS.

Bareback studies have been mainly written in the USA99. Shernoff M. Condomless Sex: Gay Men, Barebacking, and Harm Reduction. Social Work 2006; 51(2):106-113.,1212. Nuno N, Pamela V, Ana V, Emily M, Carballo AD. The Internet profiles of men who have sex with men within bareback websites. Cult Health Sex 2011; 13(9):1015-1029.

13. Lewin EW, Leap L. Out in theory: The emergence of lesbian and gay anthropology. Chicago: University of Illinois Press; 2002.

14. Cole, GW. Barebacking: Transformations, dissociations, and the theatre of countertransference. Studies in Gender and Sexuality 2007; 8(1):49-68.
-1515. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS 2002; 16(4):653-659.,1818. Halkitis PN. Behavioral patterns, identity, and health characteristics of self-identified barebackers: Implications for HIV prevention andintervention. Journal of GLBT Health Research 2007; 3(1):37-48.,2121. Iván CB, Carballo-Diéguez A, Ventuneac A, Robert HR, Dolezal C, Ford J. HIV-negative Men-who-Have-Sex-with-Men who Bareback are Concerned about HIV Infection: Implications for HIV Risk Reduction Interventions. Arch Sex Behav 2013; 42(2):279-289 although some approaches are found in Europe1717. Elford J, Bolding G, Davis M, Sherr L, Hart G. Barebacking among HIV-positive gay men in London. Sexually Transmitted Diseases 2007; 34(2):93-98. and Latin countries such as Mexico1919. Cuadra-Hernández SM, Baruch-Domínguez R, César I, Granados-Cosme JA. Dame una pastilla”: los significados del VIH/sida en la práctica del bareback en la ciudad de México e implicaciones para la prevención. Salud Pública de México 2015; 57(2):113-118.,2626. Bazaldúa D. Evaluación actitudinal y conceptos asociados al Bareback en hombres que tienen sexo con otros hombres en la Ciudad de Mexico. Revista Salud & Sociedad 2010; 1(1):41-50. and Brazil1010. Silva, LA. Cybersexuality and online research: some reflections about the concept of barebacking. Interface (Botucatu) 2010;14(34):513-528.,1111. Silva LA, Iriart JA. Practices and meanings of barebacking among HIV-positive men who have sex with men. Interface (Botucatu) 2010; 14(35):739-752.,2323. Silva LA. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafios. Redução de riscos na perspectiva dos praticantes de barebacking: possibilidades e desafíos. Psicología & Sociedade 2012; 24(2):327-336.. Barebackers are a group with disruptive practices within the gay world and are a change in the values and meanings associated with what is considered politically correct in the field of HIV prevention, such as the appropriate and systematic use of condoms1919. Cuadra-Hernández SM, Baruch-Domínguez R, César I, Granados-Cosme JA. Dame una pastilla”: los significados del VIH/sida en la práctica del bareback en la ciudad de México e implicaciones para la prevención. Salud Pública de México 2015; 57(2):113-118..

In general terms, researchers and scholars have concluded two critical elements that had to be included in the definition of barebacking: the intentionality of unprotected sex and the acceptance of the risk of contracting STI/HIV1515. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS 2002; 16(4):653-659.,2727. Vasconcelos LA. Barebacking e a possibilidade de soroconversão. Cad Saude Publica 2009; 25(6):1381-1389. Due to the hidden nature of the MSM population, bareback prevalence rates cannot be retrieved accurately. However, some investigations approach the problem from measures of self-reported behavior. For example, a cross-sectional study conducted in New York2828. Halkitis PN, Parsons JT. Intentional unsafe sex (barebacking) among HIV-positive gay men who seek sexual partners on the Internet. AIDS Care 2003; 15(3):367-378.,2929. Halkitis PN, Wilton L, Galatowitsch P. What’s in a term? How gay and bisexual men understand barebacking. Journal of Gay & Lesbian Psychotherapy 2005c; 9(3-4):35-48. indicates a prevalence of 34.9-45.5%, another in San Francisco 10%1515. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS 2002; 16(4):653-659., in Central Arizona 65%3030. Huebner DM, Proescholdbell RJ, Nemeroff CJ. Do gay and bisexual men share researchers’ definition of barebacking? Journal of Psychology & Human Sexuality 2006; 18(1):67-77., 12.3% in London1717. Elford J, Bolding G, Davis M, Sherr L, Hart G. Barebacking among HIV-positive gay men in London. Sexually Transmitted Diseases 2007; 34(2):93-98. and between 39.2% and 83.9% of MSM who report online to practice bareback throughout the United States2828. Halkitis PN, Parsons JT. Intentional unsafe sex (barebacking) among HIV-positive gay men who seek sexual partners on the Internet. AIDS Care 2003; 15(3):367-378.,3131. Berg RC. Barebacking among MSM Internet users. AIDS and Behavior 2008; 12(5):822-833..

Factors associated with barebacking

Several authors have tried to explain barebacking from different methodological designs, population, and theoretical approaches. In a review study on this practice, Berg1616. Berg RC. Barebacking: A Review of the Literature. Archives of Sexual Behavior 2009; 38(5):754-764. proposes a conceptual model that reflects the dynamics of the relationships that serve as the basis for understanding barebacking. This author proposes four levels in which this behavior develops.

Macro level

One of the essential factors that influence these behaviors is the ideology of heterosexuals, which is restrictive and alienating for homosexuals. This series of arrogant heterosexual concepts and beliefs have in some way caused the emergence of the so-called “homonegativism”, contributing to the social rejection of homosexuals as minorities. Some social researchers3232. Blechner MJ. Intimacy, pleasure, risk, and safety: Discussion of Cheuvront’s ‘High-risk sexual behavior in the treatment of HIV negative patients’. Journal of Gay & Lesbian Psychotherapy 2002; 6(3):27-33.,3333. Crossley ML. Making sense of ‘barebacking’: Gay men’s narratives, unsafe sex, and the ‘resistance habitus’. British Journal of Social Psychology 2004; 43(Pt 2):225-244. frame barebacking in an oppressive society where some homosexual men, in protest, affirm transgressive behaviors such as bareback. Another critical issue is associated with the effects and positive coverage of Antiretroviral Therapy, which has undoubtedly allowed a slowing of the progression of the disease and significantly reduced AIDS-related deaths. This progress has caused the homosexual community to perceive HIV as another chronic disease, which is easily managed by doctors extending survival years, which, therefore, contributes to the maintenance of bareback behaviors since concern about seroconversion is reduced.

The Internet has become a social structure that provides dating services through endless opportunities, among which are chat rooms, personal ads, email lists, and so forth. This platform facilitates and serves as a means for barebackers to find pairs. The homosexual community also considers it the most common medium2828. Halkitis PN, Parsons JT. Intentional unsafe sex (barebacking) among HIV-positive gay men who seek sexual partners on the Internet. AIDS Care 2003; 15(3):367-378.. The results of studies on Internet use3131. Berg RC. Barebacking among MSM Internet users. AIDS and Behavior 2008; 12(5):822-833.,3434. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS 2002; 16(4):653-659.,3535. Jonas K J, Hawk ST, Vastenburg D, de Groot P. ‘Bareback’’Pornography Consumption and Safe-Sex Intentions of Men Having Sex with Men. Arch Sex Behav 2014; 43(4):745-753. show how 63% of homosexuals use the Internet to search for partners, and barebackers use this network the most.

Meso-level

Among the factors related to the emergence of barebacking, in a 2001 study, Carballo-Diéguez3636. Carballo-Dieguez A. HIV, barebacking, and gay men’s sexuality, circa 2001. Journal of Sex Education and Therapy 2001; 26:225-233. mention the lack of social activism in campaigns in favor of the homosexual community’s rights, as well as a feeling that the cultural climate in which homosexuals developed had changed, and an increased lack of responsibility was noted. Also, another study shows that barebackers report a lower perception of sexual protection norms compared to the population that does not practice bareback3131. Berg RC. Barebacking among MSM Internet users. AIDS and Behavior 2008; 12(5):822-833..

Interpersonal level

Other factors that promote bareback are related to shared sexual behaviors, such as unprotected anal sex, which are interpersonal processes in which meaning is created and emotions are expressed with the sexual partner3434. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. ‘Barebacking’ in a diverse sample of men who have sex with men. AIDS 2002; 16(4):653-659.. Other studies show that the serological status of the sexual partner seems irrelevant. In a recent study, a quarter of HIV negative or unknown barebackers reported that their sexual partners were HIV+ or unaware of their seropositivity3737. Berg RC. Barebacking among MSM Internet users. AIDS and Behavior 2008; 12(5):822-833..

Internet sex dating sites include discussion of sexual preference and serological status. Also, one can fill this informationin user profiles. However, in the specific sites of barebacking users, any discussion about serological status and condom use is waived since entering these sites assumes that this rule is unconditionally accepted.

Intrapersonal level

There are three main approaches at this level. The first is related to the sociodemographic characteristics of barebackers. Barebacking has been studied in white, black and Latino men, and whites were the most prevalent. Barebackers are associated with variables such as lower educational level, young age and HIV2929. Halkitis PN, Wilton L, Galatowitsch P. What’s in a term? How gay and bisexual men understand barebacking. Journal of Gay & Lesbian Psychotherapy 2005c; 9(3-4):35-48.,3838. Wilton L, Halkitis PN, English G, Roberson M. An exploratory study of barebacking, club drug use, and meanings of sex in Black and Latino gay and bisexual men in the age of AIDS. Journal of Gay & Lesbian Psychotherapy 2005; 9(3-4):49-72.,3939. Carballo-Diéguez A, Ventuneac A, Dowsett GW, Balan I, Bauermeister J, Remien RH, et al. Sexual Pleasure and Intimacy Among Men who Engage in “Bareback sex. AIDS Behav 2011; 15(1):57-65.. Another important and central aspect of this whole plot is related to the reasons why barebackingis performed.

One of the most described reasons is the desire for pleasure and seeking new sensations. Others are related to the affirmation of masculinity, a display of virility and greater masculine sexuality. The romantic obsession is another category very much related to sexual adventure, sexual compulsivity and search of sexual sensations. These results are based on the thesis that barebackers are possibly the seekers of sexual sensations that show a higher intensity and willingness to accept or even seek sexual risk encounters4040. Carballo-Dieguez A, Bauermeister J. ‘‘Barebacking’’: Intentional condomless anal sex in HIV-risk contexts. Reasons for and against it. Journal of Homosexuality 2004; 47(1):1-16.. Finally, the consumption of alcohol and psychoactive substances has been associated with barebacking in various studies.

Bug Chaser

The “Bug Chasers” group is a homosexual subculture that voluntarily shows a willingness to acquire HIV4141. Moskowitz DA, Roloff ME. The Existence of a Bug Chasing Subculture. Culture, Health and Sexuality 2010; 9(4):347-357.. The first approaches to the subject were mainly press reports4242. Gendin S. Riding bareback: Skin-on skin sex been there, done that, want more. POZ Magazine 1997; 25:64-65.

43. Gauthier DK, Forsyth CJ. Bareback sex, bug chasing, and the gift of death. Deviant Behaviour 1999; 20(1):85-100.

44. Freeman GA. In search of death. Rolling Stone 2003; 915:44-48.
-4545. Hatfield K. A Quest for belonging: exploring the story of the bug chasing phenomenon. Paper presented at the National Communication Association Conference; Chicago; IL; 2004.. However, a group of written papers where the subject is addressed more clearly4141. Moskowitz DA, Roloff ME. The Existence of a Bug Chasing Subculture. Culture, Health and Sexuality 2010; 9(4):347-357.,4646. Graydon M. Don’t Bother to Wrap It: Online Giftgiver and Bugchaser Newsgroups, the Social. Impact of Gift Exchanges and the “Carnivalesque”. Culture, Health & Sexuality 2007; 9(3):277-292.

47. Grov C, Parsons JT. Bug Chasing and Gift Giving: The Potential for HIV transmission Among Barebackers on the Internet. AIDS Education and Prevention 2006; 18(6):490-503.

48. Moskowitz DA, Roloff ME. The Ultimate High: Sexual Addiction and the Bug. Chasing Phenomenon. Sexual Addiction and Compulsivity 2007; 14(1):21-40.
-4949. Malkowski Jennifer. Beyond Prevention: Containment Rhetoric in the Case of Bug Chasing. J Med Humanit 2014; 35(2):211-228. is already found in the literature. Faced with this risky behavior, a logical question arises: What differences lie between Barebackers and Bug Chasers?

Some authors have addressed the issue of Barebackers and Bug Chasers as if these behaviors were the same4242. Gendin S. Riding bareback: Skin-on skin sex been there, done that, want more. POZ Magazine 1997; 25:64-65.,5050. Peyser M. A deadly dance. Newsweek 1997; 130:76-77.. Although they share commonalities, such as homosexual sexual orientation and the performance of unprotected anal sex, it is essential to clarify that the primary intention of the Bug Chaser is seeking HIV infection. In the case of the Barebackers, one of the previously commented reasons as to why these practices were produced is the desire for pleasure and seeking new sensations.Bug Chasers may also share these unique sensations to which the fact of the possibility of becoming infected as a relevant extra element is added. Bugchasing is also deemed intensely erotic and the act of being infected is for them the ultimate taboo, the extreme sexual act there is.It is also known that someone that is HIV-negative and in a relationship with someone who is HIV+ looks for the infection as a way to strengthen the relationship, especially when the HIV+partner could end the relationship to avoid transmission of the virus to his seronegative partner. In a study conducted in the USA with a user population of barebacking sites4141. Moskowitz DA, Roloff ME. The Existence of a Bug Chasing Subculture. Culture, Health and Sexuality 2010; 9(4):347-357., it was first established that the issue of the existence of Bug Chasers was not a legend, and then that the use of drugs was more likely in Barebackers than in Bug Chasers, which clears all doubtsconcerning the performance of these acts unconsciously.

Unprotected sex

In the field of sexual risk, a sexual risk behavior would be the exposure of the individual to a situation that may cause harm to his health or the health of another person, primarily through the possibility of infection by sexually transmitted diseases such as HIV5151. Espada-Sánchez JP, Quiles-Sebastián MJ, Méndez-Carrillo JM. Conductas sexuales de riesgo y prevención del Sida en la adolescencia. Papeles del Psicólogo 2003; 24(85):1-15.. HIV continues to spread worldwide mainly through sexual transmission and mainly among MSM. A group of studies in different regions and countries around the world has addressed the issue of the factors associated with these risk practices in the MSM group.In Europe, data collected from the European Men-Who-Have-Sex-With-Men Internet Survey5252. Kramer C S, Schmidt JA, Berg CR, Furegato M, Hospers H, Folch C, Marcus U, EMIS Network. Factors associated with unprotected anal sex with multiple non-steady partners in the past 12 months: results from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS 2010). BMC Public Health 2016; 16:47. show that unprotected sex in this population is mainly associated with being diagnosed with HIV/AIDS, having suffered violence physical due to sexual orientation in the last 12 months, having viewed Gay sex sites in the last 4 weeks, having bought or sold sex, knowledge that antiretroviral treatment reduces the risk of infection, drug use, feelings of loneliness and experience of sexual abuse and intimidation. Another study conducted in Lebanon5353. Glenn JW, Hoover M, Green H, Tohme J, Mokhbat J. Social, Relational and Network Determinants of Unprotected Anal Sex and HIV Testing Among Men Who Have Sex with Men in Beirut, Lebanon. Int J Sex Health 2015; 27(3):264-275. shows some determinants of unprotected anal sex behaviors, such as having a younger age, university education, being in a committed relationship, little communication about HIV/AIDS with a partner, discrimination due to sexual orientation and low self-efficacy in the use of condoms. In Asia, specifically in China5454. Li D, Li C, Wang Z, Lau JTF. Prevalence and Associated Factors of Unprotected Anal Intercourse with Regular Male Sex Partners among HIV Negative Men Who Have Sex with Men in China: A Cross-Sectional Survey. PLoS ONE 2015 10(3):e0119977., a study was conducted to determine the prevalence and factors associated with unprotected anal intercourse among MSM. A prevalence of 52.4% of unprotected sexual intercourse in the previous three months was reported, and the multivariate analysis showed that trust and intimacy within the relationship with the steady partner and the presence of clinical symptoms of depression were positively associated with unprotected anal sex.

Effectively within the topic related to risk behaviors, the relationship of depression with unprotected sex among MSM is being studied5555. Safren SA, Traeger L, Skeer MR, O’Cleirigh C, Meade CS, Covahey C, Mayer KH. Testing a social-cognitive model of HIV transmission risk behaviors in HIV infected MSM with and without depression. Health Psychology 2010; 29(2):215-221.

56. DeSantis JP, Vasquez EP. A pilot study to evaluate ethnic/racial differences in depressive symptoms, self-esteem, and sexual behaviors among men who have sex with men. Journal of Gay and Lesbian Social Services 2011; 23(2):147-164.
-5757. Klein H. Depression and HIV Risk Taking among Men Who Have Sex with Other Men (MSM) and Who Use the Internet to Find Partners for Unprotected Sex. J Gay Lesbian Ment Health 2014; 18(2):164-189.. The first line of thinking supports the idea that depression decreases men’s libido by making them less sexually active5858. Bancroft J, Janssen E, Strong D, Vukadinovic Z. The relation between mood and sexuality in gay men. Archives of Sexual Behavior 2003; 32(3):231-242.,5959. Phillips RL, Slaughter JR. Depression and sexual desire. Am Fam Physician 2000; 62(4):782-786.. Consequently, during periods of active depression, men’s participation in risk behaviors will be lower than at other times when they are not depressed or when they are experiencing less depressive symptoms.

On the other hand, the second line of thought alleges that men who are depressed incur substance abuse and risky sexual behaviors as a means of escape to cope with their negative emotional state5656. DeSantis JP, Vasquez EP. A pilot study to evaluate ethnic/racial differences in depressive symptoms, self-esteem, and sexual behaviors among men who have sex with men. Journal of Gay and Lesbian Social Services 2011; 23(2):147-164.,6060. Parsons JT, Halkitis PN. Sexual and drug-using practices of HIV-positive men who frequent public and commercial sex environments. AIDS Care 2002; 14(6):815-826..

Finally, an interesting topic to address that has been hardly written about is undoubtedly the issue of unprotected sex in females. According to some studies, unprotected sex is perceived by women as a promoter of intimacy between the couple, romance, trust and as a support for stability in the couple6161. Diekman AB, McDonald M, Gardner WL. Love means never having to be careful: The relationship between reading romance novels and safe sex behavior. Psychology of Women Quarterly 2000; 24(2):179-188.

62. Jones R. The reliability and validity of the sexual pressure scale. Res Nurs Health 2006; 29(4):281-293.
-6363. Jones R. Sex scripts and power: A framework to explain urban women’s HIV sexual risk with male partners. Nurs Clin North Am 2006; 41(3):425-436.. A focus group study involving a total of 43 women from different cities in the U.S. mainly aimed to gain an understanding of the reasons why young adult women from urban areas with high HIV prevalence had unprotected sex with men whom they perceived with some mistrust6464. Jones R, Oliver M. Young Urban Women’s Patterns of Unprotected Sex with Men Engaging in HIV Risk Behaviors. AIDS Behav 2007; 11(6):812-821.. The discourse of women at first was nuanced by the idea of sex as a means to ensure a partner in a society where most women seek to satisfy the men’s desires regardless of the risk because, otherwise, men look out elsewhere for many others who are willing to do so. They also argue that if men treat them well, provide them with financial security and fulfill their responsibilities, the risky behaviors they may resort to as long as the man feels satisfied do not matter. These women argued that having unprotected sex was a strategy, since women know what they want in relationships in the long run and that developing strategies from the statement “Sex to secure him, sex to compensate” is an example of unprotected sexual intercourse as a strategy to maintain long-term commitment. After having unprotected sex with high-risk partners, these women felt worried and wanted to be tested for HIV. The interesting thing about all of this is that they continued to have unprotected sex despite these alerts.

Discussion

This paper collects a review of a group of behaviors that put health at risk, mainly of the population of men who have sex with other men around the world. Within the HIV epidemic, significant changes have taken place at the level of health policies, such as scientific and technical advances, in order to provide a comprehensive response to address the multiple consequences of HIV/AIDS infection to health and systems.

The very fact that there are human behaviors that promote, cause and, in some cases, intentionally seek out a disease, undoubtedly shows a different perspective for the organization of preventive plans. According to Cuadra-Hernández6565. Cuadra-Hernández SM, Baruch-Domínguez R, Infante C, Granados-Cosme JA. “Dame una pastilla”: los significados del VIH/sida en la práctica del bareback en la ciudad de México e implicaciones para la prevención. Salud Publica Mex 2015; 57(2):113-118., we are witnessing the “so-called ‘prevention fatigue’, in which fatigue is implicit in the traditional message of condom use, and is a clear example that current strategies do not consider the meanings of the main groups affected regarding their sexuality.” The truth is that the perceived risk of acquiring HIV/AIDS decreases by the day. This disease has gone from being a disease associated with an idea of immediate death to the idea of a drug-controlled chronic disease.

This review shows some realities which science must take into account to plan preventive systems. At a social level, we find the ongoing rejection of homosexuals. Unfortunately, the problem is recurrent despite the “development” achieved in the promotion of social rights, equality and non-discrimination towards this community. This process has resulted in the so-called homonegativism, which is defined as a group of prejudiced beliefs, emotional reactions, and behaviors of stigmatization towards homosexuals6666. Currie M, Cunningham E, Findlay B. The Short Internalized Homonegativity Scale: Examination of the Factorial Structure of a New Measure of Internalized Homophobia. Educational and Psychological Measurement 2004; 64(6):1053-1067.. Some social researchers3232. Blechner MJ. Intimacy, pleasure, risk, and safety: Discussion of Cheuvront’s ‘High-risk sexual behavior in the treatment of HIV negative patients’. Journal of Gay & Lesbian Psychotherapy 2002; 6(3):27-33.,3333. Crossley ML. Making sense of ‘barebacking’: Gay men’s narratives, unsafe sex, and the ‘resistance habitus’. British Journal of Social Psychology 2004; 43(Pt 2):225-244. frame barebacking in an oppressive society where some homosexual men, in protest, claim transgressive behaviors such as bareback. Undoubtedly, these reactions of the MSM community that lead to risky behaviors endanger health, showing once again that social pressure towards minority groups affects not only the affected person’s emotional realm, but also behaviors that can lead to death.

Continuing with the issue of risk we find a facilitating entity which is undoubtedly the Internet. The network of networks provides an essential platform for all kinds of sexual behaviors to be managed among MSM. The social networks that comprise it serve as a facilitator to find a partner and to discuss sexual standards and expectations. According to studies by Carballo-Diéguez3636. Carballo-Dieguez A. HIV, barebacking, and gay men’s sexuality, circa 2001. Journal of Sex Education and Therapy 2001; 26:225-233.,6767. Carballo-Dieguez A, Dowsett GW, Ventuneac A, Remien RH, Balan I, Dolezal C, Luciano O, Lin P. Cybercartography of popular Internet sites used by New York City men who have sex with men interested in bareback sex. AIDS Education and Prevention 2006; 18(6):475-489., most of the MSM-related sites display sex images without a condom and a webdesign with information of highly sex-oriented profiles that include previously determined fields to obtain detailed information on the expected sexual activity. The above highlights that many of the high-risk behaviors are anticipated by fantasy, which in turn translates into settings created by men in articulation with the possibilities and situations they would like the website to develop with the practices that they wish to access, which usually includes identifiable elements of risk.

At the individual level, another important factor that has contributed to the decreased perception of the risk of acquiring HIV and increased risk behaviors is undoubtedly related to antiretroviral therapy (ART). According to Ostrow et al.6868. Ostrow DE, Fox KJ, Chmiel JS, Silvestre A, Visscher BR, Vanable PA, Jacobson LP, Strathdee SA. Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men. AIDS 2002; 16(5):775-780., the triple therapy, as it is also known, has modified the natural history of HIV infection, causing a considerable reduction in mortality, intercurrent complications, and hospitalizations.So much change has undoubtedly led the infection to be perceived no longer as associated with death, but rather as a long-term chronic disease and with several medical alternatives6969. Woolf-King SE, Maisto SA. Alcohol use and high-risk sexual behavior in Sub-Saharan Africa: a narrative review. Arch Sex Behav 2011; 40(1):17-42.. These authors found in this study that more than 50% of a sample of MSM had had unprotected sex, indicating that the arrival of ART had reduced their concern for protection.

The consumption of alcohol and psychoactive substances are behaviors that serve as gateways to behaviors at risk of HIV acquisition. Studies conducted in Africa show an association that is replicated in the rest of the world: people who drink, consume and inject psychoactive substances more are more engaged in risk behaviors and are more likely to acquire an HIV infection6969. Woolf-King SE, Maisto SA. Alcohol use and high-risk sexual behavior in Sub-Saharan Africa: a narrative review. Arch Sex Behav 2011; 40(1):17-42.

70. Shuper PA, Joharchi N, Irving H, Rehm J. Alcohol as a correlate of unprotected sexual behavior among people living with HIV/AIDS: Review and meta-analysis. AIDS Behav 2009; 13(6):1021-1036.

71. Baliunas D, Rehm J, Irving H, Shuper P. Alcohol consumption and risk of incident human immunodeficiency virus infection: a meta-analysis. Int J Public Health 2010; 55(3):159-166.

72. Scott-Sheldon LJ, Walstrom P, Carey K, Johnson B, Carey M. Alcohol use and sexual risk behaviors among individuals infected with HIV: a systematic review and meta-analysis 2012 to early 2013. Current HIV/AIDS Rep 2013; 10(4):314-323.
-7373. Steele CM, Josephs RA. Alcohol myopia. Its prized and dangerous effects. Am Psychol 1990; 45(8):921-933.. One of the most accurate theories to explain this relationship is proposed by Steele & Josephs74, and they called it the “Theory of Myopia”. This theory argues that drugs reduce the ability of individual cognitive processing and block the response to conflict with some inhibition. Unprotected sexual intercourse is in itself a conflict for many individuals and this dissonance is suppressed with the ingestion of these drugs. Many people believe that drugs and sex go hand in hand. Some users exchange sex for drugs, or for money to buy drugs. Some people associate the use of drugs with unprotected sex.

Without a doubt, we are witnessing an era of changes and these transformations are not always accompanied by advances in health indicators and improvement of the systems responsible for planning strategies and preventing diseases. One of the most critical challenges has to do with the behaviors that place the individual closer to the disease. This group of behaviors is perfectly preventable through an adequate promotion and prevention, but to do this, we must gain an in-depth knowledge of the dynamics of the processes that participate and cause the illness of a human being.

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History

  • Received
    16 Nov 2016
  • Reviewed
    27 June 2017
  • Accepted
    29 June 2017
  • Online publication
    02 May 2019
  • Issue publication
    Apr 2019
ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br