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The buzz-word in terms of HIV prevention among gay and bisexual men plus other men who have sex with men (MSM, which includes straight men who occasionally play) is undoubtedly combination prevention. This implies a combination of bio-medical, behavioural and related strategies that, in various combinations, offer the best prevention against STIs and HIV.

The buffet of prevention strategies allows gay guys and same-sex couples to choose the most effective strategy that satisfies their needs and lifestyles.
It is no longer realistic to merely promote a single method of HIV prevention to gay men. Why this emphasis on combination prevention? Quite simply, we know that although consistent use of condoms and condom-compatible lubrication is important, many gay men in South Africa do not follow this strategy. So exactly what is on the prevention menu?
The basic starters are generally behavioural and include more frequent masturbation and the use of sex toys as opposed to going out to meet a guy for sex. Being honest, increased masturbation and using sex toys help to curb our cruising, although I obviously acknowledge that gay men cruise because of multiple reasons other than simply being horny. Cam sex (internet-based sex using cameras) is becoming increasingly popular as it allows an element of visual stimulation and interaction, if not direct physical contact. Interestingly cam sex also provides a perfect opportunity for bi-curious straight men to explore their homo-erotic fantasies because they remain in control of what they show and can remain – quite literally – both cocked and faceless, which hasn’t been readily possible since the demise of glory holes in most South African urban centres.
Relatively new buzz-words in terms of gay sex and prevention strategies include sero-adaptive behaviours, PrEP, PEP, condoms and appropriate lubricant. And of course there’s early treatment, or TasP.
Sero-adaptive behaviours include sero-sorting and sero-positioning. Sero-sorting involves guys looking for a sexual partner with the same HIV status, either positive or negative. We see evidence of this on cruising sites: “I’m negative and you should be too” or “Disease free, want same”. While sero-sorting may work for HIV positive guys who are looking for other positive guys to play with, it clearly doesn’t work for HIV negative guys seeking negative guys: most guys who claim to be negative cannot be sure of their status because of ongoing risk-taking and exposure to the virus.
Sero-positioning, often used by sero-discordant couples (one being HIV positive and the other being either negative or with an unknown HIV status) implies an attempt to reduce the risk of transmission to the negative partner by not exposing him to the positive partner’s semen. The HIV negative partner therefor assumes the top role during anal penetration and thus avoids the positive partner’s semen from entering the negative partner’s anus.
Medical male circumcision (MMC) is a valid prevention strategy for men who also have sex with women in that it prevents their being infected with HIV if they have sex with an HIV positive woman. Circumcision doesn’t curtail a man’s risk of spreading the virus if he is HIV positive and – importantly – it has no proven benefits regarding HIV prevention during anal sex. Gay guys who only ever have sex with men don’t appear to benefit from MMC in terms of HIV prevention, but the data here is inconclusive.
PrEP (pre-exposure prophylaxis) refers to the use of antiretroviral drugs (ARVs, treatment used to manage HIV) as a prevention strategy prior to exposure to the virus. This can be compared to someone taking anti-malarial medication before and whilst visiting an area in which malaria is prevalent. Research has shown that PrEP is effective for gay guys who are able to take the medication regularly, but many men in research studies were unable to be adherent and dynamics surrounding this need further investigation.
PEP (post-exposure prophylaxis) refers to the use of ARVs to limit the chances of HIV infection following a high-risk exposure to the virus. PEP, which must be initiated within 72 hours of exposure to the virus, is taken for 28 days post exposure and must be scripted by a doctor or a suitably-qualified nurse.
Treatment as prevention and early treatment (TasP) involves treating HIV positive men to lower the amount of HIV in their bodies and thus in their blood and semen, reducing their risk of infecting a partner. An undetectable viral load significantly reduces the risk of transmission.
Additions to the range of preventive technologies currently being research include anal microbicides; in a nutshell these will consist of a lubricant suitable for anal sex containing a substance that will help prevent HIV transmission. A very nifty idea!
Government-issue male condoms, in their blue Choice packaging, are generally available. Health4Men’s specially imported condoms are a viable alternative, being slightly larger (and hence more comfortable and less likely to cause erectile dysfunction) and available in both natural and black. All male condoms must be used with water-based lubricant; any lubricant containing oils will weaken the latex, contributing to condom breakage. Health4Men also promotes the use of what are currently referred to as female condoms for anal sex.
Combination prevention relies on changing behaviours to lower the risks of HIV transmission, coupled with technology such as medication, condoms and latex-compatible lubricants to reduce infection risks. No single HIV prevention method is fool-proof or provides 100% protection; a combination of methods is best. Remember that consistent use of condoms and appropriate lube should form the basis of any prevention package.
See Health4Men’s extensive range of informative fact sheets on various sexual health topics, including combination prevention, at health4men.co.za.


Glenn is the programme manager of Health4Men, a project of the Anova Health Institute.

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