1. Sex in the Age of PrEP and U=U
Presented by:
Tim Vincent, MS
2018
Riverside County
SYPHILIS COMMUNITY COLLABORATIVE

2. Notes for Reviewer
Riverside County has long led the way in activities to address the syphilis epidemic amongst gay men and other MSM. As seen in many programs providers are struggling with talking to their patients about the reality of U=U and PrEP. There are many provider concerns about promoting these and the effect they have on STD rates. The Syphilis Community Collaborative sought assistance with helping providers gain trust in the effectiveness of biomedical interventions, and began the dialog of how they can inform patients. Additionally, the Collaborative wanted to assure providers are being sensitive to the sexual context of gay men and other MSM and interacting in a sex positive, affirming manner. The presentation starts with the evidence for effectiveness of U=U, discusses the impact of sex negativity and lays the foundation for a sex positive approach.

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4. Note: Interactive poll presented in live session.

5. Note: Virtual whiteboard used during live session
Note: Virtual whiteboard used during live session. Participants are able to type via their phone to populate the whiteboard.

6. Sex Positive Messaging
Tenets to Set Context
Harm Reduction
Sex Positive Messaging
Sexual Health Focus 6

7. DefinDeition of Sexual Health (World Health Organization’s 2006a)
“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” 
DefinDeition of Sexual Health (World Health Organization’s 2006a)
“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” 
Close this section with then definition of sexual health form the WHO. Acknowledge that there are many definitions out there. 7

9. Note: Interactive poll presented in live session.

10. Healthy Sexuality I am comfortable with my body and my sexuality.
I am able to recognize risks and ways to reduce them.  
I know how to access and use health care services and information.  
I can talk effectively with my peers, family, and partners.  
I am able to set boundaries when it comes to sex and sexual relationships.  
I know my body and how it functions.  
I understand the risks, responsibilities, and consequences of sexual behavior.  
I act responsibly according to my personal values.  
I am able to form and maintain healthy relationships.
[1] New York State Department of Health: Guiding Principles for Sexual Health Education for Young People: A Guide for Community-Based Organizations

11. Risk of HIV Transmission: if no condoms, no PrEP, and no treatment, transmission per 10,000 sex acts
Patel et al (2014). Estimating per-act HIV transmission risk: a systematic review. AIDS, 28(10),

12. CDC Estimates of Efficacy Treatment >96% PrEP for MSM >92%, heterosexuals 90% Condoms 63% to 80%
Patel et al (2014). Estimating per-act HIV transmission risk: a systematic review. AIDS, 28(10),

13. https://wwwn.cdc.gov/hivrisk/estimator.html#-~sb

14. History Matters

15. Risk Compensation

16. When ART results in viral suppression, defined as less than 200 copies/ml or undetectable levels, it prevents sexual HIV transmission. Across three different studies, including thousands of couples and many thousand acts of sex without a condom or pre-exposure prophylaxis (PrEP), no HIV transmissions to an HIV-negative partner were observed when the HIV-positive person was virally suppressed. This means that people who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitted the virus to an HIV-negative partner.
Emphasis Added

17. Video link to the community talking about U=U

18. Risk Compensation
Risk “homeostasis” is defined as “a system in which individuals accept a certain level of subjectively estimated [or “perceived”] risk to their health in exchange for benefits they expect to receive from the behavior.
In accepting a particular level of risk of an adverse event, individuals maintain an approximate risk set point.
However, introduction of an intervention that reduces the perceived risk of the behavior or activity may cause a person to increase risky behavior—this is called “risk compensation” [8] so that the discrepancy between the level of risk he or she takes and the perceived risk increases.
Risk Compensation in PrEP: An Old Debate Emerges Yet Again- Blumenthal, J, Haubrich, R.

19. Sex Negativity The idea or belief that sex is BAD Dangerous Sinful
Dirty
Shameful
Redeemed only by procreation, marriage, and/or love
Judges the what & who, rather than the how & why
How do we reinforce these concepts in our work?
Who is left out of sexual redemption?
Charlie Glickman, PHD. Adapted from, “The Language of Sex Positivity,” Loving More Magazine #21 Spring 2000.

20. Negative Effects on Sexual Health
Makes us question our normality
Fosters Secrecy & Silence
Stops exploration
Barrier to Client/Provider communication
Promotes unrealistic expectations
Funding issues
Ineffective programs
How do we reinforce these concepts in our work?
Who is left out of sexual redemption?
Charlie Glickman, PHD. Adapted from, “The Language of Sex Positivity,” Loving More Magazine #21 Spring 2000.

24. Note: Virtual whiteboard used during live session
Note: Virtual whiteboard used during live session. Participants are able to type via their phone to populate the whiteboard.

25. Tim Vincent tim.vincent@ucsf.edu
Thank You
Tim Vincent
California Prevention Training Center
300 Frank Ogawa Plaza, Suite #520
Oakland, Ca
@CA PTC_CBA