When safe sex isn't safe

Seventy-five gay and homosexually active men in Sydney who had recently seroconverted were recruited through their doctors and interviewed in depth between 1993 and 1999 about the event(s) they believed led to their becoming infected with HIV. Interview transcripts were analysed by thematic indexing to explore how the sexual practices reported were organized and negotiated within casual sex encounters, and how men integrated safety considerations into their sexual practice. Accepted patterns of sexual interaction included the following features: (1) oral sex was almost always practised without condoms, (2) nudging or brief anal insertion of the penis without a condom was often not regarded as 'anal intercourse', (3) there was often semen on men's bodies or hands, (4) fisting was usually done with gloves, but fingering was not. Perception of risk focused largely on the visible (e.g. blood or semen). Preventive practice was constrained and enabled by social expectation of reasonable behaviour in contexts such as sex-on-premises venues. Thus, even in a community where the practice of 'safe sex' is explicitly accepted, there is considerable room for HIV transmission. Prevention programme planners need to consider whether clear messages that condoms are not 100% protective would be beneficial and to reconsider the way in which they communicate the idea of 'body fluids'.