An Interview with David Seal

Michigan HIV News, Winter 2001 issue 

David Seal, PhD is an Assistant Professor at the Center for AIDS Intervention Research (CAIR), Medical College of Wisconsin. He is the Milwaukee-Detroit Principal Investigator for the Community Intervention Trial for Youth (CITY Project)- a national study of young men who have sex with men (YMSM). The Midwest AIDS Prevention Project in metro Detroit and the AIDS Resource Center of Wisconsin are the two community-based organizations collaborating for this study. Seal visited MAPP in January for a report on a 1999 survey of HIV risk behavior among YMSM in Detroit and Milwaukee. Following this public forum, Michigan HIV News interviewed Seal.

News:  Will you explain the basic fundamentals of the study, how many cities are participating, and how long has it been going on?

Seal:    Yes, this project is funded by the Centers for Disease Control and Prevention and there are 8 research teams in 13 research sites doing study activities targeting men, aged 15-25, who have sex with other men. The first four years we spent learning about risk behavior patterns and where men congregate, and what strategies to use for intervening particularly with the younger populations, men not of age to go to bars yet.

We are now starting the intervention phase. Half the cities were randomized to receive a community level intervention, and half are the comparison cities. We will do annual surveys in 1999 (the baseline), 2000, and 2001 and 2002. We will then know whether the intervention was successful in the intervention cities relative to the comparison cities.  We will then work on disseminating the program to community-based organizations, and communities that want to develop similar types of programs.

News: What is the most significant factor that you have discovered in behavior this first survey?

Seal:  Number one we're seeing very high rates of testing and we're seeing, by and large, high rates of condom use. People are having sex, but they’re not having tons of unprotected sex. So we're seeing in some ways outreach goals that we've had for years being realized in this younger generation of gay men. We've seen inklings of this in our previous qualitative open-ended work that was previously presented here. But I think it's been affirmed by the quantitative data now, which isn't surprising, but it's certainly of interest to us.

There's again the paradox of the African American communities having the highest rates of condom use and also showing the highest sero-conversion rates. And we're seeing growing sero-conversion rates and prevalence rates among young men who have sex with men, but we're not seeing the high rates of risk behavior that we were seeing in the gay community, say ten or fifteen years ago. We're seeing this reduced risk behavior, but we're still seeing growing rates of seroprevalence, and therefore new cases of HIV-positive people. That is just something that we don't understand yet.

News: You just mentioned some of the significant racial differences.

Seal: Yes, in general I think the most consistent pattern in our crop of findings is that African Americans are reporting more sex, but also more protected anal sex. And we're seeing higher rates of unprotected sex among non-blacks. We're also seeing much higher rates of HIV testing among African Americans than non-African Americans.  And we're showing that African Americans are reporting more intervention exposure within the last six months than other populations. Whether or not those three are correlated or causational, I don't know. Certainly there's a pattern there of African Americans getting more intervention exposure. And even though they're reporting more anal sex, they're protecting themselves more. So they are protecting themselves and they're obtaining high rates of HIV testing. I think those are all positive indicators and it may well be indicative of the targeted work that's been done in the African American community in the last couple years.

News:  There also seem to be a lot of differences between the three age groups.

Seal:  Basically the biggest pattern that we're seeing there is, younger people (aged 15-20) are more involved in intervention programs and report more exposure to HIV education, and I think they're probably hungry for knowledge. The older people, 21-25, probably figure they don't need this anymore. On the other hand we're seeing a lot more anal sex among older men, irrespective of whether it's receptive, insertive, protected or unprotected – which again makes sense. People in their early twenties report more sex than people under 20.

News: But as far as the protection, how did that compare between the age groups?

Seal: The younger kids are reporting less sex. They're having so much less sex – it's less protected sex, but it's also less unprotected sex too. In the 15 -17-age group, it makes sense they're not having a lot of anal sex. It's something the older part of the cohort is going to report, more anal sex.  So, do I make a lot of the fact that (the older groups) are having more protected sex but they're also having more unprotected? They're just having more anal sex in general.

And we're also seeing more substance use in conjunction with anal sex with the older people but again, the older people can go to bars legally, so it's the kind of trend you expect to see and you would question if you didn't see them. I do think it's encouraging though that the younger kids are reporting a lot of intervention exposure. That's not to say that the older people don't need it but at least the younger ones – who we all know do need it – are getting it at much higher rates. So that's a positive.

News: You mentioned that the youngest group seems to be talking more but you're wondering about the quality or the negative effect of that communication.

Seal: Right. The question was "The last time you had sex with a partner did you communicate about condom use?" And it was pointed out that some people could interpret that communication as nonverbal, and we didn't separate that out. But it was found that younger people and African Americans were more likely to report communication, which is good. I think we would all promote communication. There was a time we just taught them to use a condom, and “Know your partner.” I think we need to be careful with the new message of negotiated safety – what some people have relabeled negotiated harm – because talk, number one, doesn't translate into effective knowledge.

For example, the response, "Yeah, I talked about AIDS with my partner; yeah, I talked about condoms" – maybe the talk was "gee condoms are good," or maybe the talk was "I don't like condoms."  I mean we don't know the nature of the talk. Effective talk is talk that will allow you to make an informed decision about the level of risk your partner has, their STD history, their past sexual history in terms of partners or types of behaviors, whether they've received an HIV test and when they've received their test.

The other thing is sometimes when people talk they may actually be less inclined to use condoms because now they do know their partner. They've had one partner for a year, they've used condoms for all that time, they've been HIV tested and think, "Yeah, I really don't think I need to use a condom." And there is a lot of philosophical debate about absolutism and condom use and communication. I've not really taken a position on it. I think it's something that we need to understand better so that we can really help people. I think that's important to people, so we can empower people to make informed decisions, empower them to be able to enact and negotiate their decisions, to feel comfortable with their sexuality.

And if we can do that in a way that doesn't pathologize sexuality and intimacy, then I think we're getting somewhere. I think the field is moving that way, but I don't think we're there yet. I think part of it is that we just don't understand these issues; we haven't studied them. Look at the history of HIV prevention in this country. We went from the very early messages of "Don't be gay; don't be an injection drug user; don't have sex with them and you'll be okay." And then it was "Use a condom; be monogamous" you know, tight messages, "a hundred percent of the time forever." Well those messages really didn't reflect reality either. Then we kind of went to this wave of message, "Know your partner." People took that as "Well, I know them, I've known them for five years," although that knowledge may have nothing to do with their sexual practices. Now we've moved to a generation of messages around negotiated safety. I think that time will tell really, what are the pitfalls of this message, what are the strengths of this message. I think we're starting to see some of that.

News:  Another thing, the surveys seem to indicate that people were actually finding out the sero-status of partners.

Seal:  Yes, one of the questions is "Do you know your partner’s status?" Really the question that we're asking is "what is your perception," or it begs the question “How do you know?”  We actually asked the question “How do you know?” in this study. What we found is that over 75% of men thought their main partner was negative. And the reason they “knew” was that they had been tested together or they saw their partner’s test results. Both of those are somewhat objective measures. That's what I would consider effective communication, effective knowledge that would allow me to make an informed choice. 

On the other hand, with non-main partners, only about a third of men said that the last non-main partner they had sex with was definitively HIV-negative. With non-main partners, we saw the big reason was "My partner told me," or they simply guessed. People use a variety of methods –"Well, they're clean, I know they don't inject drugs, or they don't drink, or they looked healthy" – that are subjective and not based on objective data. To me those are less effective, if not ineffective strategies. So I think it is a real case of question when you ask people “Do you know your partner's status?” It's really how they know that becomes really critical, not what they think their status is.

News: What was the difference between condom use for known partners versus unknown partners?

Seal:    People reported more anal sex with main partners versus non-main partners. Among people who reported main-partner versus people who reported non-main partner, the reported condom use rates were much higher for non-main. Again it makes sense, that's what you’d want to see, men tending to restrict anal sex to main-partners. And when they are having sex with non-main partners, they’re using condoms with a much higher rate.  Those are all in the direction of healthier sexuality. Certainly from a public health perspective those would be desirable goals.

There always is this tension, sexual health promotion from a public health perspective versus healthy sexuality. I just came back from an international think-tank in New York really looking at this question of sexual health promotion. By the end of the two days a lot of the people were asking, “Is that really the right question or should we really be talking about healthy sexuality?” Public health is about disease prevention, unplanned pregnancy prevention, and HIV prevention. Where a healthy sexuality really applies issues of pleasure, free choice, non-coercive sexuality. The two are not mutually exclusive, but I think in our history of HIV prevention we often excluded healthy sexuality in favor of sexual health promotion. I think its time to go back and maybe even start with healthy sexuality, rather than public sexual health promotion, with people. 

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