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AIDS CARE (June 2003), VOL. 15, NO. 3, pp.

367 /378

Intentional unsafe sex (barebacking) among

HIV-positive gay men who seek sexual
partners on the Internet

New York University & 2Hunter College, City University of New York, USA

Abstract While unsafe sex has been reported throughout the HIV epidemic, the underlying
assumption has been that most persons do not seek to purposely have unprotected sex. Within the gay
community, the term barebacking has emerged to refer to intentional unsafe anal sex. The prevalence
of barebacking is evidenced among gay men, particularly those who are HIV-positive, by the number
of internet sites devoted to barebacking and the number of men seeking sexual partners through the use
of the internet. To gain insight into barebacking, a sample of 112 HIV-positive gay men were recruited
from internet sites where men seek to meet each other for sex. The majority of participants (84%)
reported engaging in barebacking in the past three months, and 43% of the men reported recent
bareback sex with a partner of unknown serostatus. These results indicate the potential for widespread
transmission of HIV to uninfected men by the partners they meet on the internet. Analyses revealed
that men who reported bareback sex only with HIV-positive partners scored lower in sexual
adventurism than those who had bareback sex regardless of partner serostatus. A significant
correlation was observed between defining masculinity as sexual prowess and intentional unprotected
anal sex. There are serious implications for HIV prevention efforts, in that internet-based education
should be a priority in order to reach men who rely on this mechanism to find sexual partners.

In the last several years, the phenomenon of barebacking or intentional unsafe anal sex
among HIV-positive gay men has gained increased attention in the gay popular press (Gendin,
1997, 1999; Halkitis, 2000; Halkitis & Parsons, 1998; Kirby, 1999; Mann, 1999; Scarce,
1999) and in the psychological community (Gauthier & Forsyth, 1999; Goodroad et al. ,
2000; Halkitis, 2001; Halkitis, Parsons & Wilton, in press; Rofes, 1999; Suarez & Miller,
2001). Recent studies have noted that complacency towards safer sexual behaviours among
HIV-positive gay men coupled with the rise of barebacking may be related, in part, to the
optimism resulting from the success of highly active antiretroviral therapy (HAART) (Dilley et

Address for correspondence: Perry N. Halkitis, New York University, Department of Applied Psychology, 239
Greene Street, East Building 537G, New York, NY 10003, USA. Tel: /1 (212) 998 5373; E-mail:

ISSN 0954-0121 print/ISSN 1360-0451 online/03/030367-12 # Taylor & Francis Ltd

DOI: 10.1080/0954012031000105423



al. , 1997; Kravcik et al. , 1998; Miller et al. , 2000; Remien et al. , 1998; Van de Ven et al. ,
1999; Vanable et al. , 2000).
Barebacking is a potential health threat to the gay community for several reasons.
Unprotected anal intercourse can result in new infections with HIV, as well as the
transmission of more virulent and drug resistant strains of the virus which have emerged in
part as a result of HAART (Flexner, 1998; Pomerantz, 1999; Shafer et al. , 1998). Among
HIV-positive men, barebacking may result in reinfection with more potent strains of HIV
(Angel et al. , 2000; Ramos et al. , 1999). Finally, unprotected anal sex may lead to the
transmission of other sexually transmitted diseases (STDs). Such behaviour is likely the
reason for the rising gonorrhoea rates among gay men (CDC, 1999; Ciesielski & Beidinger,
1999) and the more recent surge in syphilis rates among many HIV-positive gay men in Los
Angeles, New York City and other major metropolitan areas (Condon, 2000). While unsafe
sex has been reported throughout the HIV epidemic, the term barebacking and the notion of
intentionally seeking out unprotected anal sex has evolved in a gay cultural context (Halkitis,
In effect, barebacking poses enormous health consequences for all gay and bisexual men,
regardless of serostatus. For HIV-negative men, initial infection with HIV is the most
immediate consequence of these unsafe anal behaviours and is further exacerbated by the
potential for initial infection with medication resistant/untreatable HIV mutant variants
(Boden et al. , 1999; Hicks et al. , 2001; Little et al. , 1999). For HIV-positive gay/bisexual
men, unprotected anal intercourse may place them at risk for reinfection or superinfection
(Angel et al. , 2000; Fultz et al. , 1998; Halkitis & Wilton, 1999), rapid loss of CD4 cells,
especially through continual ejaculate exposure (Wiley et al. , 2000) and risk for contracting
other STDs which may lead to opportunistic infections such as Karposis Sarcoma (OBrien et
al. , 1999; Rezza et al. , 1999), co-infection with hepatitis C (HCV) (Flichman et al. , 1999), as
well as immune system deterioration (Bonnell et al. , 2000).
The barebacking movement has emerged at a time when an increasing number of both
HIV-positive and -negative gay men are finding sexual partners via the Internet (Cooper et al. ,
1999; Elford et al. , 2001; Halkitis, 2001; Shaw, 1997; Weinrich, 1997). The Internet is a
system of interconnected computers creating a matrix of information exchange, which
provides the structure for e-mail (electronic mail), WWW (world wide web), FTP (file
transfer programs), listservs (special interest group mailing lists) and IRCs (Internet relay chat
rooms) (DeGuzman & Ross, 1999).
As more individuals have access to this technology, the modes of communication and
interaction have evolved within the gay community. Meeting potential sex partners via the
Internet is now common (Elford et al. , 2001). This medium has also provided a forum for
men who bareback to seek others interested in anal sex without condoms (Halkitis, 2001).
Both public (listservs and websites) and private (user profiles) forums are available to those
using the Internet to meet sex partners who are also interested in barebacking. Searches for
the term barebacking on the Internet yielded hundreds of listservs and websites dedicated to
barebackers who seek to communicate with others, as well as IRCs for those seeking
barebacking opportunities (Gauthier & Forsyth, 1999). User profiles explicitly stating the
desire for barebacking may be found abundantly throughout the Internet. Evidence of
unprotected sex among men who meet their sexual partners in this manner was noted in San
Francisco in 1999, when six syphilis cases were traced back to individuals who had met their
potential sex partners on one of the nations leading Internet providers (Klausner et al. ,
2000). Other work in this area has suggested that sexual risk taking is related to high levels of
sexual compulsivity and cybersex compulsivity among gay men who seek partners using the
Internet (Cooper et al. , 1999, 2000), and that men using the Internet are likely to



demonstrate more sexual risk than those not seeking sex in this venue (Bull et al. , 2001;
McFarlane et al. , 2000).
In this paper, we will: (1) describe the barebacking behaviours of a sample of 112 HIVpositive gay identified men who seek sexual partners via the Internet; (2) assess frequencies of
barebacking behaviours according to partner serostatus; and (3) describe differences among
these men in terms of health and psychosocial characteristics.

The data for this investigation were recently gathered utilizing a cross-sectional survey. The
data were collected via the Internet, such that men who expressed interest in participating
were sent an electronic file of the survey and the consent form using e-mail.
Participants and procedures
Electronic postings were placed on listserv accounts and IRCs tailored to HIV-positive men
seeking sexual partners, describing the study and asking interested participants to contact the
researcher via e-mail to request a survey. The listserv sites were identified by the use of the
terms poz, positive or HIV/, in combination with the terms men for men or m4m. No
sites with an identified geographic location (e.g. New York m4m) were targeted, as the goal of
the investigation was to obtain a sample of men from throughout North America. In the end,
four such sites were identified upon which postings were placed. In addition, active
recruitment was undertaken via communication through one IRC specifically tailored to
HIV-positive men seeking other HIV-positive men. Postings on the listservs were undertaken
three times throughout the duration of the study, and active recruitment was undertaken on
20 separate occasions over the duration of the study. Participants were informed of the study
with use of the following statement: HIV/ gay men are sought to complete a survey on HIV,
masculinity, and gay identity. The word barebacking was never used in order to prevent the
respondents from being skewed to those with strong opinions about the behaviours.
No information was gathered with regard to the site of recruitment of the final set of
participants. However, to prevent duplication of participants, the entered data were checked
for matches on age, postal code and years since testing HIV-positive. This analysis yielded one
set of duplicate data, which were eliminated from the final data set.
To be eligible for the study participants were required to: (1) be 18 years of age or older;
(2) self-report as HIV-positive; and (3) possess reading ability of English. Participants who
completed the survey were asked to return their response via e-mail; they were also given the
option of sending the responses via traditional mail or fax. All e-mail correspondences were
deleted from the investigators account upon downloading responses. All procedures were
approved by the Institutional Review Board of the primary authors university.
Sexual behaviour. Participants were asked to indicate whether or not they had engaged in
bareback sex in the three months prior to assessment. Participants responded to each question
separately for HIV-positive sex partners and HIV-negative or partners of unknown status.
Participants who reported bareback sex were then asked to indicate the number of times in



which the bareback sex was anal insertive (How many times did you top) and anal receptive
(How many times did you bottom?) for both types of partner. Using an open response
format to collect frequency data on sexual behaviours has been shown to increase reliability
(Catania et al. , 1990; Kalichman et al. , 1997; Kauth et al. , 1991). Based on their responses,
participants were placed into one of four mutually-exclusive categories: no barebacking,
barebacking with HIV-positive partners only, barebacking with HIV-negative/unknown
partners only, or barebacking with both partner types.
Sexual adventurism (SADV). The construct of sexual adventurism was assessed through an
initial set of 12 items developed for the purposes of this investigation. Based on psychometric
analyses, two items were dropped from this scale, yielding a final set of ten items (alpha /
0.92). Item responses were based on a five-point Likert scale (1/not at all like me, to 5 /
completely like me). Items included: I try to have bareback sex, I go to bathhouses and sex
clubs to look for sex and I love taking the cum of other men. Exploratory factor analyses of
this scale yielded one factor for the ten items accounting for 57.39% of the variance and factor
loadings ranging from 0.41 to 0.87. Higher scores reflected higher levels of sexual
AIDS related internalized homophobia. Shidlos (1994) AIDS Related Internalized Homophobia (ARIH) scale was used to assess this construct. The 14 items used a five-point Likert
scale (1/strongly disagree, to 5 /strongly agree) to assess internalized homophobic feelings
that may be AIDS related. This scale was previously piloted with gay/bisexual males of various
races/ethnicities and was determined to have an internal consistency reliability of 0.82
(Shidlo, 1994). In our sample of Internet users, we computed an alpha of 0.68. Higher scores
reflected higher levels of internalized homophobia.
Sex as a definition of masculinity (MAS). We assessed mens perception of masculinity as
defined by sexual prowess based on the ethnographic work undertaken by the first author
(Halkitis, 2001). Three five-point Likert items (1/strongly disagree, to 5 /strongly agree)
were used to assess this construct. Items were: Sexual performance is an important part of
masculinity, A masculine man has lots of sex and Sex is a celebration of masculinity. The
three items loaded on one factor, accounting for 66.67% of the variance and the scale had a
coefficient alpha 0.75.
Health characteristics. Participants provided self-reported information for the number of years
since they had tested HIV-positive, whether they had received an AIDS diagnosis, and the
medications that they were taking to treat HIV from a checklist of federally-approved
antiretorvirals, as well as an open-ended item asking about other HIV medications.
Sociodemographics. Participants were asked to indicate the postal code associated with their
residence, age and race/ethnicity via three open-ended items. Postal codes were grouped via
region of North America; race/ethnicity responses also were collapsed to create categories.

Sample characteristics
A total of 112 men completed the survey. The mean age for the sample was 41.98 (SD /6.86,
range/27 /57). The participants had first tested HIV-positive an average of 10.67 (SD /



5.29) years earlier. In terms of HIV disease, 38.4% (n / 43) indicated that they had been
diagnosed with AIDS and 85.6% (n / 96) indicated that they were currently on some form of
HIV antiretroviral therapy. The sample was predominantly Caucasian (76.8%; n / 86). A
total of 9.8% (n/ 11) of the participants were African American and 6.3% (n /7) were
Latino. A small percentage (7.1%; n/ 8) provided no racial/ethnic identification.
Because the data were collected via the Internet, the men were sampled from various
geographical areas of North America. The majority of the participants identified a postal code
in the Northeast (n / 65; 58.0%). In addition, 17.9% (n /20) were from the South/
Southeast, 16.1% (n/ 18) were from the West/Southwest, 2.7% (n/ 3) were from the
Midwest and 3.6% (n / 4) were from Canada.

Barebacking behaviour
Of the 112 participants, 16.1% (n/ 18) indicated no barebacking behaviour in the three
months prior to evaluation, while 83.9% (n / 94) indicated at least one act of barebacking.
While cell size was insufficient to conduct bivariate tests across geographical region, the data
suggested consistent patterns across the five geographical regions from which participants
were drawn. Of the full sample, 82.1% (n / 92) reported at least one occasion of bareback sex
with an HIV-positive partner, while 42.9% (n/ 48) reported bareback sex with an HIVnegative/unknown partner. Among those 94 men reporting any barebacking, 48.9% (n/ 46)
reported barebacking only with other HIV-positive men, 48.9% (n/ 46) reported barebacking with both HIV-positive and HIV-negative/unknown partners and only 2.1% (n/ 2)
reported barebacking with only HIV-negative/unknown partners.
Table 1 provides information regarding frequency of intentional unprotected anal
insertive and anal receptive behaviours across those who report barebacking only with HIVpositive partners, barebacking with only HIV-negative/unknown partners and barebacking
with both types of partner. Among those who reported barebacking sex with HIV-positive
partners only, frequencies of anal insertive and anal receptive acts were not significantly
different. For those who reported both HIV-positive and HIV-negative/unknown partners,
behaviour varied across partner types. Specifically these men reported significantly more acts
of anal insertive bareback sex with HIV-positive partners than with HIV-negative/unknown
partners (F (1,41) /9.44, p B/0.01), as well as more acts of anal receptive bareback sex with
HIV-positive partners than with HIV-negative/unknown partners (F (1,39)/11.32, p B/
0.01). When we controlled for serostatus of the partner, no significant differences regarding
the frequencies of receptive and insertive bareback sex within each partner type were found.

Barebacking correlates
The relationship between barebacking behaviours and sociodemographic and psychosocial
variables was also examined. Comparisons across those who did not report any barebacking,
those who reported bareback sex with other HIV-positive partners only and those who
reported bareback sex with men regardless of partner serostatus, revealed no significant
differences in terms of age, years since HIV-positive, having an AIDS diagnosis or being on
antiviral treatment (see Table 2). Further, no significant differences were found with regard to
AIDS-related internalized homophobia (ARIH) or sex as a definition of masculinity (MAS).
However, a significant difference was found in terms of sexual adventurism (SADV)



Table 1. Mean frequencies of bareback behaviour during the past three months
Men who bareback only
Men who bareback with both
with other HIV-positive HIV-positive and HIV-negative or
men (n /46)
unknown status men (n /46)
HIV-positive partners
Anal insertive
Anal receptive

6.37 (7.45*)
5.23 (7.95)

HIV-negative/unknown partners
Anal insertive
Anal receptive

10.35 (13.28)
11.55 (16.35)

3.38 (5.17)
4.40 (4.90)

*Standard deviation.

Table 2. Participant health and psychosocial characteristics by intentional unprotected anal intercourse (barebacking)

No barebacking

only (n/46)

Seroconcordant and
barebacking (n/46)

Years HIV-positive

44.00 (5.99**)
13.00 (5.40)

42.44 (6.95)
10.03 (5.25)

40.41 (6.72)
10.27 (5.19)

AIDS diagnosis (%)

treatment (%)





28.53 (9.37)
8.29 (2.69)
20.31 (11.39)

27.02 (5.79)
8.72 (3.04)
31.00 (10.19)

28.98 (6.13)
9.00 (2.95)
36.71 (9.73)

*p B/0.001; **standard deviation.

(F (2,98) /13.70, p B/0.001). Specifically, those who reported barebacking with both HIVpositive and HIV-negative/unknown partners were found to have higher levels of sexual
adventurism than those who did not report any barebacking (p B/0.001), as well as those who
reported barebacking only with other HIV-positive men (p B/0.001).
In terms of frequency of barebacking behaviours by psychosocial characteristics, bivariate
correlations revealed that those with higher levels of SADV also reported more insertive
bareback sex with HIV-positive partners (r/0.32, p B/0.01), more receptive bareback sex
with HIV-positive partners (r /0.39, p B/0.001), more receptive bareback sex with HIVnegative/unknown partners (r/0.37, p B/0.001) and marginally more insertive bareback sex
with HIV-negative/unknown partners (r/0.18, p / 0. 08). Similar patterns emerged regarding MAS. Those who scored higher on the MAS also reported more frequent insertive
bareback sex with HIV-positive partners (r /0.25, p / 0.01), receptive bareback sex with
HIV-positive partners (r/0.26, p / 0. 01) and receptive bareback sex with HIV-negative/
unknown partners (r /0.27, p B/0.01).



Consistent with other studies of the sexual behaviours of HIV-positive gay men (Fisher et al. ,
1998; Hoff et al. , 1997; Marks et al. , 1994; Parsons & Halkitis, 2002), the current study
found that unprotected anal sex occurs more frequently with other HIV-positive partners than
with HIV-negative or status unknown partners. A small percentage of men (16.1%) reported
no barebacking behaviour in the three months prior to assessment. This could represent an
overestimate, as men may have felt uncomfortable disclosing this behaviour via the Internet
survey and in light of gay community norms for safer sex. It should be noted, however, that
men were recruited from Internet sites focused on meeting sex partners, not specifically
focused on meeting partners for purposes of barebacking. A sizeable number of men (42.9%),
however, did report barebacking with HIV-negative or HIV status unknown men. This
behaviour places their partners at risk of HIV infection. Previous community-based work with
HIV-positive gay men has found greater levels of unprotected anal sex with HIV status
unknown partners compared to HIV-negative partners (Ekstrand et al. , 1999; Parsons &
Halkitis, 2002). It is likely that much of the barebacking reported by the sample occurred with
serostatus unknown partners, potentially due to assumptions that these partners were HIVpositive.
In light of recent reports of HIV superinfection (Angel et al. , 2000) and other healthrelated matters, the high frequency of barebacking with other HIV-positive partners is also
cause for concern. Men in this study reported more frequent acts of both unprotected
insertive and receptive anal sex with other HIV-positive partners. Given the prevalence of
HIV-1 subtype, men are potentially becoming reinfected with numerous strains of HIV, which
may lead to the development of drug resistant mosaic strains (Kravcik et al. , 1998; Ramos et
al. , 1999), although the impact of reinfection has yet to be clinically realized and understood.
Further, such frequent unprotected anal sex with other HIV-positive partners poses the risk of
infection with other STDs, which may compromise the immune system (Hook, 1995).
The men who reported barebacking with both HIV-positive and HIV-negative/unknown
status partners were more sexually adventurous than men reporting no barebacking or
barebacking with only other HIV-positive men. This suggests that HIV-positive men who,
through barebacking, place HIV-negative or unknown status partners at risk of HIV infection,
may have higher levels of sensation seeking or need for novel or exciting sexual situations.
These men appear to be focused on having bareback sex without regard to partners
A dominant cultural phenomenon in the gay community is the emphasis on both sex and
physical appearance as a means of defining ones masculinity (Halkitis, 2001). HIV-positive
gay men report that bareback sex provides them with affirmation of their physical
attractiveness, as well as a sense of greater connectedness to their sex partners. Our results
found a relationship between sex as a definition of masculinity and barebacking. As such, it is
possible that some HIV-positive gay men place greater importance on their achieving or
maintaining a masculine or buff appearance as a means to being attractive to other men, and
subsequently achieve the goal of bareback sex.

The use of the Internet for psychological research is relatively new. As such, much remains to
be learned about this methodology as the bias in recruiting participants in this manner for
sexually-related studies is different from those of traditional methods (Binik et al. , 1999). One
study of gay men in Los Angeles found that users of the Internet tended to be unemployed,



disabled and less educated (Koch & Shockman, 1998). In the general population, Internet
users tend to be male, college educated, middle class and in their late thirties (New York Times,
2000 ). Because we intentionally did not collect sociodemographic data other than selfidentified race/ethnicity so as to further enhance the privacy of the participants, we cannot
comment on this matter. Furthermore, our findings are limited due to the sites selected for
participant recruitment. While we identified four listservs and one IRC dedicated to HIVpositive men seeking sex with other men, we cannot with total certainty assure that these
Internet sites were representative of all sites available to such men, and our data are thus
constrained with regard to this matter. Finally, because we do not have data with regard to the
men who may have viewed our postings yet refused to participate, we are unable to determine
the extent to which the men in our study are truly representative of HIV-positive men seeking
sexual partners on the Internet. However, we feel that our attempts to recruit participants
through both passive and active means and the variability of our sample in terms of geographic
regions suggests that our data may be somewhat generalizable. Further, our data are
corroborated in other studies of barebacking among HIV-positive men using larger samples
(Halkitis, Parsons & Wilton, in press).
Turner et al. (1998) have suggested that computer-based data collection is advantageous
as it allows us to gather sensitive information in a manner that ensures confidentiality and a
high level of anonymity. Further, the use of the Internet allows for the collection of data from
participants across geographical regions in a relatively cost-effective manner, including those
who are from geographically isolated areas (Ross et al. , 2000). The validity of the knowledge
generated from this investigation appears to be high, as men completed the questionnaires
thoroughly, with less than 1% of the data being missing.
Demographically, the participants in this study were predominately white, relatively
healthy, had a mean age of 42 and had tested HIV-positive over a decade ago. This represents
a somewhat different sample than is typical of previously published studies of the sexual
behaviours of HIV-positive gay men, as our sample is older and has been HIV-positive for a
longer period of time. As such, the sexual behaviours of men in the present study could be
different from the behaviours of younger HIV-positive gay men, as well as men who have more
recently seroconverted. In addition, the use of HAART and the non-progression of HIV in
this sample could be creating a sense of optimism and complacency regarding sexual
behaviours, as well as a general sense of wellbeing which may be related to more active sexual
lives. This has been documented elsewhere, in that those in better health, on HAART, with
undetectable viral loads, tend to perceive that they are less likely to infect a partner with HIV
(Miller et al. , 2000; Remien et al. , 1998; Vanable et al. , 2000). Finally, the issue of infectivity
is central to this discussion as it remains unclear how infectious men who are undergoing
HAART actually are. As a result, the question is raised about how much potential threat for
HIV transmission truly exists through insertive or receptive barebacking under these
circumstances, where HAART may lead to undetectable viral load (Suarez & Miller,
2001). These considerations should be kept in mind in light of the fact that 89% of the
men in our study who reported sex with HIV-negative/unknown status partners were on
HAART, and only 40% reported an AIDS diagnosis.

The current data differs from previously published studies of unprotected sex in that we
assessed intentional unprotected anal sex among HIV-positive gay men. Previous research
efforts have examined unprotected anal sex among HIV-positive men, but have not



specifically looked at barebacking. Thus, the rates of unprotected anal sex in these other
studies may include incidents of unintentional unsafe sex (e.g. the person did not seek out
unprotected sex, the person planned to use condoms but had a slip or a relapse, the person
experienced condom breakage or failure). Barebacking should be viewed as a sociological (as
well as a medical and public health) issue in that such behaviour may provide a sense of
intimacy and belonging with other HIV-positive men (Halkitis, 2001).
It is possible that the lack of HIV prevention messages on the Internet (and particularly
on sites where gay men look for sexual partners) may attract HIV-positive men who are trying
to escape from the focus on safer sex. Perhaps barebacking is a way for HIV-positive men to
rebel against the safer sex messages which have dominated the gay community for the last
several years. In fact, in a study of barebacking utilizing a brief street intercept, 47% of gay and
bisexual men reported the belief that the barebacking phenomenon is due to AIDS-related
fatigue (Halkitis, Parsons & Wilton, in press). Certainly, these are areas that warrant further
Clearly, the Internet represents an efficient mode for quickly screening large numbers of
potential sexual partners, thus facilitating barebacking behaviours by performing searches for
other men interested in such behaviours (Weinrich, 1997). In addition, as others have
suggested (Ross et al. , 2000), the Internet not only provides a vehicle through which large
amounts of data may be collected, but also a system of communication that may facilitate the
sharing of knowledge and the potential to deliver services to those who have access to the
system. Such a mechanism may allow those who are less gay identified and acculturated in the
gay community to access behavioural risk reduction information in a manner that is somewhat
confidential. The Internet may also provide a comfortable forum for the discussion of
potentially embarrassing or controversial concerns of HIV-positive gay and bisexual men
among themselves and between themselves and service providers.

The authors would like to thank David Bimbi for his help on this project, as well as the
contributions of Michael Ross and two anonymous reviewers.

ANGEL, S., KRAVCIK, E., BALASKAS, P., YEN, A.D., BADLEY, D., CAMERON, W. & HU, Y.W. (2000). Documentation
of HIV-1 superinfection and acceleration of disease progression. Paper presented at the 7th Conference on
Retroviruses and Opportunistic Infections, San Francisco, CA.
BINIK, Y.M., MAH, K. & KIESLER, S. (1999). Ethical issues in conducting sex research on the Internet. Journal of Sex
Research , 36 , 82 /90.
MARKOWITZ, M. (1999). HIV-1 drug resistance in newly infected individuals. Journal of the American Medical
Association, 282 (1), 135 /141.
BONNELL, C., WEATHERBURN, P. & HICKSON, F. (2000). Sexually transmitted infection as a risk factor for homosexual
HIV transmission: a systematic review of epidemiological studies. International Journal of STD & AIDS , 11 , 697 /
BULL, S., MCFARLANE, M. & RIETMEIJER, C. (2001). HIV/STD risk behaviors among men seeking sex with men
online. American Journal of Public Health , 91 (6), 988 /989.
CATANIA, J., GIBSON, D., CHITWOOD, D. & COATES, T. (1990). Methodological problems in AIDS behavioral
research: influences on measurement error and participation bias in studies of sexual behavior. Psychological Bulletin ,
108 , 339 /362.
CENTERS FOR DISEASE CONTROL AND PREVENTION (1999). Increases in unsafe sex and rectal gonorrhea among men
who have sex with men */San Francisco, California, 1994 /1997. Morbidity and Mortality Report, 48 (3), 45 /58.



CIESIELSKI, C. & BEIDINGER, H.A. (1999). Changing epidemiology of primary and secondary syphilis in Chicago */
emergence of the impact of MSM. Paper presented at the National HIV Prevention Conference, Atlanta, GA.
CONDON, L. (2000). Outbreak: experts fear a recent rash of syphilis cases may signal an impeding wave of HIV
transmission. The Advocate , May 23, pp. 40, 43.
COOPER, A., DELMONICO, D.L. & BURG, R. (2000). Cybersex users, abuse, and compulsives: new findings and
implications. Sexual Addiction & Compulsivity , 7 , 5 /29.
COOPER, A., PUTNAM, D.E., PLANCHON, L.A. & BOIES, S.C. (1999). Online sexual compulsivity: getting tangled in the
net. Sexual Addiction & Compulsivity , 6 , 79 /104.
DEGUZMAN, M.A. & ROSS, M.W. (1999). Assessing the implications of AIDS-related counseling and education on the
Internet. Patient Education and Counseling , 36 , 209 /228.
DILLEY, J.W., WOODS, W.J. & MCFARLAND, W. (1997). Are advances in treatment changing views about high-risk sex?
New England Journal of Medicine , 337 (7), 501 /502.
EKSTRAND, M., STALL, R.D., PAUL, J.P., OSMOND, D.H. & COATES, T.J. (1999). Gay men report high rates of
unprotected anal sex with partners of unknown or discordant HIV status. AIDS , 13 , 1525 /1533.
ELFORD, J., BOLDING, G. & SHERR, L. (2001). Seeking sex on the Internet and sexual risk behavior among gay men
using London gyms. AIDS , 15 , 1409 /1415.
FISHER, J.D., KIMBLE WILLCUTTS, D.L., MISOVICH, S.J. & WEINSTEIN, B. (1998). Dynamics of sexual behavior in
HIV infected men who have sex with men. AIDS and Behavior , 2 , 101 /105.
FLEXNER, C. (1998). HIV-protease inhibitors. New England Journal of Medicine , 338 , 1281 /1292.
FLICHMAN, D., CELLO, J., CASTANO, G., CAMPOS, R. & SOOKOIAN, S. (1999). In vivo regulation of HIV replication
after hepatitis superinfection. Medicina , 59 (4), 364 /366.
FULTZ, P., WEI, Q. & YUE, L. (1998). Are infections of two (or more) HIV-1 strains really rare events? Paper presented
at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy, San Diego, CA.
GAUTHIER, D.K. & FORSYTH, C.J. (1999). Bareback sex, bug chasers, and the gift of death. Deviant Behavior , 20 (1),
85 /100.
GENDIN, S. (1997). Riding bareback. POZ , June, 64 /65.
GENDIN, S. (1999). They shoot barebackers, dont they? POZ , February, 48 /51.
GOODROAD, B.K., KIRKSEY, K.M. & BUTENSKY, E. (2000). Bareback sex and gay men: an HIV prevention failure.
Journal of the Association of Nurses in AIDS Care , 11 (6), 29 /36.
HALKITIS, P.N. (2000). Negotiating and decision making for HIV-positive gay men: sexual dealings. The Body
Positive , June, 31 /34.
HALKITIS, P.N. (2001). An exploration of perceptions of masculinity among gay men living with HIV. Journal of Mens
Studies , 9 (3), 413 /429.
HALKITIS, P.N. & PARSONS, J.T. (1998). Drawing conclusions on barebacking. New York Blade , 2 (37), 19.
HALKITIS, P.N., PARSONS, J.T. & WILTON, L. (in press). Intentional unsafe sex, or barebacking, among gay/bisexual
men in New York City. Archives of Sexual Behavior .
HALKITIS, P.N. & WILTON, L. (1999). Beyond complacency: the effects of treatment advances on HIV transmission.
Focus: A Guide to AIDS Research and Counseling , 14 (5), 1 /5.
HICKS, C., ERON, J., LENNOX, C., PILCHER, C., MENENZES, P., GINER, J., DEAN, B. & FISCUS, S. (2001). Resistance
to antiretroviral agents in a cohort of patients with acute HIV infection acquired in non-urban areas in the
Southeastern USA. Paper presented at the 8th Conference on Retroviruses and Opportunistic Infections, Chicago,
COATES, T.J. (1997). Differences in sexual behavior among HIV discordant and concordant gay men in primary
relationships. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 14 (1), 72 /78.
HOOK, E.W. (1995). HIV/sexually transmitted disease interactions in women. In: MINKOFF, H., DEHOVITZ, J.A. &
DUERR, A. (Eds), HIV infection in women (pp. 229 /240). New York: Raven Press.
KALICHMAN, S.C., GREENBERG, J. & ABEL, G.G. (1997). HIV-seropositive men who engage in high-risk sexual
behaviour: psychological characteristics and implications for prevention. AIDS Care , 9 (4), 441 /450.
KAUTH, M.R., ST. LAWRENCE, J.S. & KELLY, J.A. (1991). Reliability of retrospective assessments of sexual HIV risk
behavior: a comparison of biweekly, three month, and twelve month self-reports. AIDS Education and Prevention , 3 ,
207 /214.
KIRBY, C. (1999). Risky business: barebacking celebrates unprotected sex and raises difficult issues about AIDS
prevention. The Advocate , April 13, 41 /45.
KLAUSNER, J.D., WOLF, W., FISCHER-PONCE, L., ZOLT, I. & KATZ, M.H. (2000). Tracing a syphilis outbreak through
cyberspace. Journal of the American Medical Association , 284 (4), 447 /449.
KOCH, S. & SHOCKMAN, H.E. (1998). Democratizing Internet in the lesbian, gay, and bisexual communities. In: B.
Ebo (Ed.), Cyberghetto or cybertopia? Race , class , and gender on the Internet (pp. 170 / 184). Westport, CT: Praeger.



CAMERON, D.W. (1998). Effect of antiretroviral therapy and viral load on the perceived risk of HIV transmission
and the need for safer sexual practices. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology,
19 , 124 /129.
HIV drug susceptibility among patients with primary HIV infection. Journal of the American Medical Association , 282
(12), 1142 /1149.
MANN, W.J. (1999). Why some gay men are choosing to have sex without condoms. Frontiers Newsmagazine , October
29, 8 /12.
intercourse and disclosure of HIV infection among seropositive gay and bisexual men. Journal of Acquired Immune
Deficiency Syndromes , 7 , 866 /869.
MCFARLANE, M., BULL, S. & RIETMEIJER, C.A. (2000). Use of the Internet to solicit sex partners and related STD
among an inner city STD clinic population. Journal of the American Medical Association , 284 (4), 443 /446.
GROUP (2000). Sexual behavior changes and protease inhibitor therapy. AIDS, 14 (4), 33 /39.
NEW YORK TIMES (2000). The New York Times 2000 almanac . New York: New York Times .
OBRIEN, T.R., KEDES, D., GANEM, D., MACRAE, D., ROSENBERG, P., MOLDEN, J. & GOEDERT, J. (1999). Evidence of
concurrent epidemics of human herpes virus 8 and human immunodeficiency virus type 1 in US homosexual men:
rates, risk factors, and relationship to Karposis sarcoma. Journal of Infectious Diseases , 180 , 1010 /1017.
PARSONS, J.T. & HALKITIS, P.N. (2002). Sexual and drug using practices of HIV/ men who frequent public and
commercial sex environments. AIDS Care , 14 , 815 /826.
POMERANTZ, R.J. (1999). Primary HIV-1 resistance: a new phase in the epidemic? Journal of the American Medical
Association , 282 (12), 1777 /1179.
PIENIAZEK, D. (1999). Dual and recombinant infections: an integral part of the HIV-1 epidemic in Brazil. Emerging
Infectious Diseases , 5 (1), 65 /74.
REMIEN, R.H., HALKITIS, P.N., OLEARY, A. & HAYS, R. (1998). Medical treatment advances: attitudes and sexual
risk among HIV positive men. Paper presented at the meeting of the American Psychological Association, San
Francisco, CA.
herpesvirus 8 seropositivity and risk of Karposis Sarcoma and other acquired immunodeficiency syndrome related
diseases. Journal of the National Cancer Institute , 91 , 1468 /1474.
ROFES, E. (1999). Barebacking and unprotected anal sex: identical, distinct, or flip sides of the same coin? Paper
presented at the 4th International Conference on the Biopsychosocial Aspects of AIDS, Ottawa, Canada.
ROSS, M.W., TIKKANEN, R. & MANSSON, S.A. (2000). Differences between Internet samples and conventional samples
of men who have sex with men: implications for research and HIV interventions. Social Science & Medicine , 51 ,
749 /758.
SCARCE, M. (1999). A ride on the wild side. POZ , February, 52 /55, 70 /71.
SHAFER, R.W., WINTERS, M.A., PALMER, S. & MERIGAN, T. (1998). Multiple concurrent reverse transcriptase and
protease and multidrug resistance of HIV-1 isolates from heavily treated patients. Annals of Internal Medicine , 128 ,
906 /911.
SHAW, D.F. (1997). Gay men and computer communication: a disclosure of sex and identity in cyberspace. In: JONES,
S.G. (Ed.), Virtual culture: identity and communication in cybersociety (pp. 133 /145). London: Sage.
SHIDLO, A. (1994). Internalized homophobia: conceptual and empirical issues in measurement. In: GREEN, B. &
HEREK, G. (Eds), Psychological perspectives on lesbian and gay issues: theory, research and clinical applications . Thousand
Oaks, CA: Sage.
SUAREZ, T. & MILLER, J. (2001). Negotiating risks in context: a perspective on unprotected anal intercourse and
barebacking among men who have sex with men */where do we go from here? Archives of Sexual Research , 30 (3),
287 /300.
TURNER, C.F., KU, L., ROGERS, S.M., LINDBERG, L.D., PLECK, J.H. & SONENSTEIN, F.L. (1998). Adolescent sexual
behavior, drug use, and violence: increased reporting with computer survey technology. Science , 280 , 867 /873.
VANABLE, P.A., OSTROW, DG., MCKIMAN, D.J., TAYWADITEP, KJ & HOPE, B.A. (2000). Impact of combination
therapies on HIV risk perceptions and sexual risk taking among HIV-positive and HIV-negative gay and bisexual
men. Health Psychology, 19 (2), 134 /145.



VAN DE VEN, P., KIPPAX, S., KNOX, S., PRESTAGE, G. & CRAWFORD, J. (1999). HIV treatment optimism and sexual
behavior among gay men in Sydney and Melbourne. AIDS , 13 , 2289 /2294.
WEINRICH, J.D. (1997). Strange bedfellows: homosexuality, gay liberation and the Internet. Journal of Sex Education
and Therapy, 22 , 58 /66.
DETELS, R. (2000) Evidence that anoreceptive intercourse with ejaculate exposure is associated with rapid CD4
loss. AIDS, 14 , 707 /715.