HIV in the Modern Era
The face of the epidemic has changed; it’s time for us to do the same
At the recent AIDS 2018 conference in Amsterdam, results from the latest PARTNER study were revealed.
The PARTNER study has been running since 2010 and was expanded to include more gay men since 2014. It set out to investigate if HIV positive individuals with an undetectable viral load (very few or no copies of the virus present in the blood) were able to pass the virus onto their HIV negative partners.
The PARTNER study specifically looked at instances of condomless sex where the HIV negative partner was not on pre-exposure prophylaxis (PrEP). Thus, this would provide solid evidence that those with an undetectable viral load cannot pass the virus on.
783 couples had condomless sex 77000 times.
There were zero linked new HIV infections arising from condomless sex when the HIV positive partner was on successful treatment with an undetectable viral load. This was the case for both straight and gay couples.
This adds to building conclusive evidence that an undetectable viral load stops HIV infection.
Yet, it appears that the broader public, and members of the LGBTQ community, are not yet ready to fully accept and believe this message.
Indeed, Treatment as Prevention (TasP) is hardly touted as the incredible preventative method that it clearly is. There is still a dearth of information out in the public domain about the potential far-reaching impacts of this finding.
A recent New York Times opinion piece by Patrick William Kelly entitled (rather dramatically) The End of Safe Gay Sex stated:
“The nonchalant dismissal of the condom today flies in the face of the very culture of sexual health that gay men and lesbians constructed in the 1980s.”
Various HIV experts and activists have slammed this opinion piece for being inaccurate and elevating the condom to the status of being ‘the only way to have safe sex’. The author equated ‘safe gay sex’ with condom use.
Nothing could be further from the truth.
We now have an array of ways in which to have safer sex. Whether we choose to use condoms, PrEP (Pre-Exposure Prophylaxis which is used to prevent HIV infection in HIV negative individuals and has been shown to be incredibly effective) or TasP (Treatment as Prevention by having sex with someone with an undetectable viral load), we have numerous tools at our disposal.
While the author of the opinion piece quoted above was attempting to draw our attention to the rise of other sexually-transmitted infections (some of which may be resistant to antibiotic treatment), all he managed to do was to signal doom and gloom and to insinuate that there are only certain ways in which to have safe gay sex: a moral condemnation echoing from decades past.
In fact, research by the Centers for Disease Control and Prevention shows that increased PrEP use may actually decrease the number of new bacterial STIs — even if people reduce their use of condoms while on PrEP — because increased testing and treatment is very effective prevention for STIs.
The bottom line is that the face of the epidemic has changed and so should our definition of what constitutes ‘safe sex’.
Yes, other STIs exist and antiretroviral medications offer no protection against them as they do with HIV. However, it can be argued that in most instances these are curable or treatable and they simply do not pose the same threat to mortality that is posed by AIDS. Regular testing and monitoring for sexually active individuals and managing any infections as they arise is yet another way of enacting ‘safer sex’.
Additionally, being a sexually active individual in the world is always going to carry some level of risk, akin to driving a car on a busy highway.
In the case of HIV, I would further argue that disclosure of HIV status also needs to be reframed in light of recent biomedical advances. For too long, the burden has fallen squarely on the shoulders of the HIV positive individual to protect others from acquiring the infection.
In many countries, there remains the ever-present risk of incurring criminal charges for non-disclosure of HIV status. Prosecution may even occur for ‘exposure’ to the virus, even where no actual transmission has taken place (yet the statistical chances of actual exposure are rarely taken into account in a scientifically plausible manner). This is pure stigmatization of HIV positive individuals, which has taken place since the beginning of the epidemic.
Do these criminalization laws actually help stop new infections? No.
Are the majority of defendants in these instances malicious creatures who wanted to intentionally spread their HIV to others? No.
With further conclusive evidence that an undetectable viral load prevents infection, we need to view the HIV positive individual’s efforts to take care of their health and to keep their viral load undetectable as their way of engaging in ‘safer sex’, as a means of ‘taking responsibility’ towards sexual partners and ‘not exposing them to risk’.
The focus needs to move away from the inherently stigmatizing act of disclosure to sexual partners (or worse — disclosing publicly such as on a Grindr profile) to ensuring that we do what actually works: for HIV negative individuals, this means using PrEP and for HIV positive individuals, maintaining an undetectable viral load so that the virus cannot be transmitted to others. It also means constantly working to provide access to these medications for underserved populations.
If these two powerful tools are combined, it means an end to the epidemic.
It is no longer 1981. The face of HIV has changed. Maybe it’s time for our attitudes towards HIV positive people to do the same.
For more information on U=U (Undetectable = Untransmittable) and the Can’t Pass It On campaign by the Terrence Higgins Trust in the UK, see links below:
U=U at AIDS 2018 #UUAIDS2018
Equal Access to the HIV Prevention Revolution / HIV Undetectable = Untransmittable / #UequalsU
Krishen Samuel is a queer author with a master’s degree in Public Health and has previously written for the Huffington Post UK and the Gay and Lesbian Review Worldwide.