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November 3, 2009

Refusing to Have Sex With HIV-Positive People: Why It's Not a Prevention Strategy, and Why It's Harmful to Our Communities
FILED UNDER: "Gay Men's Health & Culture"
TAGS: gay men's healthHIV PreventionHIV-positivepublic healthserosorting
By Trevor

serodiscordant_magnets.gif

I was having drinks with a friend of mine -- we'll call him Patrick here -- this weekend when the subject of having sex with HIV-positive men came up. "Oh, I would never have sex with an HIV-positive guy," he casually remarked -- as if such a thing were already obvious. I was shocked not just by Patrick's statement, but also by the categorical bravado in his delivery. To have sex with HIV-positive men, as he went on to explain, was to expose himself to unnecessary risk of infection. I've been replaying this conversation again and again in my head. How could he be so outrageously calculating in his cooIly expressed exclusionary strategy? Today I want to spend a few moments reflecting on these kinds of statements, because I think many people would uncritically read them as legitimate prevention strategies. I will argue here, however, that in reality that these kinds of strategies that are totally bankrupt in terms of actual risk reduction. Moreover, what I think this kind of statement actually tends to do is not actually promote any real reduction in risk, but rather to reinforce and reproduce harmful stigma against HIV-positive people.

Before we get into a discussion of the ethics of "serosorting" -- the practice of choosing to engage in sex with only sero-concordant men -- I think we should bracket my friend's comments as existing only at the very periphery of this term's broad meaning. While taken at face value, it does indeed seem that my friend is practicing serosorting. But correct me if I'm wrong here, but it seems to me that serosorting was more intended to describe men who were seeking to minimize risk of transmission while engaging in sex without condoms. For my friend, this wasn't the goal of his strategy -- condom use was still part of his risk reduction strategy with other HIV-negative men. This is a very important distinction. What I'm going to be talking about here is men who report consistent condom use, but who continue to latch onto serosorting discourses that discourage serodiscordant sexual practices.

Because of these important differences, I want to suggest that Patrick's comments cannot possibly be said to be purely a method of risk reduction. To explain why I think this is so, we need to evaluate whether or not there is actually any risk worth avoiding by excluding HIV-positive men from your pool of eligible partners. Thus, to help illustrate this, let's attempt to assess the risk of transmission between a known HIV-positive partner and an HIV-negative partner when condoms are used. There is no data to suggest that many HIV infections occur in these contexts, absent condom failure -- rates of which are outrageously low (between 0.4% and 2.3%, depending on who you ask). If we take a generous account, let's presume that rate is 2%. In a single incidence, then, the risk of potential exposure is 1:50.

But exposure does not equal transmission. You can be exposed to the virus and not actually seroconvert. Thus, we need to add into this equation the risk of transmission per sexual encounter in the absence of condoms,which vary depending on a number of factors: whether the poz guy is insertive or receptive, his viral load, genital ulcerations, etc. Let's say the poz guy is doing the fucking, for example's sake. The generic risk in this scenario for a receptive HIV-negative man is 1:122 -- that is, statistically speaking, there is a 1 in 122 risk of seroconversion after getting fucked once without a condom by an HIV-positive man (see here for a summary of this data). If we multiply these two risks together, we get something like a 1 in 6000 probability -- give or take. According to risks of death statistics, this puts a person's risk of seroconversion in this abstract, theoretical scenario somewhere between their risk of death by electrocution (1:5000) and their risk of death by drowning (1:8942). Obviously, this is a gross use of statistics -- but I think it helps illustrate the point: the risk of transmission between serodiscordant couples in one sexual encounter when using condoms is EXTREMELY low. Just about negligible. And this example likely grossly overestimates the risk, due to the fact that condom failure is not the same as sex without condoms. Many people will quickly realize the condom has broken, leading to a much smaller window of possibility for exposure. Thus, the 2% exposure rate included in this example is likely much, much smaller in practice.

Obviously, if we extend this risk over time, then we run into increased risk of transmission for a variety of reasons -- namely condom fatigue reported within serodiscordant couples. But if you use condoms, your risk of becoming infected from hooking up with a HIV-positive guy is probabilistically very low. Thus, excluding them from your dating pool cannot and should not be considered a risk reduction strategy -- unless you are having unprotected sex.

Now that we've established that there is no real prevention rationale for categorically excluding HIV-positive men from your pool of eligible partners, we need to seriously consider the ways in which doing so actually works to reinforce stigma against HIV-positive men. If you ask any HIV-positive man what kinds of difficulties come with seroconversion, many will immediately respond that stigma and the resulting fear of disclosure are today some of their most pressing concerns. New medications have alleviated what used to be a very immediate sense of death, and their adverse side-effects have been dramatically reduced with even more recent advances in treatment protocols. Rather than "purely" medical, the problems that men describe today with living with HIV are very much in the realm of the social.

Take for example a scenario another friend (we'll call him Matt here) described to me recently at a gay bar in Detroit. Matt was dancing with a cute young man, who curiously told him that "You should stay away from me. I'm dangerous." Matt asked him why, and he ambiguously answered that he was contaminated. Matt then asked him directly if he was HIV-positive, at which point the guy stiffened and gave a sheepish affirmative reply before running away. In this scenario, the young man had so internalized this harmful discourse of transmission that paints HIV-positive people as dirty and dangerous, that he himself did the running away. Matt has slept with HIV-positive men before -- this is not a problem for him. But he didn't even have to not reject him -- the HIV-positive man did the rejecting for him!

While this seems like a very contextual and bracketed example, I think it serves to illustrate the kind of emotional damage that stigmatizing discourses may be having on HIV-positive people's lives. I contend that Public Health -- in its ambiguous and contradictory uses of the term "serosorting" (a topic for another essay) -- is part of the problem here. By refusing to explain what this term means, and by remaining quiet in the way it gets practiced, Public Health is serving to reinforce stigma against HIV-positive people by allowing many men to use it as a rationale for their exclusionary practices. This essay is just a gloss on these issues -- it admittedly raises more questions than it answers -- but I desperately think we need to think critically about the way we (I mean both we as gay men, and we as people invested in promoting Public Health) allow stigma to continue operating in our communities through the lens of "health" and "risk reduction." Backed by medical logic, stigma seems rational, logical, and unproblematic. But we need to expose the ways in which these allegedly science-based logics are actually totally bunk in terms of their validity -- and are actually just forms of stigma veiled by scientific authority.

Author's Note: After publishing, I corrected the 1:122 risk of transmission per incidence for HIV-negative people engaging in unprotected receptive anal intercourse with HIV-positive men from the originally cited 1:132. I also added a link to Poz Magazine's summation of this theoretical risk data. Many people have emailed their frustrations with my gross misuse of statistics. I don't dispute this. Indeed, the kind of very sketchy analysis I engage in is problematic if you are interested in the actual, "real" statistical risk. I'm not really so interested in the precise number, and I don't think it matters much in making this argument. To my knowledge, even if we look at the outcomes here -- seroconversions reported when using condoms with HIV-positive partners -- we just don't see large numbers of transmissions. But I certainly welcome and encourage further research that is invested in precisely quantifying these risks -- and the variety of factors that are bound to contextualize them.

PERMALINK | Posted at 10:12 AM | Post a Comment (17)

17 Comments

The PEP guidelines we use in Australia (available at www.ashm.org.au) posit a 1:33 risk of infection for a known-positive insertive partner who comes inside. I guess I'm a bit skeptical about the Poz.com description of where they got their estimate, and I would call it an estimate rather than "data".

Like you, I'm troubled by the easy confidence of the neg guy who breezily announces he would never have sex with a poz guy due to his right to self-protection. But I explain it using the concept of stigma rather than risk calculation. You could step out the risk calculation -- risk of condom breaking times risk of infection times risk of PEP failure = 1 in 10,000 year risk at an average rate of partner change -- and he'll still insist that's too big a risk to take, and by that point he'll be really defensive too.

I think it's more effective if you can get him to acknowledge how he feels about the possibility of HIV infection, validate his right to protect himself, and express the hope he can act on that right without causing pain to any poz guy he might encounter along the way.

Author Profile Page Daniel Reeders User Profile | November 3, 2009 3:46 PM

Thanks Trevor, as always, in both your reaction to your friend's statement and following through with this essay.

This plain dismissal of an entire portion of our community based upon serostatus is an all too common one, both for myself and I'm sure for the many others that attempt to bridge the divide - for many different reasons.

If only rationality, reason, or even compassion were at play here, but alas that often doesn't seem to be the case. I see this as no different as being dismissed for being too old, or not being the right color. It's outright discrimination based upon fear, ignorance, and a lack of human compassion. One that is often wholly supported by many of our peers, institutions, and so-called community organizations as being at the least politically correct and at best justifiable. Unfortunately this is not relegated to any particular demographic and I have encountered flat refusals to even converse or have any kind of interaction solely based upon serostatus from many different individuals, no matter their education, experience, background, or geography.

The not-so-great irony and sad realization is that these are the same forms of discrimination based upon sickness, disease, and undesirability that have plagued and made our communities suffer for countless generations. I suffer each time I am flatly rejected with no recourse and we all suffer as a community by these falsely constructed barriers between us. I feel deep regret for the individuals who falsely believe and use these beliefs to discriminate actively, thinking that they are somehow protecting themselves by exorcising the sick and diseased from their "healthy" world. These same individuals when they perchance seroconvert or god forbid have their 30th, 40th, or 50th birthday, will they be that dancer on the dancefloor with Matt? If so, I'd much rather work on the sero-divide now rather than continue to suffer the ongoing consequences of decades of poor public health policies, little to no sexuality education, and social marketing campaigns and interventions that preach but don't educate!

Author Profile Page Larry User Profile | November 3, 2009 7:18 PM

In terms of risk of infection, for our work we use Vittinghof's per-contact estimates, here's what he says:

"Estimated per-contact infectivity of URA with HTVseropositive partners was 0.82 percent (table 3), while per-contact risk of URA with HIV-positive and unknown partners combined was 0.27 percent. In contrast, per-contact risk of PRA with HIV-positive or unknown partners was 0.18 percent, although a substantial proportion of this risk may be due to condom failure."

Which is a less than a one in 100 chance, hence Poz's quote of 1:122. It seems the Australians are quoting the upper-end of the 95% confidence interval for these estimates.

As usual these are generalized estimates and do not take into account such things as Trevor mentioned, such as the actual infectivity of the individual (are the virally suppressed), other STDs present, etc.

You can read the article here for free:

http://aje.oxfordjournals.org/cgi/reprint/150/3/306

Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K and Buchbinder SP. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. American Journal of Epidemiology 1999;150:306-11.

Author Profile Page Larry User Profile | November 3, 2009 7:44 PM


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