Refusing to Have Sex With HIV-Positive People: Why It’s Not a Prevention Strategy


This article originally appeared at Trevorade, and is reprinted here with permission from Trevor Hoppe.

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: Many people have emailed their
frustrations with my use of statistics. 
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.

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  • edwinjbernard

    Nicely written blog post.

    I’ve experienced such rejection myself, and I believe that this kind of stigma within the gay community is the reason why so many positive people do not want to reveal their status even where condoms are not used but where the law mandates that they should either disclose, or use condoms (and in some places, both). Of course, the law does not police the bedroom (or backroom) so can’t protect you – only you can protect yourself.

    You could also have mentioned that someone who knows their status will almost always have a much lower viral than the 1-in-3 gay men (at minimum, in some parts of the US it is close to 80%) with HIV who are undiagnosed. This is because untreated early HIV disease has the highest risk of transmission; untreated end-stage HIV diseas the next highest risk; untreated chronic HIV disease; the next highest; and treated early or chronic disease the lowest risk.

    If someone is on successful treatment (with an undetectable viral load in the blood), the amount of virus in the semen and rectal lining is almost always the same (there are rare exceptions). This will  reduce the risk of active or passive anal sex, with condoms, to zero (and without condoms, without STDs, to about the same kind of risk you describe in your blog for condom use).

     

    Edwin J Bernard
    writing about HIV
    http://www.edwinjbernard.com

    For the latest news on criminal HIV transmission around the world, visit my blog:
    http://criminalhivtransmission.blogspot.com

  • progo35

    Look, I’m sorry, but your premise is absolutely ridiculous. It is perfectly reasonable to want to avoid having sex with someone who has a communicable, degenerative disease. 1:22 or 1:50 risk for exposure is very high when we’re dealing with something like that. For instance, once I went to a doctor who wanted me to take a certain medication. There was a 1 percent chance of getting a flesh eating rash that kills you in two weeks. I said no way, Jose. Unless you are entering into some sort of long term marital or common law commitment with someone and are going to use protection, it is a GREAT idea to avoid having sex with HIV positive people. We’re talking about people’s lives here.

    "Well behaved women seldom make history."-Laurel Thatcher Ulrich

  • dcgirl

    “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.”

    How did you move from infection statistic to an exposure statistic? You mention yourself that exposure does not an infection make…

    Did I misunderstand what rates your referring to? Where did they come from? if the .4% – 2.3% is the rate of infection when using condoms without failure, then to reduce that rate via the 1:122 number doesn’t make sense… similarly the 1:122 ratio seems to be what people really want to think about; since that more accurately discusses the choice presented for each encounter, and since any given sexual encounter is statistically independent, the risk of any given act is the same — 1:122.

    I agree with the first comment though — very meaningful to consider that people who know their status are likely to have a lower viral load — in same ways, by reinforcing stigmas, and therefore discouraging people from knowing their status, could actually cause higher risk for people choosing to have sex with men who don’t know if they are HIV poz — which is really the group one selects when the reject men who know their poz status.

  • momtfh

    In my neck of the woods, South Florida, 1 in 6 gay men are HIV positive, and up to 40% don’t know that they are HIV positive.

    How is a gay man supposed to serosort effectively with those numbers? Unless they are staying abstinent, testing, and retesting when the window period is up, and then stay completely monogamous, there is no way to know who is truly HIV positive. This applies to any sex partners (or needle sharers), not just gay men.

    So, drop the stigma. Better an informed and medicated HIV positive partner than a new HIV case with a huge viral load who doesn’t know his status.

  • progo35

    This post also makes me angry because it seems to assert that HIV positive people, and people in general, have some sort of “right” to other people’s bodies, and that the other people who don’t want to have sex with them are “discriminating” against them and denying them equality in some way.

    "Well behaved women seldom make history."-Laurel Thatcher Ulrich

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  • don-warner-saklad

    How widespread is the phenomenon?… of the strategy of "Let’s get tested 2GETHER B4 we have sex, 4 A VARIETY of STDs.
    Do sexual health checkups reduce ambiguity and can they be like anything else POTENTIAL sex partners do together?…
    See also
    http://notb4weknow.blogspot.com
    http://continuedat.blogspot.com