How many will you infect in ’09?

Of all the people living with HIV in North America (1.1 million in the US and 58,000 in Canada), how many of them will transmit the virus to somebody new in 2009? Or, put another way: what percentage of poz people will hit New Year’s Eve 2009 and say with confidence, “HIV ends with me. I did not infect any sexual partners this year”?

The answer is important for lots of reasons (for example, measuring the efficacy of prevention efforts), but one reason stands out more than others. Tracking transmission rates holds the key to proving or debunking the widespread belief that HIV-positive people are reckless, selfish assholes who don’t care very much if they infect other people or not.

Think I’m overstating the issue? To recognize World AIDS Day 2008, gay.com ran a story about the new Ontario campaign to fight HIV stigma ( www.hivstigma.com). Reader reactions were visceral. One man wrote:

“I’ve been HIV-positive for 12 years in the Midwest. Through experience I’ve come to the conclusion that 99 percent of gay men won’t have sex with HIV-positive guys, even if you’re totally fucking hot. I’ve resorted to going to bathhouses and bookstores and just sucking cock without disclosing.”

Another man responded:

“Absolutely disgusting. You are a horrible person. You are the reason there is no cure for this. You are the reason this disease continues to spread. You are a lying, manipulative, awful animal. You should be castrated. Being rejected because of your status is good. It means that [HIV-negative] men are starting to respect themselves. You are a worthless piece of humanity; complete genetic debris.”

In 2009, a mere five percent of American people living with HIV will transmit the virus to someone else. The vast majority — 95 percent — will pass all 12 calendar months without infecting a single person. So say researchers from Johns Hopkins University and the US Centers for Disease Control in a letter published in the Journal of Acquired Immune Deficiency Syndrome this week.

And let’s not forget that the CDC previously stated 54-70 percent of new HIV infections in the US are attributable to the 25 percent of HIV-positive Americans who are unaware of their status. Will all those self-righteous but untested HIV-negative men please raise their hands?

That means a mere two percent of all people living with HIV in the US know they are positive and will infect a sexual partner in 2009. Two percent. Two! If you line up 100 American poz folks (whether they know their status or not), five of them will infect someone else this year and just two of those five will pass the virus on knowing they are positive. And those two infections may very well occur between partners who know the risks and make an informed choice to take them.

I’ve gotta say, I have been waiting for evidence like this for a long, long time. All this bullshit of putting HIV-positive people in jail. All this useless sero-sorting by negative guys thinking they’re home-free if their one night stand duly protests that he’s clean. All this shame and misplaced blame about poz dudes sucking cock at the baths without disclosing when there’s no evidence of HIV ever being transmitted this way. May the hatred of HIV-positive people now officially end.

The rate of transmission (the annual number of new HIV infections transmitted per 100 persons living with HIV) has significantly declined over the course of the US epidemic.

Why is that? Well, in 1980 the transmission rate was 92 percent (meaning there were 92 new infections for every 100 poz folks). Once we identified AIDS, and later HIV, and used that scientific knowledge to shape HIV prevention messages, transmission rates began to fall. Transmission rates peaked (44 transmissions per 100 persons living with HIV) in 1984, just before widespread testing was introduced — confirming that if you know you are HIV-positive, you are more likely to practise safe sex. They have since declined 89 percent, to five transmissions per 100 persons living with HIV in 2006.

Richard Woltiski is a co-author of the study and acting director of CDC’s HIV/AIDS prevention division.

“I think it’s really the result of the combination — HIV prevention efforts that include HIV testing, prevention programs for people who are living with HIV and for those who are at risk for HIV, as well as the effects of HIV treatment that have prolonged the lives of so many people living with HIV,” says Woltiski. “These data really show that people living with HIV are taking steps to be responsible and protect others.”

So is the same phenomena true in Canada? It hasn’t been explicitly studied, but we can estimate the 2005 Canadian transmission rate using data from that year. Incidence divided by prevalence will give us a rough estimate of how much transmission is going on. In Canada, there are 2,300-4,500 new HIV infections a year; let’s take the midpoint. Divide that by prevalence (58,000 HIV+ Canadians) and it means that we can ballpark the number at 5.9 new HIV infections for every 100 poz Canadians in 2005. Right on par with the American data, meaning Canadians living with HIV are playing it equally safe.

And here’s what we know for sure: similar to the United States, 30 percent of gay guys who are HIV-positive in Ontario have no clue about their status. A similar dynamic is at play in the UK. We know, too, that untested HIV-positive individuals are more than twice as likely to engage in high-risk sex than those aware of their HIV-positive status. It’s estimated that 44 positive of UK gay men have never had an HIV test and Canadian gay men would be somewhere in that ballpark too.

What all of this suggests is that the constant spotlight on the sexual activities of people living with HIV is a smokescreen used by HIV-negative people (or people who think they are HIV-negative) to divert attention away from their own risky sexual choices and their reluctance to go get tested.