Last January, a team of Swiss scientists released a statement about HIV transmission that has become one of the most-talked about prevention developments this year.
The Swiss statement makes a surprising assertion. The likelihood, it says, of an HIV positive person infecting their HIV negative partner during hetero sex is less than 1 in 100,000 if all of the following conditions are met:
1. They take their medications faithfully without ever missing a dose, and
2. They are seeing their HIV doctor regularly and having their viral load monitored closely, and
3. Their viral load is consistently undetectable (no more than 40 viral copies per mL of blood) for at least six months, and
4. They are certain they have no other STIs (sexually transmitted infections) at any time.
I’ve negotiated open relationships less complicated than that! So if you’re a gay dude in Ottawa feeling a little confused about what the Swiss statement does (or doesn’t) mean for your sex life, I doubt you’re alone.
I’m simplifying, but there have basically been two types of reactions to the Swiss statement:
On one side we have mostly big institutions that have tried to keep their cool but are essentially pissed at the Swiss scientists. They worry that mere mortals cannot process a prevention message this complex and, as such, HIV infection rates will rise when people fuck up one or more of the conditions.
There are some big players in this camp: Public Health Agency of Canada, World Health Organization and UNAIDS, American Centers for Disease Control and Prevention, Canadian AIDS Treatment Information Exchange and some community AIDS service organizations like the AIDS Committee of Toronto.
This first camp’s cautions about the Swiss statement are not unfounded and are worth reflecting on. Here are some of them:
The statement is based on hetero, vaginal sex — not anal sex. But it is gay guys who bear the heaviest HIV burden in countries like Canada and anal sex is higher risk for HIV than vaginal sex — even if the Swiss conditions are met. Will gay guys realize the Swiss statement is not about them?
The statement isn’t based on sufficiently robust scientific data. While it points to a preliminary finding worthy of more research, is the data on which the statement is based solid enough to make such a bold statement at this time?
Who the hell knows if they have an STI or not when so many STIs can produce unnoticeable symptoms (or none at all!) while still increasing poz people’s infectiousness and HIV negative folks’ vulnerability. Do both HIV positive and HIV negative people understand how important it is to get regularly tested for STIs?
Furthermore, HIV positive gay men in particular tend to have higher rates of STIs, making it even less likely they would meet the Swiss conditions.
And on top of that, measuring viral load is tricky. Firstly, we test for viral load in the blood, which does not necessarily correspond to viral load in cum or vaginal fluid. Moreover, many people experience “blips” in their viral loads. And what about the time between taking a viral load test and getting the results, perhaps a couple weeks later?
Some also worry that people will use viral load strategies in place of condoms, instead of using them as complementary harm reduction tools. Will the possible benefits of the Swiss statement be nullified if people use condoms less often as a result?
The response of the second camp tends to be taken less seriously than the first because they lack hefty UN initials preceding their names or the all-knowing MD initials following. This camp tends to be comprised of people living with HIV, harm reduction activists and a handful of community organizations (usually the ones run by the community itself).
This second camp feels vindicated (sometimes smugly so) that scientific data is now beginning to confirm what they have observed anecdotally in their own lives for years. They agree with the first camp that condoms are the absolute best tool we have to reduce HIV transmission, but they also enthusiastically embrace additional harm reduction tools irrefutably proven to reduce HIV transmission.
Epidemiologist and prevention pundit Elizabeth Pisani writes: “Most people process complex information about risks and rewards every day of their lives. The life partners of people who take antiretorvirals are among the best placed in the world to understand the consequences of perhaps becoming infected with HIV. Public health professionals don’t need to treat them like idiots. Rather, we should lay out the risks as accurately as we know how, and let people decide for themselves.”
Pisani acknowledges that gay men have less to gain from the Swiss statement than straight folks, but she refuses to throw the bareback baby out with the blood-borne bathwater: “If you are a man with an infected wife, a 215 in 10,000 chance over 10 years may seem worth the risk. If you are a woman with an infected husband, we’re talking a 425 in 10,000 chance over 10, still worth a [gamble] to many people. If you’re a gay guy, the odds crash to 3,524 in 10,000, and you may want to hang on to the condoms. But isn’t it for you to decide?”
Well, is it?
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