Michael Hurley PhD of the Australian Research Centre in Sex, Health and Society analyzes the Swiss announcement re: sexual infectivity and viral loadOnly on LifeLube
I admire the Swiss
for grasping the nettle.
The Swiss Federal Commission for HIV / AIDS recently announced that people with HIV who have undetectable HIV viral load and no sexually transmitted infections are not sexually infectious for HIV This has opened the door to excited discussion of its HIV health promotion possibilities. The Swiss announcement required that:for grasping the nettle.
1. the person adheres to anti-retroviral therapy, the effects of which must be evaluated regularly by the treating physician, and
2.the viral load has been suppressed, and
3. there are no other sexually transmitted infections.
This is a very interesting development, that requires extensive consideration. If accepted, it appears to open the door for some people with HIV to negotiate unprotected anal intercourse with regular HIV negative partners in sero-discordant relationships and potentially also with HIV negative or partners of unknown sero status in casual sex. Given that we live in an instant news culture, the announcement is being discussed all over the world. One suggestion has been that we can now have Negotiated Safety (Mark 2) based on the model of Negotiated Safety named by researchers in Australia in the early 1990's and used in HIV education for gay men in several countries since the mid-90's. While I think that suggestion is mistaken, it does provide a useful way of considering matters of HIV education, prevention and health promotion.
Negotiated Safety involved HIV negative partners in a sero-concordant regular relationship choosing not to use condoms for anal sex on the basis of agreements negotiated between them. The main Australian campaign developed a protocol whereby the men Talk, Test, Trust, Test (TTTT) i.e. there was open overt discussion between the men on the nature of the relationship including where casual sex with other people outside the relationship fitted.
Some chose monogamy, many developed open relationships with or without anal intercourse with casual partners. The talk occurred in a 3 month period that included use of condoms in the relationship during that time and excluded casual anal intercourse for that period. This was accompanied by HIV tests at either end of the period to ensure both partners were HIV negative. Only after that process could Negotiated Safety properly occur and only inside the relationship. If strictly adhered to to it was a new form of safe sex within regular relationships between HIV negative men. It was accompanied by massive health promotion in the gay media in Australia and the production and circulation of resources including how to manuals. It became more complicated later with the major rise in the 2000's of STIs which increase vulnerability to HIV and it became apparent the agreements require re-negotiation over time as circumstances change (partners change, matters get taken for granted etc).
Talk, trust and testing are the central elements.
Some chose monogamy, many developed open relationships with or without anal intercourse with casual partners. The talk occurred in a 3 month period that included use of condoms in the relationship during that time and excluded casual anal intercourse for that period. This was accompanied by HIV tests at either end of the period to ensure both partners were HIV negative. Only after that process could Negotiated Safety properly occur and only inside the relationship. If strictly adhered to to it was a new form of safe sex within regular relationships between HIV negative men. It was accompanied by massive health promotion in the gay media in Australia and the production and circulation of resources including how to manuals. It became more complicated later with the major rise in the 2000's of STIs which increase vulnerability to HIV and it became apparent the agreements require re-negotiation over time as circumstances change (partners change, matters get taken for granted etc).
Talk, trust and testing are the central elements.
Because some are speculating that a new form of negotiated safety is possible on the basis of the Swiss announcement for the purposes of clarity in this discussion I am referring to Negotiated Safety (Mark 1) and Negotiated Safety (Mark 2)
BUT I AM NOT ENDORSING THIS USAGE.
The reasons why are evident in the following remarks.
BUT I AM NOT ENDORSING THIS USAGE.
The reasons why are evident in the following remarks.
Negotiated Safety (Mark 1) came from research naming existing neg-neg practices amongst some gay men in relationships AND the development of appropriate health promotion campaigns involving extensive education. The research went through a process of peer reviewed journal publication and conference presentations - see the references below. (Some people are are well versed in these histories, but others don't know them at all hence the detail in what I'm saying.)
Paul Kinder from the AIDS Council of NSW described the associated health promotion at the 1996 Vancouver AIDS Conference. I don't have the sense that Negotiated Safety has ever been systematically officially promoted in the USA (am I wrong?) as distinct from well informed people on the ground there understanding it was occurring amongst some gay men. Whereas it was systematically promoted in countries such as Australia, the Netherlands and the UK amongst others.
Paul Kinder from the AIDS Council of NSW described the associated health promotion at the 1996 Vancouver AIDS Conference. I don't have the sense that Negotiated Safety has ever been systematically officially promoted in the USA (am I wrong?) as distinct from well informed people on the ground there understanding it was occurring amongst some gay men. Whereas it was systematically promoted in countries such as Australia, the Netherlands and the UK amongst others.
My point here is twofold. The science of these matters of viral load and it's AND its use in interventions needs to be vigorously assessed and discussed by scientists, by agencies and amongst gay men. Even if the science of viral load and STIs is correct, it still has to be incorporated into effective educational and campaign materials that are made widely available. In the case of negotiated Safety (Mark 1) this took considerable time and required careful brokering between agencies, funders and affected communities.
I admire the Swiss for grasping the nettle.
A few gay men especially in adventurous sex contexts are already factoring in viral load in casual sex and and in sero-discordant relationships. While the original Negotiated Safety protocol has worked well if strictly adhered to it does have its challenges and requires ongoing evaluation and change. There is a good discussion of these issues in relationship agreement negotiation here.
The discussion must acknowledge that different countries and areas and contexts within them have different knowledge levels. Further, testing rates matter enormously for these purposes. Negotiated Safety (Mark 1) was developed in a context of very high levels of HIV testing amongst gay men in Australia. STI testing is rising but occurs at lower rates. HIV positive people would need to engage in consistent, regular viral load tests and STI tests. This costs money - who funds it and for what purposes? In countries where health promotion has installed systematic risk management practices like those involved in Negotiated Safety (Mark 1) and where HIV education has been officially pro-sex (contested as it often is) it may be there are very different levels of knowledge amongst different gay populations. See Kane Race's papers below for excellent discussions of how these risk and biomedical knowledges play out in sexual cultures
Secondly, if new health promotion occurs on the basis of the the shift marked by the Swiss policy then I think it is is better NOT named as Negotiated Safety Mark 2, Even though there are possible similarities in any talk, trust, test talk protocol that might be required, the same name would create considerable confusion. The conditions under which each form would be negotiated are very different. This matters because any new form of negotiated safety would be potentially used in both sero-discordant relationships (not so with the original) and in casual sex (not so with the original) where the neg participants would need to know quite a lot about a sexual partner's viral load but trust might have to be immediate i.e. is contextually relative to a new person rather than a longer term partner and where the HIV positive person would have to maintain the highest levels of adherence and be very sure of their viral load.
While I would argue that Negotiated Safety inside neg-neg relationships is a form of 'safe sex', it's not at all clear that the safety required could have the same basis in casual sex. Much would depend on what the men knew about each other - some casual partners know each other, many don't. While some of these aspects also apply in regular relationships the context is different. That won't stop it occurring of course, but it means health promotion has to be very careful about what it says is possible or desirable. For example, many people simply won't wait 6 months and test multiple times before engaging in it. Even in the 3 month framework of NS#1 some people skipped the second HIV test or had unprotected anal intercourse with their partners before having the second test.
A few gay men especially in adventurous sex contexts are already factoring in viral load in casual sex and and in sero-discordant relationships. While the original Negotiated Safety protocol has worked well if strictly adhered to it does have its challenges and requires ongoing evaluation and change. There is a good discussion of these issues in relationship agreement negotiation here.
The discussion must acknowledge that different countries and areas and contexts within them have different knowledge levels. Further, testing rates matter enormously for these purposes. Negotiated Safety (Mark 1) was developed in a context of very high levels of HIV testing amongst gay men in Australia. STI testing is rising but occurs at lower rates. HIV positive people would need to engage in consistent, regular viral load tests and STI tests. This costs money - who funds it and for what purposes? In countries where health promotion has installed systematic risk management practices like those involved in Negotiated Safety (Mark 1) and where HIV education has been officially pro-sex (contested as it often is) it may be there are very different levels of knowledge amongst different gay populations. See Kane Race's papers below for excellent discussions of how these risk and biomedical knowledges play out in sexual cultures
Secondly, if new health promotion occurs on the basis of the the shift marked by the Swiss policy then I think it is is better NOT named as Negotiated Safety Mark 2, Even though there are possible similarities in any talk, trust, test talk protocol that might be required, the same name would create considerable confusion. The conditions under which each form would be negotiated are very different. This matters because any new form of negotiated safety would be potentially used in both sero-discordant relationships (not so with the original) and in casual sex (not so with the original) where the neg participants would need to know quite a lot about a sexual partner's viral load but trust might have to be immediate i.e. is contextually relative to a new person rather than a longer term partner and where the HIV positive person would have to maintain the highest levels of adherence and be very sure of their viral load.
While I would argue that Negotiated Safety inside neg-neg relationships is a form of 'safe sex', it's not at all clear that the safety required could have the same basis in casual sex. Much would depend on what the men knew about each other - some casual partners know each other, many don't. While some of these aspects also apply in regular relationships the context is different. That won't stop it occurring of course, but it means health promotion has to be very careful about what it says is possible or desirable. For example, many people simply won't wait 6 months and test multiple times before engaging in it. Even in the 3 month framework of NS#1 some people skipped the second HIV test or had unprotected anal intercourse with their partners before having the second test.
In terms of health promotion I believe we need to keep a sharp distinction between safe sex and risk reduction. I include Negotiated Safety (Mark 1) in safe sex. Negotiating (talking, trusting, testing) in sero-discordant relationships and in casual anal intercourse over a 6 month period with so many circumstantial variables throws up considerable contextual differences with what is involved in including viral load and STIs in sexual risk management.
At the moment the viral load, STIs and infectiousness knowledge suggests to me that 'we' who discuss these matters and educate others and have the sex are ourselves are not clear enough on the scientific complications, much less on the educational, policy and funding implications.
We need to talk at length, preferably internationally, however it is likely that different jurisdictions and countries will come to different conclusions. I'd need to be persuaded that it was safe sex rather than risk reduction to go anywhere near associating it with Negotiated Safety. I suggest that we stop doing so immediately. I suspect that as with sero-sorting and strategic positioning we're in the realm of risk reduction. That doesn't mean we don't do health promotion around it, but lets keep it clear we are dealing with risk and risk management. The forms of negotiation that are involved are different substantively, though potentially similar formally (TTTT).
Acknowledging that some men already practice this and trying to affect how that is done is one thing but promoting it as a form of safe sex would be a mistake.
It's not just the science that determines these matters. It's also about how people live their sexual and treatment lives.
At the moment the viral load, STIs and infectiousness knowledge suggests to me that 'we' who discuss these matters and educate others and have the sex are ourselves are not clear enough on the scientific complications, much less on the educational, policy and funding implications.
We need to talk at length, preferably internationally, however it is likely that different jurisdictions and countries will come to different conclusions. I'd need to be persuaded that it was safe sex rather than risk reduction to go anywhere near associating it with Negotiated Safety. I suggest that we stop doing so immediately. I suspect that as with sero-sorting and strategic positioning we're in the realm of risk reduction. That doesn't mean we don't do health promotion around it, but lets keep it clear we are dealing with risk and risk management. The forms of negotiation that are involved are different substantively, though potentially similar formally (TTTT).
Acknowledging that some men already practice this and trying to affect how that is done is one thing but promoting it as a form of safe sex would be a mistake.
It's not just the science that determines these matters. It's also about how people live their sexual and treatment lives.
He was a member of the International Gay Men's Health Thinktank (2001-2002). His reports "Then and Now - Gay Men and HIV" and "Cultures of Care and Safe Sex Amongst HIV positive Australians" are available here
References:
Kippax, S., Crawford, J. et al. (1993). Sustaining safe sex: a longitudinal study of a sample of homosexual men. AIDS 7(2): 257263. Kippax, S., Noble, J., Prestage, G., Crawford, J. M., Campbell, D., Baxter, D., & Cooper, D. (1997). Sexual negotiation in the 'AIDS era': Negotiated safety revisited. AIDS, 11, 191-197 Crawford, June M, Rodden, Pamela Kippax, Susan, Van de Ven, Paul (2001) Negotiated safety and other agreements between men in relationships: Risk practice redefined. International Journal of STD & AIDS,,v12n3, 164-170 March 2001 Prestage G, Kippax S, Noble J, Crawford J, Cooper D, Baxter D.Sydney men and sexual health: "negotiated safety" in a cohort of homosexually active men.Annu Conf Australas Soc HIV Med. 1994 Nov 3-6; 6: 125 (unnumbered abstract).References:
Race, K. (2003) Revaluation of risk among gay men. AIDS Education and Prevention. 15, 4: 369-81. Also available here
Race, K. (2001) The undetectable crisis: changing technologies of risk. Sexualities 4, 2: 167-189.
http://www.friendtofriend.org/condom/no-condom.html
ReplyDeletehttp://www.friendtofriend.org/condom
http://www.friendtofriend.org
http://notb4weknow.blogspot.com
This is a great post from AIDS Action Cmte's blog on the topic....
ReplyDeleteIf my viral load is undetectable, do I have to use condoms?
Blog Category: HIV prevention, CDC, HIV Health — Blogged by: eric on February 6, 2008 at 11:58 am
In my work in AIDS Action’s Health Library, I’m often asked this question.
Last week, a group of Swiss HIV experts issued a statement basically saying: “No, condom use isn’t necessary – provided that certain other conditions are met.” [Emphasis mine]
Before going into more detail, I think it’s important to note that some other expert groups have disagreed with the Swiss group’s conclusions. The U.S. Centers for Disease Control and Prevention (CDC) issued a brief statement, saying that the CDC “underscores its recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners.” Likewise, UNAIDS and the World Health Organization stated that, to prevent transmission of HIV, they “strongly recommend a comprehensive package of HIV prevention approaches, including correct and consistent use of condoms.”
So, what exactly did the Swiss experts say? And why is it controversial?
In brief: Based on their review of several medical studies, the Swiss group concluded that an HIV-infected person who is on HIV treatment and has a consistently undetectable viral load “is not sexually infectious, that is, cannot transmit HIV through sexual contact.”
However, according to their statement, the following conditions must also be met:
• The person must adhere to their HIV treatment, and the effectiveness of that treatment must be regularly evaluated by their doctor.
• Their viral load must be undetectable (<40 copies) for at least 6 months.
• The person must have no other sexually transmitted infections (STIs).
The Swiss group also acknowledges that “medical and biologic data available today do not permit proof that HIV infection during effective antiretroviral therapy is impossible,” but they believe that the risk is “negligibly small.”
Critics of the Swiss statement have emphasized that research on HIV transmission and viral load has focused on heterosexual couples and vaginal intercourse – and does not necessarily apply to anal intercourse.
A number of people have also pointed out that, even if the Swiss experts are right, their conclusions about unprotected sex would apply to only a small number of HIV-infected persons: people who have excellent adherence to their HIV regimen, a consistently undetectable viral load, and no other STIs.
Practically speaking, the “no STIs” restriction could probably be met only within a monogamous relationship in which both partners were tested for STIs before stopping condom use. STI testing would be essential, because many people with STIs have no symptoms.
The bottom line for me:
Several studies have shown that reducing a person’s HIV viral load tends to reduce their risk of transmitting the virus. This is very heartening, but it does not mean that people with undetectable viral loads have no risk of transmitting the virus.
Given the limitations of current data, I personally believe it would be unwise to endorse a “no-condoms-needed-if-your-viral-load-is-undetectable” approach.
However, recent studies on viral load and HIV transmission give reason to hope that, if effective HIV treatment were widely available worldwide and properly used, the number of new HIV infections could be substantially reduced.
Universal access to treatment could be an important element in a comprehensive HIV prevention strategy that would include widespread access to HIV testing, use of the full range of existing prevention techniques and technologies, and the continued research and development of new prevention technologies, including microbicides and vaccines.
If you’d like to read more about this topic, check out the following links:
“Swiss experts say individuals with undetectable viral load and no STI cannot transmit HIV during sex.” - This article from the aidsmap.com website has a detailed summary of the Swiss experts’ statement.
“CDC underscores current recommendation for preventing HIV transmission.” - This is the brief CDC statement made in response to the Swiss report.
“Statement by WHO and UNAIDS: Antiretroviral therapy and sexual transmission of HIV.” - This is the WHO and UNAIDS response to the Swiss report.
“Experts say positive people on effective HIV meds aren’t sexually infectious.” - This is POZ’s article about the Swiss statement. The many comments posted after the article express a wide range of opinions about this news.
“Reactions to the Swiss news about ARV’s.” – This blog item contains a number of reactions to the Swiss statement. The Lifelube blog also has another posting worth looking at: “Swiss deconstruction - Undetectable = safe?”