Michael Hurley PhD of the Australian Research Centre in Sex, Health and Society analyzes the Swiss announcement re: sexual infectivity and viral load
Only on LifeLubeI 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:
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.
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.
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.
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.
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.
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:
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.
