For HIV-negative men, purposefully not having sex with other dudes carrying the virus sounds like a reasonable strategy to prevent contracting HIV. If you know a potential sex partner is HIV-positive, steering clear brings your risk level down to zero percent, since you’re not exposing yourself to the virus. (And yes, this includes sex with condoms.) For HIV-positive men, there’s also, seemingly, an advantage to avoiding sex with other poz guys: No risk of exposure to another strain of HIV that could further damage your immune system and complicate your drug regimen. Except now we’re being told this technique — of keeping your pee-pee away from anyone carrying the virus — is “bankrupt in terms of actual risk reduction”?
That’s what gay men’s health activist Trevor Hoppe is arguing, whose main point seems to be this: “exposure does not equal transmission.”
[W]e 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.
That sounds like quite a big “if” factor to us, no? One in 50? Depending on your sex routine (read: if you’re a prude or a, um, professional sex partner), you’re going to reach that magical 50 number quite quickly, all but guaranteeing exposure. But exposure isn’t the villain, says Hoppe.
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.
Oh, and if you do so? You’re just helping perpetrate that stigma that HIV-positive folks are boogeymen.
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.