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From ‘hazardous’ to hot

Undetectable HIV viral counts are changing the safer-sex game

Credit: Jamo Best

I was surprised when I realized we were leaving The Cobalt to go have sex at his place.

It had been more than a while since I’d met someone in person rather than through friends or a keyboard. Meeting a guy at the bar seemed almost quaint, but George’s carefree dancing and blond hair — so thick it was almost red — had drawn me in.

Halfway across the viaduct, my self-recriminations had already begun.

Feeling the familiar mix of shyness and apprehension, I slowed to deliver the news of my status.

"But I’ve been undetectable for six years. Do you know what that means, as far as transmission risks go?” I asked.

George had slowed with me but now picked up his pace again. He looked over at me with a one-shouldered shrug. “I’m negative, but I know the science. You’re okay if I don’t wear a condom, then?"

***

To say that safe-sex fatigue is widespread is to state the obvious. For many younger gay men, the virus is also often viewed as a formerly fierce junkyard dog, now made largely toothless in its third decade by the HIV cocktail.

In the not-so-distant past, many HIV-negative men, reluctant to meet the standard of rigorous adherence to condom use, tried to lessen their risk by serosorting – choosing lovers who are also HIV-negative.

That’s beginning to change now, as more negative men switch to seeking out partners who are positive but have undetectable levels of the virus in their systems.

The concept, backed by science, is simple enough: positive guys, already diagnosed and on treatment, are less likely to transmit HIV than guys who think they’re negative who may have contracted the virus since their last test and unwittingly be passing it on.

Choosing to have sex with an HIV-positive guy may seem counterintuitive to 30 years of AIDS education. But to a growing contingent of negative men, positive guys with undetectable viral loads are seen as worry-free sexual partners, even if a condom is not used.

***

I had carried the virus for five years before beginning the medication regimen for HIV in 2008. I remember my surprise when my doctor explained the new realities of an undetectable status to me.

I had already known how remarkably effective HIV medications can be – decreasing someone’s viral load from the millions to less than a dozen. What I hadn’t known is how unlikely I’d be to transmit the virus once my viral load became undetectable.

Recent studies suggest that when the viral load drops to less than 1,500, transmission is improbable.

The now-famous “Swiss statement” of 2008 found that HIV-positive people are “sexually non-infectious” if they’ve been undetectable for six consecutive months, have never missed a treatment and have no other sexually transmitted infections.

After years of feeling like the last kid picked for the team, it felt good to let go of the constant fear of a rubber breaking and the recurring sting of automatically being passed over by someone I was into. But psychologically? It was a massive adjustment.

At times I felt like I was trying to pull one over on a guy when I explained the reduced risk of an undetectable viral load. But in the last couple of years, that’s changed.

As the reduced risks of undetectability become common knowledge, a long-shunned status is suddenly in demand, at least to some.

***

I’m one of those that got circumcised and can’t feel much with [a condom] on – usually can’t stay hard either,” says a friend of mine, who remains negative despite preferring undetectable, HIV-positive partners.

Dom (whose name has been changed to protect his privacy) has met some of his partners on BarebackRT (BBRT), a cruising site similar to Manhunt and Grindr, except its focus is on men who choose to have sex without condoms.

In British Columbia, BBRT has more than 500 profiles from men without the virus who express interest, directly or indirectly, in undetectable partners.

If there’s an image in your mind of men like Dom – bathhouse-slick and cynical of eye – it doesn’t apply here. Dom’s demeanour is serious and reserved, and his build reflects his passion for running marathons. He sees this choice as another healthy one, in the long term.

"Definitely, I have friends who don’t understand my thinking, but this isn’t bug chasing,” he says. “I try, but I’m not always successful at sticking to the safe-sex script and got tired of PBR [post-barebacking regret]."

Another HIV-negative man I interviewed confided, “I’m into younger guys, and for 18 months at a stretch not one checked that I was negative or asked me about condoms. We both were assuming a lot. So I figure if safe sex is something I keep blowing, I should at least try to cross over into safer territory."

For negative men like these, their wariness of serosorting with other negative men seems justified by some recent findings.

In 2010, the ManCount study found that one in 40 gay men in Vancouver were HIV-positive but didn’t know it.

ManCount wasn’t the first survey of gay men’s health in Vancouver. The Sex Now surveys also asked men who have sex with men to disclose their HIV status on anonymous questionnaires between 2002 and 2008. The results paralleled ManCount’s findings: 16 percent of respondents knew they were HIV-positive.

But ManCount took the extra, unprecedented step of asking respondents for blood samples, too. The result: 2.5 percent of the men surveyed were positive but didn’t know it.

This is an enormous concern, Dr Terry Trussler told Xtra at the time. “We think it’s what’s driving the epidemic."

"We did an analysis in the survey, and we’re pretty sure that these guys think they are negative – and are serosorting with other negative guys on the false assumption that they think they are negative,” added Dr Rick Marchand, who worked with Trussler on the study.

Echoing these results, Boston’s Fenway Health HIV clinic reported in 2012 that one out of five newly infected men thought their partners were negative.

"Unfortunately, the newly infected carry the highest viral load,” explains therapist Bill Coleman, who has worked with Vancouver’s HIV community for 25 years and was one of the researchers of a recent study on viral loads. “The count went as high as 10 million in men that had recently seroconverted."

For those without the virus who choose to serosort and then bareback, this can be like fucking on a landmine.
 

***

If the answer were as simple as “stick to the HIV-positive-yet-undetectable,” we could hope for a new chapter in the sexual viability of men living – and thriving – with HIV, not to mention a new safer-sex option for all gay men.

But things are rarely that simple when it comes to sex.

The Swiss statement that sparked such hope with its non-infectious declaration was also heterosexual-based, a fact that shouldn’t be overlooked by gay men, as the virus is more likely to be transmitted through anal than vaginal sex.

An Australian study that challenged the Swiss findings suggests that HIV-positive people with undetectable viral loads be considered “less infectious” rather than “non-infectious."

The Fenway study agrees.

More sobering still, the Fenway study and a 10-year French study by Lambert-Niclot suggest that an imperceptible viral load in blood plasma does not always mean an undetectable viral level in semen.

Then there’s the variable of other sexually transmitted infections (STIs).

The Fenway and French studies also showed that HIV-undetectable men with STIs or urethritis are 29 times more likely to have detectable levels of HIV in genital secretions, even when the level in their blood is undetectable.

The average viral load counted in the Fenway study was 200. This is still far below what is considered the traditional transmission threshold of 1,000-1,500, but one must also remember this threshold is based on vaginal sex. Conjecture remains.

HIV-undetectable men also face their own health risks if they choose to take full advantage of their less-infectious status and forgo condoms.

Hepatitis C can be difficult to transmit but devastating to a positive man with a compromised immune system. Syphilis is seeing a resurgence, but much more serious is a new strain of gonorrhea appearing for the first time in the community that is resistant to available antibiotics.

Wayne Robert, executive director of Vancouver’s Health Initiative for Men (HIM), also cautions against seeing a negative-undetectable sexual pairing as a way out of using condoms.

HIM recently ran a campaign called Calculate Your Risk, urging gay men to consider the specifics of each sexual encounter, whether it be a supposedly negative monogamous couple, a threesome, or one-on-one with an undetectable man.

"This is a nuanced situation, and a conversation between them needs to take place,” Robert says. “What the best option is will not necessarily present itself in black and white."

***

The war on AIDS has changed from an epidemic to a stalemate. The rate of new infections remains stubbornly the same, which suggests those who can be reached by the safe-sex message have already heard.

Post-AIDS, barebacking has moved into our community to stay. But opinions remain in flux about how “safe” unsafe sex with an undetectable partner really is. Each study presents mixed findings; most healthcare professionals will give you an answer with reservations.

For gay men living with HIV, being seen as potentially safer partners is a chance to spit in the eye of the sexual purgatory to which our own community previously confined us. But the rules of our sexual interaction are still in transition.

The science of undetectability offers an out to men both positive and negative who are sexually discontent with the current safer-sex regime.

AIDS made many of our brothers untouchables. The new science – if it holds up to scrutiny – could change the way our community’s former pariahs are seen, and desired. It could mean they’re no longer viewed, and dismissed, simply as common vectors of transmission.