Refusing to Have Sex With HIV-Positive People: Why It’s Not a Prevention Strategy

Trevor Hoppe

"I would never have sex with an HIV-positive guy," a friend told me. But rather than promoting real risk reduction, such statements reinforce and reproduce harmful stigma against HIV-positive people.

This article originally appeared at Trevorade, and is reprinted here with permission from Trevor Hoppe.

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I
was having drinks with a friend of mine — we’ll call him Patrick here
— this weekend when the subject of having sex with HIV-positive men
came up. "Oh, I would never have sex with an HIV-positive guy," he
casually remarked — as if such a thing were already obvious. I was
shocked not just by Patrick’s statement, but also by the categorical
bravado in his delivery. To have sex with HIV-positive men, as he went
on to explain, was to expose himself to unnecessary risk of infection.
I’ve been replaying this conversation again and again in my head. How
could he be so outrageously calculating in his cooIly expressed
exclusionary strategy? Today I want to spend a few moments reflecting
on these kinds of statements, because I think many people would
uncritically read them as legitimate prevention strategies. I will
argue here, however, that in reality that these kinds of strategies
that are totally bankrupt in terms of actual risk reduction. Moreover,
what I think this kind of statement actually tends to do is not
actually promote any real reduction in risk, but rather to reinforce
and reproduce harmful stigma against HIV-positive people.

Before we get into a discussion of the ethics of "serosorting" —
the practice of choosing to engage in sex with only sero-concordant men
— I think we should bracket my friend’s comments as existing only at
the very periphery of this term’s broad meaning. While taken at face
value, it does indeed seem that my friend is practicing serosorting.
But correct me if I’m wrong here, but it seems to me that serosorting
was more intended to describe men who were seeking to minimize risk of
transmission while engaging in sex without condoms.
For my friend, this wasn’t the goal of his strategy — condom use was
still part of his risk reduction strategy with other HIV-negative men.
This is a very important distinction. What I’m going to be talking
about here is men who report consistent condom use, but who continue to
latch onto serosorting discourses that discourage serodiscordant sexual
practices.

Because of these important differences, I want to suggest that
Patrick’s comments cannot possibly be said to be purely a method of
risk reduction. To explain why I think this is so, we 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.

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.

Now that we’ve established that there is no real prevention
rationale for categorically excluding HIV-positive men from your pool
of eligible partners, we need to seriously consider the ways in which
doing so actually works to reinforce stigma against HIV-positive men.
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. This essay is
just a gloss on these issues — it admittedly raises more questions
than it answers — but I desperately think we need to think critically
about the way we (I mean both we as gay men, and we as people invested
in promoting Public Health) allow stigma to continue operating in our
communities through the lens of "health" and "risk reduction." Backed
by medical logic, stigma seems rational, logical, and unproblematic.
But we need to expose the ways in which these allegedly science-based
logics are actually totally bunk in terms of their validity — and are
actually just forms of stigma veiled by scientific authority.

Author’s Note: Many people have emailed their
frustrations with my use of statistics. 
Indeed, the kind of very sketchy analysis I engage in is problematic if
you are interested in the actual, "real" statistical risk. I’m not
really so interested in the precise number, and I don’t think it
matters much in making this argument. To my knowledge, even if we look
at the outcomes here — seroconversions reported when using condoms
with HIV-positive partners — we just don’t see large numbers of
transmissions. But I certainly welcome and encourage further research
that is invested in precisely quantifying these risks — and the
variety of factors that are bound to contextualize them.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.

Commentary Sexual Health

‘Not the Enemy, But the Answer’: Elevating the Voices of Black Women Living With HIV

Dazon Dixon Diallo

National HIV Testing Day is June 27. But for longtime advocates, ensuring that the women most affected by the epidemic can get and influence care and policy is the work of many years.

I met Juanita Williams in the mid-1980s. She was the first client at SisterLove, the then-new Atlanta nonprofit I founded for women living with AIDS.

June 27 is National HIV Testing Day, and many women will be tested during the observance. But when I met Williams, HIV was a growing reality in our communities, and women were not even recognized as a population at risk for HIV at that time.

This lack of understanding was reflected in women’s experiences when seeking care. Williams’ attempt to get a tubal ligation had been met with fear, ignorance, and hostility from a medical team who informed her she had AIDS. Not only did they refuse to provide her the medical procedure, the hospital staff promptly ushered her down the back staircase and out the door. Williams was left without information or counseling for what was devastating news.

A Black woman who grew up in Syracuse, New York, she had moved to her family’s home state of South Carolina. Her first major decision after her diagnosis was to leave South Carolina and move to Atlanta, where she believed she would get better treatment and support. She was right, and still, it wasn’t easy—not then and not now. Even today, Williams says, “Positive people are not taken seriously, and positive women are taken even less seriously. People think positive people are way down on the totem pole.”

As communities across the United States observe National HIV Testing Day and emphasize taking control of our health and lives, women’s voices are an essential but still neglected part of the conversation. The experiences of Black women living with HIV, within the broader context of their sexual and reproductive health, highlight the need to address systemic health disparities and the promise of a powerful movement at the intersection of sexual and reproductive justice.

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The urgency of adopting an intersectional approach to sexual and reproductive health comes to light when considering the disproportionate impact of HIV on women of color. Black women account for 69 percent of all HIV diagnoses among women in the South. Advocates also acknowledge the history of biomedical and reproductive oppression that Black women have suffered throughout American history, including forced pregnancy and childrearing during slavery to forced sterilization afterward. Keeping these matters in mind helps us understand how the HIV epidemic is a matter of sexual and reproductive justice.

Taking seriously the perspectives of women such as Williams would amplify our collective efforts to eradicate HIV’s impacts while elevating women’s health, dignity, and agency. This is especially pressing for women living with HIV who experience the greatest disparities and access barriers to the broad spectrum of reproductive health, including contraception and abortion.

The policy context has created additional barriers to advancing the reproductive health of women living with HIV. For example, the 2015 National HIV AIDS Strategy Update neglected to mention family planning or reproductive health services as arenas for providing HIV prevention care. Yet, in many instances, a reproductive health clinic is a woman’s primary or only point of access to health care in a given year. Providing HIV prevention and care in family planning clinics is a way to provide a space where women can expect to receive guidance about their risk of exposure to HIV.

As advocates for women living with HIV, we at SisterLove are committed to ensuring that human rights values are at the center of social change efforts to protect and advance the sexual and reproductive health and rights of women and their families. We work to transform the policy frame to one that asserts women’s agency to make decisions that are best for themselves and their loved ones. We draw strength from the resilience and determination of the women we serve.

Several years after becoming deeply involved with SisterLove, Williams became an advocate for her own reproductive health and began speaking out on behalf of other Black women living with HIV. She eventually became a trainer, counselor, and health outreach worker.

Later, in 2004, Williams was the only woman living with HIV invited to be a main speaker at the historic March for Women’s Lives in Washington, D.C. She is a mother, grandmother, and great-grandmother who has returned to South Carolina, where she teaches other women living with HIV about sexual and reproductive justice and human rights. Williams uses her own story and strength to help other women find theirs.

“Give [women living with HIV] a voice and a platform for that voice,” she has said. “Give a safe place to let their voices be heard and validate them …. We need positive women’s voices to continue to fight the stigma. How do we do that? We tell our stories and reflect each other. I am not the enemy, I am the answer.”

Advocates need strength as we work at many critical intersections where the lives of women and girls are shaped. We cannot address HIV and AIDS without access to contraception and abortion care; health and pay equity; recognition of domestic and gender-based violence; and the end of HIV criminalization. And as advocates for sexual and reproductive health in our communities, SisterLove is working alongside our sisters to support National HIV Testing Day and ensure all people have the information, tools, and agency to take control of their health.

Elevating the health and dignity of people living with HIV calls for special attention to the epidemic’s implications for women of color and Black women, particularly those within marginalized communities and in the Deep South. The voices and leadership of the most affected women and people living with HIV are essential to making our efforts more relevant and powerful. Together, we can advance the long-term vision for sexual and reproductive justice while working to eradicate HIV for all people.