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  • Clinging to my [personal] pessimism
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Ken Monteith

Ken Monteith

Ken Monteith was diagnosed with AIDS and 4 CD4 cells in 1997. Ken is a recovering lawyer (it's a process!) living in Montréal, where he obsessively counts his CD4s with equal fluency in English and French, pausing only to glare at those who dare to taunt him with their higher numbers.

May14

Risk for me and risk for you

Thursday, 14 May 2015 Written by // Ken Monteith - Montreal Correspondent Categories // Gay Men, Health, Sexual Health, Living with HIV, Opinion Pieces, Population Specific , Sex and Sexuality , Ken Monteith

Our Montreal correspondent Ken Monteith delves into personal risk assessment, and emerges with a fairy tale all his own.

Risk for me and risk for you

The numbers

I’ve been asked by a few people what to make of the results of various studies on new prevention technologies, especially with respect to PrEP. The PROUD  and Ipergay studies both reported interim results of 86% reduction in the risk of HIV transmission, and the iPrEx study before that came back with a risk reduction of 44% or 92%, depending on who you are listening to. (The 44% was for the totality of study participants, the 92% for those who were the most observant in taking their pills daily.) 

The sciencey answer to those questions is that the level of risk of transmission is reduced by the percentage named, so a 100% risk (theoretical: HIV is not that efficient) would become a 14% risk with the 86% reduction. The same 86% reduction would make a 50% risk (still too efficient for HIV) into a 7% risk. It’s multiplication, not subtraction, and probably a lot more technical than I have presented it. 

The numbers sound impressive — or not — but what does it mean to have something other than 100%? Certainty would be much more helpful in making decisions for oneself, but it will never happen (he said with what sounds like 100% certainty). Science just isn’t like that. We are left with trying to make sense out of how to apply the numbers to our lives and the decisions we make for ourselves.

What the numbers mean for me 

Now from my perspective, there isn’t much pertinence — not to my life — of determining how much to trust PrEP as a prevention tool. I’m already positive, so it isn’t a tool for me. Would it be a tool for a potential partner of mine? Quite possibly. Do I have something to say about that as the partner? There’s a question for you. 

I’m sure I am not alone in having deployed some unilateral prevention decisions over the years. I have diligently kept my viral load undetectable (with a couple of low blips that would still exculpate me in the eyes of the Supreme Court), I have chosen activities with much lower risk of transmission and, on those rare occasions rapidly fading from memory, have insisted on the use of a condom where appropriate. Often, these things were not accompanied by a disclosure of my status and a discussion. Instead, we each made our decisions based on our own calculations and then fit them together as smoothly or as awkwardly as these things fit together.

Mostly, however, my sex life has been the tragic fairy tale of a shorn Rapunzel in a tower with no Prince Charming in sight. Well, at least she has electricity and rechargeable sex toys! 

If some nutty prince managed to make it all the way up to my window to announce that he was on PrEP and, combined with my undetectable viral load, he wanted to have his way with me with no condoms, how would I feel? Here’s where we delve into Rapunzel’s past to see what life events have formed her world view and we run smack into her experience of HIV as it used to be. That’s where she (and I do mean I) becomes rather conservative in the prevention choices department. I have always been confident in being able to say that I have not transmitted HIV to anyone, at least not since I was diagnosed and aware of my status. I’m not so sure that 86% is enough for me, even if it would be enough for Prince Charming. Or maybe, at my advancing age, sex just isn’t as important to me as my perfect record. 

Each to his own

Don’t get me wrong here: the only possible other people I am imposing my world view on are my potential partners, so that pretty much leaves everyone to make their own decision about their prevention choices. And I think the evidence is pretty clear that PrEP is a valid and effective choice among many out there. I just can’t get past my history and my own fear of transmitting, so I wouldn’t be ready to accept condomless sex with a negative guy, even one on PrEP.

Others will make other decisions, and those decisions will be logical and science-based. Well, except for the couple I saw on Scruff a while back: both negative and on PrEP, only play with other negative guys, and only with condoms. (Someone is wasting their money on an expensive pill, I think.) Getting back to the logical decisions, I respect them. For my own illogical reasons, I won’t participate in them personally. 

And that, ladies and gentlemen, is Rapunzel’s prerogative.

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