The challenge for the new Safe Sex 2.0 effort will be trying to capture the attention span of someone who lives life and thinks in 140 characters. In this Internet age, we in the HIV+ and HIV- community (basically that is everyone) have been given the dual-edged sword of the internet as a tool for advocacy and outreach.  The internet is definitely useful in finding the answer to almost anything, and it has exponentially increased the means by which information can be disseminated to the masses.  However, the internet has also created vast, huge, and deep canyons between us, where we are only as connected as our wi-fi signal allows us to be. 

Back in the “old days”, we in the older gay community used to go to gay bars.  At those gay bars there were bowls of free condoms.  They were right there on the bar or by the door so that they were always on hand. Back then, we cared about protecting our community.  Back then it was not as controversial or offensive to talk about or insinuate safe sex. Safe sex was viewed as a normal, healthy part of the greater gay conversation. 

At some point though, this changed. Bars are no longer the meeting places of gay men.  Grindr, Scruff, and Adam4Adam have taken their place. Face to face caring was replaced by the cold glow of a computer screen.  Our community became diffused and fragmented and it dispersed like smoke in the wind. There were always those that didn’t go to the gay bars, just as there are those who do not go online today, but they were in the minority I believe.  

Our sense of community has been replaced by a transactional approach, where one’s personal opinions seem to trump the collective wisdom that has been tempered by experience.  Collaboration and compromise have been thrown down the toilet, to be replaced by the louder squeaky wheel of personal, selfish freedoms.

Now, if you were to talk about safe/safer sex or condoms, a method that is clinically proven to reduce HIV and other STDs, you are yelled at, or someone posts a pages long diatribe about how out of touch you are, and how it is their God-given right to have unsafe sex. They pull one tenuous statistic (that successful HAART treatment prevents 96% of HIV transmissions) and they have built an amendment to the sexual constitution, much like gun proponents clutch onto the 2nd Amendment. They ignore the fact that an undetectable viral load in the blood is NOT equal to an undetectable viral load in semen or in anal fluids/tissues. 

And so, the uninformed and unwilling shun proven methods of safety: condoms, HIV testing, non-sexual forms of intimacy.  (Apparently in the age of Grindr, intimacy seems to be an outdated concept as well.)  And then when they contract HIV, they then have this sense of confusion and incredulity, knowing in the back of their mind that they knew their risk all along but chose to ignore it and live in the moment.  There is even a hashtag for that, #YOLO (You Only Live Once).  

Because one in five urban gay men do not even know their HIV status, it is imperative to again find a way to encourage HIV testing and to advocate condom use. People proceed with actions based upon their perception of risk, as opposed to the actual risk at stake.   Stigma is still very high and the pervasive HIV stigma within the gay community (as well as outside of the gay community) prohibits those at the highest risk for HIV from getting tested. When those at highest HIV risk continue to contract the virus year after year after year, there should be a more aggressive approach to HIV testing and condom use.   

It is ironic that studies have shown that when a person is diagnosed with HIV, that person’s sexual behavior becomes safer. They care more about not wanting to infect others. But on the flip side of that is the callous carelessness that pervades young gay men, who believe their greatest source of angst is over what to wear to a Lady Gaga concert.  These guys repel conversations about HIV/risk/safety like Teflon repels an egg.  If you try to mention HIV, they all the sudden stop texting you back, or they fade from your Facebook...they become silent and they disappear.  

I believe there needs to be a new call to action, one in which the new ways of the internet and the social media expertise of the young are merged with the proven, effective methods of prevention.  And through all of this we must figure out how to burn of the fog that has settled on everyone regarding HIV:  for the older people who are tired and exhausted from 30+ years of advocacy and for the young, know-it-all youth who live in ignorance and bliss.

I wish I had the answer on how to do that, because until that answer is figured out, I fear we will again see a rise in HIV infections.  I believe the coming storm will rival the pre-HAART era. Before HAART, people died because there was no medicine.  Now, I believe stigma and indifference has become just as deadly as those early days. 

About the author: I am 38, a gay male from Knoxville, TN who is not ashamed of my HIV+ status. I am optimism personified. I am strength realized. I am just me.

Website: embacingpozitivity.blogspot.com.Twitter @jjemcdonald 

“Can I give you a hand with that?” were the first words the young man made to me in his perfect British accent.  He was tall, incredibly dark skinned, and lithe but in that athletic way only men who regularly run or play soccer can be.  His body was flawless, with that patch of hair in the middle of his chest denoting he was, in fact, a man, and when he removed his towel, the facts surrounding his being a man were decidedly and enormously to his credit. 

“And where are you from?” I responded after telling him to come into my room.  Even now, I have a habit of finding out the most banal, but eventually telling and vital to understanding, facts about men I meet under even the most anonymous and purely sexual of circumstances.

“Kenya,” he said.  I quickly started wondering whether or not I had enough personal knowledge of Kenya to validate his story.  Were they colonized by the British, which would explain his accent?  Is he just a crazy person from West Philadelphia who gets high and speaks, as I knew one young man to do, in a British accent for his own amusement or involuntary compulsion?  In a few seconds, I stopped my neurotic, thought-based assessments and was distracted by the only reason we both were seemingly in a bathhouse.  We said nothing more aside from his incredibly polite, “It was very nice to meet you,” as he left my room, leaving the door wide open and me, out of breath, on my bed.

As I write this, I am in a bathhouse.  Last night, I had an amusing and long conversation with a friend of mine at Woody’s in Philadelphia, the flagship gay bar here, and he asked me if I was willing to play wingman for his first foray into the globally popular gay male hobby of going to the bathhouse.  While he said he wanted more time before he personally dove in feet first, or up in the air rather, I had already alone decided to take advantage of half price Tuesday at Philadelphia’s only currently operating bathhouse off Rittenhouse Square.  After all, it wasn’t like I had planned on doing anything else last night, like building model airplanes, volunteering, or, most annoyingly stereotypical but factually accurate to my personal behavior, watching HGTV.  And so, when my friend and I parted ways, he went to his house, I went to the bathhouse, and I let my insecurities stay outside.  But, before we parted, he asked me some questions about the practical ins and outs of this quietly popular hobby in gay culture.

Rooms in most bathhouses in my experience are no larger than the square footage of a small storage shed in a suburban backyard.  Typically, each room has a light with a dimmer switch, no furniture or decoration aside from high gloss wall paint, tile or parquet flooring, and, more often than not, a single bed built into the floor or wall reminiscent of a submarine’s barracks.  Generally, these rooms have a television playing one or several stations of hardcore pornography or a speaker for, naturally, dance music.  These rooms usually have keys on small lanyards men can wrap around their ankles or wrists getting rid of the need of pockets and, therefore implicitly, the wearing of any clothing aside from a single towel provided upon check-in.

Originally, these businesses were started as a means to easily launder money.  After all, like all cash businesses related to the LGBT community, records were, at one time, non-existent or kept on two sets of books, and revenues somehow always found their way to Irish or Italian organized enterprises.  Today, however, these businesses, if run honestly, kept clean, and established on a premise outside of pretense or judgment, are genuinely profitable and a key, but rarely talked about, component of LGBT culture and economy.

Throughout the course of a day or night, dozens of men walk around in their towels, letting their leers and facial expressions communicate their desires, and have sex with each other.  In some cases, this sex is tender lovemaking, and in other cases, this sex is as aggressive as it is fulfilling.  In both cases, adults are consenting to engage in an activity, knowing full well the possible risks or lack thereof depending on their activity and partner of choice, and, hopefully, engaging in these acts for the right reasons.  In the overwhelming majority of bathhouses, condoms are provided at no cost to guests, and guests have every right to use them or not use them.  After all, part of being an adult is assessing risk, or lack thereof, and behaving accordingly to still enjoy life.

Often, my writing is misinterpreted, particularly in relation to sex and barebacking.  Quite literally, a reader recently implied that I was killing people by arguing against the, now obvious, ineffectual nature condom only campaigns are having on HIV transmission rates and the horrendously stigmatic approach inherent using the words “safe” or “clean” in relation to sex and HIV status.  Rather than recognize that I am simply pointing out a reality enjoyed by the overwhelming majority of LGBT folks, these readers are, instead, opting to promote their own particular agenda sustained by decades of conventional wisdom that, while once valuable to counteract a literal plague decimating the gay community, are now outdated as much as they are hurtful.  And, rather than understand that I make no point in advocating in favor of a particular activity, that I am merely pointing out the obvious reality of life, nothing more, nothing less, these readers would rather trot me out as the murderer of laughably characterized and non-existent “innocent victims.”

Last night, I engaged in mutually enjoyable and consensual sex in an overtly sexual environment.  And, the fact of the matter is that I am the rule, not the exception.  Acknowledging this does not condone or promote going to bathhouses; rather, it simply highlights that this goes on, that it is an important reality facing many gay men, and that judging this behavior or somehow insinuating that it is reckless or anything but net positive or neutral toward advancement of our loosely affiliated community is, at best, naive and, at worst, deceptive.  In both cases, such criticism is unwarranted, without merit, and, frankly, indicative of the very things that I routinely discredit, including judgmental and stigmatic practices in relation to sexual behavior.

This article first appeared in Josh’s own blog here. 

This important article by James Wilton first appeared in Prevention in Focus on the CATE website here.

Une version française est disponible ici. 

Since the beginning of the HIV epidemic, condoms have been a cornerstone of our HIV prevention efforts—often promoted as the most effective way to prevent the sexual transmission of the virus. However, in the past few years the number of HIV prevention options has increased and some people are interested in, or are already using, newer strategies. As a result, frontline service providers are being asked challenging questions: Are condoms the most effective strategy available? How do they compare to other strategies? This article explores the evidence on how effectively condoms prevent HIV transmission and the implications for our HIV prevention messaging.

Condoms 101

Condoms are physical barriers used during sex to prevent parts of the body that are vulnerable to HIV infection (such as the penis, vagina, rectum and mouth) from coming into contact with fluids that may contain HIV and other infections. We currently have two main types of condoms: the male condom (also known as the external condom) and the female condom (also known as the internal or insertive condom).

What are they made of? Most male and female condoms are made from nitrile, latex, polyisopropene or polyurethane, all of which cannot be penetrated by the viruses and bacteria that cause sexually transmitted infections (STIs), including HIV.1 Lambskin condoms, which are made from sheep intestines, can be penetrated by bacteria and viruses and should therefore never be used to prevent the transmission of HIV.

To lube or not to lube? Sexual lubricants are commonly used in combination with condoms to increase pleasure. The use of lubricant is also recommended to decrease friction that can cause breakage, particularly during anal sex. Water- and silicone-based lubricants are safe to use with all condoms, but oil-based lubricants can compromise the integrity of latex and polyisopropene condoms and increase the risk of the condom breaking.

Using condoms correctly and consistently

Since condoms are impermeable to viruses, shouldn’t we expect them to be 100% protective against HIV? Unfortunately, it’s not that simple. As with any type of prevention strategy, condoms only work if they are used correctly and consistently. Inconsistent use can greatly decrease their ability to prevent HIV transmission.

Incorrect use of condoms can also compromise their effectiveness. For example, some people may use condoms that are too small or too large, damaged or expired; unroll condoms before putting them on; not pinch the tip when putting them on; use sharp objects to open condom packages; not use enough lubrication in combination with condoms or use oil-based lubrication with latex or polyisopropene condoms; or not hold the rim of the condom when pulling out. All of these can potentially increase the risk of HIV transmission by causing a condom to break, slip or leak.

Incorrect condom use can also take the form of putting on a condom late (after intercourse has started), removing the condom early (before ejaculation has occurred) or putting the condom on inside out and then flipping it over to use. If a condom is used incorrectly in these ways, then HIV transmission could occur even though the condom does not break, slip or leak.

A recent literature review of 50 studies revealed that the incorrect use of male condoms is surprisingly common.2 For example:

• Studies found that 17 to 51% of participants reported not putting on a condom until after intercourse had started.
• Some studies also reported high rates of condom problems, such as breakage (0 to 33%), slippage (0 to 78%) and leakage (0 to 7%), which could lead to HIV transmission. Errors in condom use may be partly responsible for these problems. For example, 24 to 46% of participants reported not pinching the tip of the condom and 16 to 26% reported using a condom that was not lubricated.

How often do condoms break, slip or leak when they are used perfectly in every possible way? We don’t know and probably never will. However, when condoms are used correctly, the rates of breakage, slippage, and leakage are likely quite low. Research shows that education and more experience using condoms can help lower rates of condom failure.3,4

So how effective are male condoms?

The best evidence we have on the effectiveness of male condoms comes from an analysis of 14 observational studies that enrolled heterosexual serodiscordant couples (where one partner is HIV-positive and the other is HIV-negative).5 The analysis compared the rate of HIV transmission between couples who said they always used male condoms to the rate among couples who said they never used male condoms. The analysis found that the rate of HIV transmission was 80% lower among couples who reported always using condoms.

For many people working in HIV prevention, an 80% effectiveness rate may be lower than you thought or have previously told clients and patients. However, it is important to consider the limitations of this analysis when interpreting its results. There are three reasons why this analysis may make condoms look less effective than they can be: 

Incorrect use. The couples who said they always used condoms may not have been using condoms correctly. This would have increased their risk of HIV transmission and reduced condom effectiveness.

Inconsistent use. The couples who said they always used condoms, in reality, may not always use them! Some of the couples may have had trouble remembering how often they used condoms or felt uncomfortable saying that they did not use condoms. This would have increased their risk of HIV transmission and made condoms appear less effective.

Differences in behaviour. The risk-taking behaviours of the couples who said that they always used condoms may have been different from those couples who said they never use condoms. For example, couples who reported always using condoms may have engaged in behaviours that increased their risk of HIV transmission, such as having sex more often or engaging in higher-risk types of sex. If this was the case, these behaviours would have increased their risk of HIV transmission, making condoms appear to be less effective. It’s also possible that people who reported never using condoms may have engaged in behaviours that put them at lower risk of HIV transmission, such as having sex less often or only engaging in lower-risk types of sex (such as oral sex). If this was the case, this would make it appear as though there was less of a difference in HIV transmission rate between the two groups and make condoms appear less effective.

Given these limitations, the estimate of 80% likely does not reflect how effective condoms can be in preventing heterosexual HIV transmission. If used consistently and correctly, condom effectiveness is likely much higher.

Is the same true for men who have sex with men?

Are male condoms also effective at reducing HIV transmission when used by gay men or other men who have sex with men? Several studies have explored this question and estimated a similar effectiveness rate of 70 to 80% for consistent condom use during anal sex.6,7,8 However, these studies are affected by the same three limitations as studies of heterosexual couples—incorrect use, inconsistent use and differences in behaviour. So the effectiveness rate for consistent and correct condom use during anal sex is likely higher.

What about female condoms?

No studies have evaluated the effectiveness of female condoms in preventing HIV transmission during vaginal sex or anal sex. However, research shows that they are as effective as male condoms at preventing other STIs.9,10,11

The expanding HIV prevention toolkit

In the past decade the number of HIV prevention options available to reduce the risk of HIV transmission has increased. Some of these strategies are generating a lot of excitement because they may provide an option for people who don’t want to, or are unable to, use condoms. These include the following:

Antiretroviral treatment – which reduced the risk of HIV transmission by 96% among heterosexual serodiscordant couples in a randomized controlled trial (RCT).12

Pre-exposure prophylaxis (PrEP) – which reduced the risk of HIV transmission by 40 to 70% for gay men13 and heterosexual men and women14,15 in RCTs. Further analysis suggested that PrEP may have reduced HIV risk by up to 90% among those who always took their pills.13,14

Post-exposure prophylaxis (PEP) – which reduced the risk of HIV transmission by up to 80% in an observational study of healthcare workers exposed to HIV in the workplace.16

Observational studies suggest that behavioural strategies such as serosorting, strategic positioning and withdrawal may slightly reduce the risk of HIV transmission.17

People who want to use, or are already using, these strategies may want to know how effective they are compared to condoms. These questions can be challenging to answer and it’s important that, in our responses, we don’t compare apples and oranges. For example, comparing results from different types of studies can be problematic. Some of the new prevention strategies were evaluated using an RCT while condoms were evaluated using observational studies. Comparing the results from these two kinds of studies can be problematic for a number of reasons:

• In RCTs the two groups are randomized to ensure that there are no differences between the groups other than whether or not they received the intervention. This is important because we know that each group should have similar risk behaviours and that neither group should be more or less likely to get HIV. However, in observational studies (such as those used to assess condoms), one group could be having sex more often or engaging in riskier sex. This could impact the results and make a strategy, such as condoms, appear to be less effective than they actually are.
• RCTs create “ideal” conditions that can make a strategy appear more effective than it would be in the “real world.” For example, RCT participants are supported to ensure they use the strategy correctly and all participants are provided with a comprehensive package of prevention services, including STI testing and treatment, free condoms, and intensive adherence and risk-reduction counselling. By contrast, observational studies, such as those used to evaluate condoms, generally do not provide participants with additional supports. Therefore, these results may not be directly comparable to the results of RCTs.

When it comes to comparing the effectiveness of two prevention strategies, we need to pay attention to the research design used to measure that effectiveness. Most new prevention strategies, such as PrEP or treatment as prevention, have been evaluated using RCTs, which can tell us about the effectiveness of the strategy under “ideal conditions.” Unfortunately, we don’t know how effective condoms would be under the ideal conditions of an RCT; however, we have good reason to believe that they would be more than 80% effective when used consistently and correctly.

Implications for HIV prevention messaging

Safer sex messaging and prevention counselling need to emphasize that the correct and consistent use of condoms is a very highly effective method of preventing the sexual transmission of HIV.

When answering questions about the effectiveness of condoms, it’s important to emphasize that they have several advantages over other options. Key messages include the following:

• If a condom is used correctly and it doesn’t break, slip or leak, then it is virtually 100% protective. However, there is a still a possibility that condoms will break, slip, or leak even when used correctly. Condoms do not eliminate the risk of HIV transmission.
• Condom effectiveness does not rely on accurate knowledge of a person’s HIV status, as opposed to serosorting, which requires accurate knowledge of the HIV status of both partners—something that is often difficult to know for certain.
• Whereas the goal of some other strategies—such as PEP, PrEP or having an undetectable viral load— is to reduce the risk of an exposure leading to an infection, condoms prevent an exposure to HIV from occurring in the first place.
• Other prevention options may be less effective if either partner has an STI, a higher viral load or other biological factors that affect HIV risk whereas condom effectiveness is not affected by these.
• If they don’t break, slip or leak, condoms can reduce the risk of HIV transmission for both anal and vaginal sex to the same level. However, the risk of HIV transmission while using PrEP or when the viral load is undetectable may be higher for anal sex than for vaginal sex. (This is because anal sex has a higher baseline risk of HIV transmission than vaginal sex.18)
• Condoms also reduce the risk of other STIs, such as gonorrhea, chlamydia, herpes and syphilis.19 Although other strategies may reduce the risk of HIV transmission, they do not reduce the risk of STI transmission. This is important because STIs can increase a person’s risk of HIV transmission.20
• Condoms can reduce the risk of unintended pregnancy.
• Condoms are less expensive, more readily available and less toxic than strategies that involve antiretroviral medications, such as PEP and PrEP.

Despite the advantages of condoms, we can’t ignore the important role that other prevention strategies may play in helping someone reduce their risk of HIV transmission. Condoms are not without their disadvantages and these can make it difficult for people to use them consistently and correctly. For example, condom use can be difficult to negotiate, condoms can decrease sexual pleasure and intimacy, they need to be available at the time of intercourse, they may be difficult to use when under the influence of alcohol or drugs, and they do not allow a woman to conceive. For these reasons, some people may choose to reduce their risk of HIV transmission in other ways.

Conclusion

HIV prevention efforts need to focus on helping people adopt prevention strategies that are appropriate to their circumstances and will be most effective for them. If people are having difficulty using condoms or are having problems with condom breakage, slippage or leakage, counselling may help them use condoms more consistently and correctly.

At the same time, alternative strategies for reducing the risk of HIV transmission may need to be discussed with these clients. When exploring other prevention options, it’s important to clearly explain their limitations, factors that may decrease their effectiveness and how a person can keep their risk of HIV transmission as low as possible while using these strategies. No strategy—including condoms—is 100% effective; all have their limitations and can fail in different ways. Since condoms provide less than 100% protection, using other strategies in combination with condoms will help decrease a person's overall risk of HIV transmission. However, if a client or patient decreases their condom use in favour of a less protective strategy, they may be increasing their overall risk of HIV transmission.

Resources

AIDSMAP – Do condoms work?

CATIE News – High prevalence of condom use errors and problems – implications for HIV prevention messaging

Canadian HIV/AIDS Legal Network – HIV non-disclosure and the criminal law: Implications of recent Supreme Court of Canada decisions for people living with HIV: Questions & Answers

References

1. Lytle CD, Routson LB, Seaborn GB, Dixon LG, Bushar HF, Cyr WH. An in vitro evaluation of condoms as barriers to a small virus. Sex Transm Dis. 1997 Mar;24(3):161–4.

2. Sanders SA, Yarber WL, Kaufman EL, Crosby RA, Graham CA, Milhausen RR. Condom use errors and problems: a global view. Sex. Health. 2012 Feb 17;9(1):81–95.

3. Lindberg L, Sonenstein F, Ku L, Levine G. Young men’s experience with condom breakage. Family Planning Perspectives. 1997 Jun;29(3):128–31.

4. Steiner MJ, Taylor D, Hylton-Kong T, Mehta N, Figueroa JP, Bourne D, et al. Decreased condom breakage and slippage rates after counseling men at a sexually transmitted infection clinic in Jamaica. Contraception. 2007 Apr;75(4):289–93.

5. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255.

6. Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder SP. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Am. J. Epidemiol. 1999 Aug 1;150(3):306–11.

7. Golden M. HIV serosorting among men who have sex with men: implications for prevention. 13th Conference on Retroviruses and Opportunistic Infections. 2006;Abstract 163.

8. Detels R, English P, Visscher BR, Jacobson L, Kingsley LA, Chmiel JS, et al. Seroconversion, sexual activity, and condom use among 2915 HIV seronegative men followed for up to 2 years. J. Acquir. Immune Defic. Syndr. 1989;2(1):77–83.

9. Minnis AM, Padian NS. Effectiveness of female controlled barrier methods in preventing sexually transmitted infections and HIV: current evidence and future research directions. Sex Transm Infect. 2005 Jun;81(3):193–200.

10. French PP, Latka M, Gollub EL, Rogers C, Hoover DR, Stein ZA. Use-effectiveness of the female versus male condom in preventing sexually transmitted disease in women. Sex Transm Dis. 2003 May;30(5):433–9.

11. Kelvin EA, Mantell JE, Candelario N, Hoffman S, Exner TM, Stackhouse W, et al. Off-label use of the female condom for anal intercourse among men in New York City. Am J Public Health. 2011 Dec;101(12):2241–4.

12. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N. Engl. J. Med. 2011 Aug 11;365(6):493–505.

13.a. b. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N. Engl. J. Med. 2010 Dec 30;363(27):2587–99.

14.a. b. Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N. Engl. J. Med. 2012 Aug 2;367(5):399–410.

15. Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N. Engl. J. Med. 2012 Aug 2;367(5):423–34.

16. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N. Engl. J. Med. 1997 Nov 20;337(21):1485–90.

17. Vallabhaneni S, Li X, Vittinghoff E, Donnell D, Pilcher CD, Buchbinder SP. Seroadaptive Practices: Association with HIV Acquisition among HIV-Negative Men Who Have Sex with Men. PLoS ONE. 2012;7(10):e45718.

18. Boily M-C, Baggaley RF, Wang L, Masse B, White RG, Hayes RJ, et al. Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies. Lancet Infect Dis. 2009 Feb;9(2):118–29.

19. Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull. World Health Organ. 2004 Jun;82(6):454–61.

20. Ward H, Rönn M. Contribution of sexually transmitted infections to the sexual transmission of HIV. Curr Opin HIV AIDS. 2010 Jul;5(4):305–10.

About the author: 

James Wilton is the Coordinator of the Biomedical Science of HIV Prevention Project at CATIE. James is currently completing his master’s degree of Public Health in Epidemiology at the University of Toronto and has completed an undergraduate degree in Microbiology and Immunology at the University of British Columbia.

One hundred and eighty degree turns happen in a variety of ways. Sometimes we seize the steering wheel of our lives and in one fell swoop travel along an opposite path.  Other times, we take the turn slowly, one degree at a time, gradually realizing the path we are on leads nowhere and we need to go off in radically new directions. That’s been the case with my realizing that most of my once fervently held objections to treatment as prevention, in 2013, make much less sense than they once did.

Why? In the last decade, our knowledge of disease progression has changed as has how much we know about the impact of ART on our ability to transmit the virus. But treatments have changed too, and so has my own willingness to look at both sides of the argument, to weigh them against each other and to make informed choices which recognize, above all, a shifting environment.

As well, the realist in me tells me that when it comes to HIV prevention, the status quo isn’t working. I respect those who work in the prevention community. But, to be blunt,  those who continue to play with the same old tricks – plugging condom use when we know the limits to their efficacy in real life situations, trying to effect behavioural change with the odd stray missile thrown at the social determinants of health  - are playing in the wrong sandbox. Let’s not fool ourselves. None of these things will stop the epidemic. We need new tools.

Enter my new friend, treatment as prevention.

Accepting it as a valid, in fact necessary, tool hasn’t been a slam dunk.  My early introduction to it left me decidedly unimpressed.  At the Canadian AIDS Society (CAS) eight years ago I echoed the concerns of the Quebec caucus who first bought the issue of treatment as prevention to the floor, concerned at the notion of people being put on treatment without informed consent and with no demonstrable benefit to their health. If memory serves me I moved a motion that was approved at a CAS AGM condemning treatment as prevention - and in fact was instrumental  in drafting a highly critical position paper when I was subsequently elected to the CAS board.

Fast forward a few years. I was still a treatment as prevention doubter in January 2012 when, through my work for PositiveLite.com, I nervously picked up the phone to talk with Dr Julio Montaner, the distinguished former head of the International AIDS Society, now heading the British Columbia Centre for Excellence in HIV/AIDS.  Montaner is of course a leading expert on, and advocate for, treatment as prevention. His arguments though, have not persuaded all in the HIV/AIDS movement, notably many people living with HIV/AIDS. 

Going in to that long conversation with Montaner, which you can read in two parts here and here I had real reservations as to whether treatment as prevention was ethical or even good for people living with HIV, yet alone effective. I’ll get to how I’ve processed those issues since, but let me first say a few words about Montaner.

As I said in my interview, he‘s a passionate man. One to one, he speaks with excitement born of frustration. But the thing that impressed me most was how so much of our conversation was rooted in his obvious burning sense of justice, of civil rights, of the conviction he has of what is the right thing to do. Far from down treading on patients’ rights, for instance, he was vocal and insistent about the need for informed consent and hugely concerned about disparities in access to treatment and care.

He’s also very persuasive, both in his manner and in his arguments. More of that later.

In any event, I wanted to look at the commonly used arguments against treatment as prevention, ones which I once upheld, and share why there has been a shift in my appraisal of them since those early days at CAS. Beginning with . . .

1.Let’s not start treatment earlier than we absolutely have to . . . 

There is an oft expressed concern, or was, that HIV treatments are toxic. If this is true, why expose the body to HIV meds longer than necessary? Montaner makes the point that while not perfect, treatments have improved considerably. More importantly, he suggests most everybody will need to start treatment sooner or later; delaying a few years until the immune system is showing signs of collapse results in a only a few year's respite from meds out of what will almost certainly be many decades of treatment. Blunt words, but I found that argument quite persuasive.

2. There is no demonstrable benefit to the patient to starting treatment early.

There was always the belief, now the certainty since HPTN052  (CATIE dubbed it “the trial that changed everything”), that antiretrovirals could have a marked impact in reducing one’s ability to transmit the virus. Experts now believe that benefit can, in the right circumstances, be as effective as condom use.  That’s powerful. But whether there any other benefits has been a thorny subject. The evidence now seems to firmly suggest there are. The negative impact of inflammation, for instance, even when CD4 counts are holding strong, has been well documented. As CATIE’s James Wilton said to me in a recent interview  . . . 

“More and more research is showing that even early on in the course of HIV infection the virus can begin to cause long-lasting and permanent changes to certain organs and the way the immune system works.  Research is also showing that uncontrolled HIV replication causes ongoing inflammation which may lead to premature aging of the immune system and accelerated development of age-related conditions such as cardiovascular disease.”

The botton line? Others may, but I’m not prepared to ignore the evidence that, simply put, starting treatment early really is better for us.

3. But what about side effects if I have to start treatment now?

When I started advocating against treatment as prevention at CAS, going on treatment was full of problems for many. It's way less problematic now. In fact many who’ve  started on one-pill-a-day treatments like Truvada, a particularly well tolerated medication, will answer “what side effects?”  But the fact is if you are going to experience them, and I hope you won't, that’s not likely to change whether you start treatment now or later.

4. But what about long term side effects? Those treatments may look safe now, but side effects can often emerge over the longer term.  Why encounter that prospect earlier than you might need to.

This is a variation on 1. above and for many years, I felt it to be a very persuasive argument. After all I suffer from both lipodystrophy and peripheral neuropathy, the latter very badly, consequences of talking medications whose latent side effects came as a surprise to all. So yes, I know side effects can happen downstream.  But this argument is not so much an argument against treatment as prevention as treatment in general.  So while I don’t discount this argument entirely, I’ve learned to put my faith in the fact that modern day meds are better than those that have caused myself and others grief in the past.  And, you know, sometimes, as throughout the history of HIV treatment, we just have to take a chance, recognizing that few things in life are certain.

5. People are going to be given treatment against their will because someone decides it's best for them.

First of all, suggesting treatment be offered for a condition not long after diagnosis is hardly exclusive to HIV – think cancer – and there are always dangers inherent in this process. Informed consent is the issue as is the opportunity for coercion. It’s tricky to ensure informed consent happens always, but certainly not insurmountable – and that’s where we can and must do the work.  Says  CATIE’s James Wilton  . . . 

“It’s important that people living with HIV have constructive and meaningful discussions with their healthcare provider before they make the decision to start treatment. These discussions need to explore their readiness to start treatment, the risks and benefits of initiating treatment and what the evidence does, and does not, tell us. Ultimately the decision needs to rest with the person living with HIV. The tools we need are those that support the doctor-patient relationship to ensure informed decision-making and treatment readiness. CATIE has developed several of these tools, such as an HIV treatment talking tool (Your Doc Talk), treatment videos (Starting HIV treatment: Personal Stories), A Practical Guide to HIV Drug Treatment, and workshops. Some of these tools are available at http://www.catie.ca/en/starting-treatment.”

6. It’s unethical to put public health interests ahead of patient interests by promoting the need to get viral load down at the population level.

First of all, I love that there is an ethical component to this debate; more on that later. But I wouldn’t deny there is certainly meat in the above argument. PositiveLite.com writer Ken Monteith recently said .

“I do believe that a person can validly choose to embark on treatment early, but not in a context where the background information is being manipulated for another purpose. Treatment guidelines are supposed to be about the health of the person being treated, not a pharmaceutical control of that person's sexuality.”

He’s right of course. We need to be vigilant that that doesn’t happen. Certainly treatment as prevention advocates, including Montaner in particular, stress that the decision when to start treatment has dual benefits – better clinical outcomes and reduced ability to pass on the virus to others. We need to make sure, though, that the health of the individual is paramount. I believe we as a community are up to that task.

 And finally . . .7.Treatment as prevention doesn’t work.

Sure it does at the individual level.  On that the verdict is in. But at the population level? Certainly San Francisco, the province of British Columbia and some locales in Africa have claimed success in the form of reducing numbers of new infections. The problem is that treatment as prevention, on a population basis, doesn’t seem to be working in gay men. 

There has been much debate about why, some of it anatomically based and frankly, in this writer’s opinion, bordering on the ridiculous. The saner consensus that seems to have emerged, though, is that  because MSM infection rates are already very high, including in the untested, existing treatment coverage (just 28% in the States, with a similar figure estimated for Canada) testing/early treatment at existing levels is just not enough to bring infection rates down. I buy that, which is why I also buy in to the concept of moving people, wherever possible, along the treatment cascade, a cycle which encompasses detection through to viral suppression that’s outlined here, as handily as we can.

When it comes to MSM, it’s interesting that only some of the more progressive  gay men’s sexual health initiatives have really bought in to the concept of treatment as prevention. ACON, for instance,  out of New South Wales, is a leader in promoting both testing and early treatment with an aggressive (some will say overly aggressive)  target of getting 90% of gay men on treatment.  The language may be too strong for some but it’s beginning to look like these sorts of high levels are necessary to end the epidemic.  Certainly this is what the Brits are saying too. 

Other organizations, particularly in Canada, are less than enthusiastic. There is, for instance, a position paper from the Toronto PWA Foundation from 2010 that you can read here which is complete as to all possible objections to treatment as prevention, but which provides less attention to its benefits. I would like to have seen more balance here.

And there is the rub, isn’t it? Deciding whether new technologies like treatment as prevention including PrEP - even home testing - are to be supported involves weighing the pros and cons, not looking merely at one side of the scale. And in the changing environment in which we live, I’ve come to believe that in the last year or two the scales have been tipped in favour of looking at treatment as prevention, both at the individual and populations levels, as something to be embraced.

Many have made the point, though, that treatment as prevention needs to work in tandem with other prevention technologies, and condoms in particular. They are right, of course. Let’s not go overboard here. HIV-negative people in particular need to be encouraged to use them. Positive folks who are undetectable? The verdict is still out, but I’ll wager that it will come to pass that it’s not just between heterosexual discordant couples where one is undetectable that the chances of transmitting the virus are close to zero.

In any event, you know where I stand now. Know too that in Ontario it sometimes feels lonely to be a proponent of treatment as prevention, but I’m OK with that.  Besides, group think has never been a virtue I’ve bought in to.

One final argument for treatment as prevention I’ll throw in, and it’s an ethical one we seldom hear because – well. we seldom talk ethics. But here’s the thing. Our community has had an amazing record of grappling with the epidemic from within. That’s because we care for each other. We understand community. So we promoted condom use, for instance, when condoms were just a birth control device, even when we didn't like them.  We created an amazing community-based health infrastructure that has become a model for others. Now we have a chance to end the epidemic – again from within.  And people living with HIV now have the power to make that happen.

As I said earlier, it’s become patently clear that existing prevention strategies aren’t cutting it, unless you call containing the epidemic, some of the time, a success. I don’t. For the first time in years, there is a pathway to perhaps end the epidemic but it involves, amongst other things, people living with HIV actively participating. That strikes me as a huge opportunity rather than a threat.

I for one would love to see us seize that opportunity. Why? Many reasons, as you'll see above, but on top of all these - and here comes that ethical thing again - is that I now believe it’s the right thing to do. That's not so strange, is it?

So what do you think is the right thing to do?

PositiveLite.com, Canada’s most comprehensive HIV/AIDS related website, reports that a study of hundreds of sero-discordant couples, that is those with one HIV- and one HIV+ partner, resulted in a startling conclusion:  when adhering to antiretroviral therapy, the HIV+ posed no risk whatsoever of transmitting HIV to their negative partners.  In fact, the study “did not find a single example of transmission from a partner who was on antiretroviral therapy” out of 254 sexually active mixed status couples. 

Now, while this study requires more third party analysis and additional academic investigation including a partner study analyzing the effects homosexual relationships not just heterosexual ones have on HIV transmission, this study confirms what most mainstream HIV/AIDS and LGBT related organizations know to be true but refuse to publicly acknowledge:  the most effective way to combat HIV transmission and, logically, ends AIDS is free and widely available antiretroviral treatment, not condoms or stigma-based “safe” sex campaigns.

In fact, this study even breaks down the fact that the heterosexual couples analyzed were not using condoms in its acknowledgment that Muslims, who practice male circumcision like Jewish communities and most Americans, were the least likely to contract HIV as a direct result of the, unfortunately to those like me who prefer men’s genitals to be natural, beneficial side effects of being circumcised.  In the few cases where HIV was transmitted, the HIV+ partner was not on or adhering to antiretroviral medication.

Going further, the study found that “the rate of HIV infection between couples declined over time and that transmission likelihood was [directly] related to the HIV+ partner’s viral load.”  Generally, this means that the longer and more adherent the HIV+ are to triple, or greater, combination therapy ARV medications, the more infinitesimal the possibility of medicated HIV+ folks ever transmitting HIV becomes for the HIV+.

In this study, the HIV+ community has the proof it needs to demand that LGBT organizations and HIV/AIDS policy makers adjust their public health campaigns and incredibly backward and counterproductive obsessions with condoms, the conventional wisdom of a schoolmarm attitude toward bareback sex, and finger wagging at the HIV+ even though an HIV+ person on antiretroviral medication poses no threat whatsoever to the HIV- community.

This young man (right) was explicitly NEG FOR NEG, so I sent him a screenshot of my GPhilly post, “Hello, I’m HIV+.” Shockingly, he never responded.

Let me say that again:  those in the HIV+ community who adhere to antiretroviral medication pose no threat whatsoever to transmitting HIV even when they never have sex with a condom.  In fact, because of the strength of modern antiretrovirals, cases of HIV/AIDS related dementia have plummeted, HIV transmission rates between ARV-adherent HIV+ people and their HIV- counterparts have become extinct, and HIV+ men and women are at long last able to focus on the banal aspects of growing older, including risk of heart disease, diabetes, and high blood pressure, aspects of mortality that the HIV- community has enjoyed suffering from since the beginning of human existence, rather than on the disenfranchising necessity to simply stay alive without regard to quality of life or absolute longevity.

Personally, I know this to be true because of the annoying regularity my physician points out that my cigarette smoking is doing me greater harm than HIV and because I’m, frankly, so healthy.  In fact, because I regularly monitor my testosterone levels, my glucose levels, my white blood cell count, and my CD4 count and my, completely non-existent HIV viral load, I am equipped to course correct my health with greater knowledge and more tools than if I were HIV-.  This irony is perhaps one of the most amusing parts of living with HIV in 2013: while whole segments of the gay community express moronic terror at our sharing their air, we will, probably, outlive most of them based upon their regular drunkenness, disregard for their overall well-being, and lack of care in relation to their stress levels. 

Of course, I recognize the sweeping generalization that is this last statement, but I am writing through the lens of someone HIV+ who has had to deal with the obnoxious stigma and patronizing victimization of the HIV+ by the overall LGBT community for years now.

Also for years, HIV case managers have existed to ensure that stress, probably the number one factor when it comes to declining health and succumbing to HIV mostly when left untreated, is mitigated as best as possible.  After all, in the early days of this plague, men and women were literally dying with such regularity that we as a community expressed outrage at the immoral neglect of our government here in the United States, we began illustrious and brilliant arts projects like the AIDS quilt, and we were focused on, figuratively, simply plugging the leaking dike. Rightly so, public health, HIV/AIDS, and LGBT organizations identified that, in addition to all of these issues, stress was having a particularly deleterious effect on the HIV+, so they worked cooperatively and actively to combat it.  As a result, most HIV+ men and women in the United States have their own advocate in the form of a case manager, typically an overworked but idealistic professional with brilliant knowledge of the social service system in whichever city or state they work.

The fact remains, however, that most LGBT organizations and HIV/AIDS organizations throughout the United States are still acting like Bill Clinton is president and “And the Band Played On” was just published.  Thankfully, other organizations, including the forward thinking Gay and Lesbian Latino AIDS Education Initiatve here in Philadelphia along with others worldwide are countering this disturbing trend, including the Ending HIV Campaign in Australia, which admittedly uses the rather inane term “safe” in its conclusion but propagates the most sex positive, realistic approach necessary to successfully end HIV diagnoses in the previously HIV-.  Dually, this campaign will stop AIDS from happening altogether amongst the HIV+ by compelling HIV+ folks to go on medication.  On the other hand, we still have American urban LGBT organizations focused almost exclusively on condom use rather than on the obviously more effective strategies of serosorting sexual partners and widespread availability and adherence of HIV medication in relation to stopping HIV transmission and, logically, AIDS.

This refusal to acknowledge reality is an inherent flaw in the overall LGBT advocacy culture throughout the United States, an institutional culture that disingenuously appeals to the most base level of human interest with sexy time fundraisers to get pink dollars while simultaneously and out of the other side of its mouth chastising the HIV+ for having vibrant, and fun, sex lives rooted in human contact instead of antiseptic latex.  Most nauseatingly, the repeated concern trolling on part of these organizations, oftentimes populated with the born again HIV+, the reformed pigs who routinely write to me saying I’m playing “Russian roulette” and who affirm that they “wouldn’t want to infect anyone else” as if they’re Hester Prynne living alone, sexless, with a scarlet HIV sewn upon their breasts, simultaneously saying they aren’t judging my sexual behavior, is sustaining the HIV infection rate in the United States, a rate that is disturbingly increasing with an obvious correlation tied to the complete inefficacy of current condom campaigns and sex-negative imagery.

People are going to have sex.  People are not always going to use condoms, or, in my case, ever use condoms.  HIV- people are still contracting HIV. But, it is not the knowingly HIV+, specifically those on antiretroviral medications, who are infecting these people as this study proves without a doubt.  Rather, it is the HIV- person who, unbeknownst to him because of these idiotic misconceptions involving “cleanliness” rooted in HIV stigmatization and who all the while has bareback sex with regularity while giving nothing but lip service to this patronizing and victim-based LGBT institutional culture, who is running around, spreading HIV,  refusing out of ignorance to respond to a medicated HIV+ man’s messages on GrindR.  And, this specter of ignorance is sustaining HIV infections, making people feel bad about their human nature, and turning otherwise innocuous, fun sexuality into shameful whispers teenagers are afraid to explore.  In turn, we as a community have built a culture of indignity around our sex lives, and this indignity and net negative institutional culture is continuing to spread a virus that, if left untreated, will kill.

Now, if you’ll excuse me, I’m going to try to find another HIV+ man who adheres to his medication to have awesome sex with.

This article first appeared on Josh’s own blog here.