This article by Roger Pebody first appeared on aidsmap.com here.
Treatment as prevention counters stigma and enhances sexuality
A greater understanding of the impact of HIV treatment on prevention is changing the experience of being in a relationship with a partner of a different HIV status, according to a qualitative Australian study published last week in the Sociology of Health and Illness. A biomedical intervention appears to be having unexpected effects – loosening the association of serodiscordant relationships with ‘risk’ and helping couples to experience their relationships as normal and safe.
Asha Persson of the University of New South Wales reports that people’s views about treatment as prevention have changed significantly in recent years. She previously researched the topic in 2009, soon after the ‘Swiss Statement’ was issued. At that time, people in a relationship with a partner of a different HIV status often expressed scepticism or uncertainty about the idea that HIV treatment could make a person non-infectious. They did not always see the relevance of the information to their own lives.
But in her more recent interviews, conducted in 2013 and 2014, couples readily discussed the implications of having an undetectable viral load. HIV treatment appears to be transforming the social and sexual lives of people living with HIV and their partners.
The research specifically focuses on so-called ‘serodiscordant couples’, in other words those in which one person has HIV and the other does not. The public health literature on serodiscordant relationships typically focuses on the risk of HIV transmission and tends to see such a relationship as inherently problematic. In contrast, Persson found that her interviewees wanted to stress how normal and positive their relationships were, with HIV being seen as ‘no big deal’.
She interviewed 38 people who were in a relationship with a person of a different HIV status in Australia. Members of 25 couples were interviewed, including 13 couples in which both partners were interviewed. As well as 16 gay couples, there were seven heterosexual couples and two which included transgender people. Of the 25 HIV-positive partners, 20 were taking HIV treatment and had an undetectable viral load, and three were about to start. Half were diagnosed before their current relationship and half were diagnosed while in it.
About half the couples had sex without a condom. Typically, heterosexual couples were monogamous and did not use condoms. Gay couples were more likely to have open relationships, and also more likely to use condoms together.
Understanding of treatment as prevention
Not all participants were familiar with the actual term ‘treatment as prevention’, but there was broad awareness of the concept that treatment reduces viral load and thereby infectiousness. Almost all interviewees volunteered that their or their partner’s viral load was undetectable and treatment was seen as key to serodiscordant relationships.
Nonetheless interviewees had different perspectives on the implications of this.
Many of the gay couples framed HIV treatment as an ‘extra layer of protection’ alongside continued condom use. The couples welcomed the greater sense of security provided by treatment as prevention (TasP) but it was not to be relied on alone, as this man explained:
“Whether it’s 4 per cent or 0.5 per cent, there’s still a risk… If there’s any risk, it doesn’t make sense because the implications of that are so great… the emotional impact of [my partner] knowing that he had given me HIV would be just too awful to bear…”
Some other couples had been having sex without a condom long before they learnt about TasP. Finding out about it provided reassurance and validation for this choice:
“The thing is that, this new information… sort of confirmed what we did, why I’m still negative.”
For another group of couples, the information about undetectable viral load and infectiousness ‘gave them permission’ to have sex without a condom:
“And then that study came out… So then we were like relieved, really, and able to kind of go ahead… I could sit there and go, ‘These are the facts. If he has his medication every day… I’m willing to take the risk because I know he’s doing everything he possibly can to keep me safe’.”
Across the board, TasP lessened anxieties about transmission, as this HIV-positive woman explained:
“[It] helps you to be able to relax and enjoy your sex life, enjoy your relationship with your partner. It’s one less thing to worry about.”
Many of the interviewees claimed to not be worried about HIV transmission, with many of the HIV-negative partners especially keen to refute the idea of being at risk or of their partner being contagious. They wanted to put that risk in perspective (“I know the probability of getting it is not zero, but I know it’s extremely low, extremely low”) and not let it define their relationship.
“I can’t see how I can have a loving relationship with Jasmine and be preoccupied with fear about becoming HIV-positive… it just seems incompatible.”
An HIV-positive man who had previously ruled out sex or relationships with HIV-negative men found himself drawn into a relationship with a man who wasn’t concerned about their different HIV statuses:
“I guess I’ve been living in a fairly limited view of how all this had to work for me and now I just feel freer… I can actually love who I love, rather than be limited to: ‘Are you positive or not?’… It gives space for, you know, relationships to happen, to evolve that I guess we once thought weren’t possible.”
Countering stigma and transforming relationships
“TasP makes possible new ways to experience and imagine serodiscordant sexuality,” Dr Persson writes. Because TasP is changing the perception of HIV as being extremely infectious, it “might work to gradually normalise and legitimise intimate serodiscordant relationships as something that can be ‘worked through’ and then enjoyed, instead of being problematised as an anomaly in need of continuous sexual risk management.”
She argues that a pharmaceutical product (or the way in which that product is perceived) may be having an impact on stigma. Antiretrovirals appear to be helping to restore a sense of social and sexual belonging in people living with HIV, allowing them to live fuller lives.
In contrast, many other sociologists have taken a critical approach to the increasing use of pharmaceutical products to manage problems that have complex social causes, including depression, obesity and sexual dysfunction. Because this can reinforce ideas of normal behaviour and appearance, it is sometimes seen as a form of social control, in which people feel pressured to use medicines to bring their bodies into line with socially expected standards.
The interviews did reveal that some HIV-negative respondents put pressure on their partners to take treatment and maintain an undetectable viral load:
“There’s no way in the world that I’d be with a positive man who wasn’t on treatment.”
“I’ll be a lot more comfortable when he’s on medication… It should resolve a number of tensions.”
But Persson’s account is generally more optimistic, focusing on the potential of TasP to transform our understanding of HIV in positive and interesting ways. TasP is not just a tool for public health, but can also enhance intimate relationships and sexual pleasure. It may help bridge the ‘sero-divide’ between HIV-negative and HIV-positive people, allowing relationships between them to be experienced as safe and legitimate.
The definition of ‘safer sex’ is expanding, so that it cannot simply be defined as the use of condoms. The focus of HIV prevention is shifting from changing sexual behaviour to encouraging people to begin antiretroviral treatment and adhere to it.
And the significant evolution of people’s views since her previous research study five years earlier suggests that further change and development is likely if not inevitable.
Persson A. 'The world has changed': Pharmaceutical citizenship and the reimagining of serodiscordant sexuality among couples with mixed HIV status in Australia. Sociology of Health and Illness, early view, 2015. (Abstract).