There has been a flurry of articles recently with headlines like “Undetectable Viral Load? Not Necessarily in Semen” like this one in POZ.  Discovery of this connection isn’t the least bit new, of course, but what’s drawn attention is new research from Boston which furthers our understanding of the associated risk a little more. More on what that research says in a moment.

The headlines may sound alarming for those who thought, because they’d reached undetectable, they were much less infectious because of low levels of virus in their blood. But if there is in fact virus in the semen, are we back to square one, the walking time bombs we’ve always been? Certainly the headlines seem to imply that. And certainly the headlines seem to reinforce the message for poz guys everywhere “wear a condom, whatever your viral load”.  But do the headlines reveal the full picture?

It’s clear we’ve made good progress towards quantifying what IS the risk of virus in the semen, and in the associated risk of HIV transmission. Today I want to look at what we’ve learned and what are the implications for people living with HIV.

Semen – the traditional view

The virus in the blood vs. virus in the semen debate is a complicated and technical one. As a result, there has been a tendency for prevention experts to try and make things simple for us. Here’s how CATIE, for example, answers the question “If my viral load is undetectable, can I still pass HIV to others?”  

“Yes. While HIV may not be detectable in the blood, there might still be enough to infect someone. Also, there may be higher levels of HIV in semen or vaginal secretions. So, even if you have an undetectable viral load, you might still infect someone if you share needles or have unprotected sex.”

There is nothing here that isn’t absolutely correct.  But the answer doesn’t help quantify the risk for us – and quantifying risk, or trying to, is exactly what informed decisions are built on. In this particular case, we need to know what science tells us about three key questions:

• What is the likelihood of virus appearing in the semen if it can’t be detected in the blood?
• Where virus is detected in semen, what are the likely concentrations?
• Are those concentrations likely to cause HIV transmission?

All three questions are answerable, albeit with provisos, from research. That research suggests, in a nutshell, that while a quarter of ‘undetectable’ gay men have HIV in semen, the risk of transmission is likely quite low.

The research on “undetectable” gay men’s semen.

The Boston research has helped quantify the likelihood of both virus being present in the semen in "undetectable" men and the likelihood of it causing transmission. This study involved 101 gay/bi men. This AIDSmeds article summarizes the results. Eighty-three of the 101 men had undetectable levels of HIV in their blood samples. Though most also had undetectable HIV in their semen samples, 25% of those had detectable seminal viral loads. This is in the range that previous studies have confirmed.

What’s interesting is that the men who had an STI were 29 times more likely to have viral discordancy. The implication is that without an STI, undetectable in the blood means, way more often than not, undetectable in the semen.

Now let’s look at those 25% of undetectable men where virus was detected in their semen, because it’s important to understand how much virus was present.  The median level in the semen was 200 - in other words, unlikely to infect anyone.  A viral load below 1,000 has in fact, rarely been associated with HIV transmission.

So let’s summarize what we’ve learned from Boston: if you have an undetectable viral load there is a one-in-four chance of virus being measurable in your semen, considerably smaller if no STIs are present. And if that virus in your semen reflects median levels found in the study, the chances of transmission are tiny.

The problem is that median levels are just that – some men will in fact have higher levels of seminal virus, thus increasing the risk of transmission.  So, while the median range for measurable semen may have been 200, the actual range was 80 to 2,560 copies. We need to look at other research to find out whether those higher levels of seminal virus are likely to cause transmission.

It’s not as clear cut as one would like, but AIDSmap reports a small 2008 study from San Francisco found that the median seminal viral load in men transmitting HIV to partners was 4,300 and the lowest was 110. A larger (1,199 gay men) 2009 study from the UK found that two out of 41 transmissions of HIV (5%) were from men with an apparently undetectable viral load, as measured in their blood.

BUT as AIDSmap  qualifies “studies of the link between viral load and transmission suffer from it being difficult to pin down transmitters in a cohort of gay men with multiple partners and where viral load may be measured months after the transmission.”  In other words, it is wrong to conclude the men had undetectable virus (in the blood) at the time of transmission.

What does all this mean? It’s hard not to suggest that in “undetectable” men, virus in semen at levels likely to result in HIV transmission represents anything other than a small but nevertheless potential risk.

How we process risk.

It’s notoriously difficult to turn research data like this in to helpful risk guidelines, a topic which was explored in some depth in my recent interview with CATIE’s James Wilton here. 

What is clear is that the risk associated with semen in otherwise undetectable men is low, but cannot be expressed as zero.

But what risk CAN be expressed as zero? Certainly not with  condoms, the cornerstone of our HIV prevention programs.  A recent literature review reported in CATIE concluded condoms can be highly unreliable. CATIE summarizes “The review found that there is a variety of ways in which condoms are being used incorrectly and the prevalence of incorrect condom use is surprisingly high.”  That and breakages, even when condoms are used properly, present an alarming  picture.  Breakage and slippage or complete failure of the condom to afford protection was reported in 25-45% of those studied, with an event rate of up to 8%.  (“Fit or feel” issues, by the way, were reported in 7-30% of those  studied and in up to 45%  of events, with erection difficulties reported by 19-20%  and up to 20% of events.)

How do condoms stack up to undetectable viral load as a means of affording protection?  Some prominent advocates have suggested that the use of condoms in people living with HIV affords LESS protection than having an undetectable viral load.  Respected POZ magazine founder Sean Strub said that here. Even Canada’s most prominent AIDS researcher, BC’s Dr Julio Montaner said in a PositiveLite.com interview “I’m very comfortable that HAART is at least as protective – or more – than condoms.”

Overall though, we’ve been slow to acknowledge the risk from unprotected sex amongst sero-discordant partners has changed radically since the advent of undetectable viral load.  But here’s a recent exception. The ever-progressive Heath Initiative for Men (HiM) said just this month ”Most of the time, guys with undetectable blood viral loads who are taking treatment as prescribed, and get tested regularly for STIs (and treated if need be), also have undetectable viral loads in cum and rectal secretions.”

They go on, very significantly, that “for some gay men, if their partner is on treatment as prescribed by his doctor, has an undetectable blood viral load that is monitored regularly and is getting tested (and treated if need be) for STIs regularly, their risk of picking up HIV is greatly reduced, even without condoms. This may be something you want to talk about with your partner, together with his doctor.”

Conclusion

Given the evidence, even with its gaps, it’s not unreasonable to suggest that  the risk of transmission associated with semen when your blood viral load is undetectable has been over emphasized and overstated.  Why? It’s hard not to think it’s connected with our desire to see condom use maintained.

Not that this desire isn’t well founded. Condoms may not be 100% effective, or even close, but they are the best prevention technology we have right now.  So let’s be clear; it’s inappropriate for people living with HIV to stop using condoms, whatever their viral load, without carefully reviewing the risk to themselves and their partners.  That, as HiM suggests, may involve discussion with your partner and your doctor, hopefully an informed one.

But ultimately it depends, as does life in general, on what risk you consider reasonable. You make similar informed decisions every time you cross the road.

PositivelIte.com writer Michael Bouldin said “It’s not that we don’t know what constitutes risky behavior; it’s that it’s simply not possible to always avoid it, or in a given moment even desirable. Walking a red light can get you killed; it can also get you to a job interview on time.”

How we process risk is fluid too.  It depends on the context – the time, the place, the partner – and to what extent we are informed.  And to be frank, there are problems here. Canadian Treatment Action Council (CTAC) chair  Alex McLelland recently said on PositiveLite.com “As a community, we have not developed or even responded with relevant guidelines on how to incorporate the new reality that people living with HIV who are on treatment and have viral suppression do not always need to use condoms.”   

So risk is a very fluid concept for us consumers, isn’t it? It’s less so for HIV educators, who need to ensure that anything less than zero risk constitutes a warning shot across our bows.

Warning shots are fine and we need them. But we need to interpret them, try to qualify the degree of risk that might apply to us, just as we hover on the curb before crossing the road. In the case of the danger of virus in semen in those of us who are undetectable, the warning shot doesn’t pack a lot of punch for me, if you peel its skin away and look at the underlying research. But your experience may vary. In the context of informed decision making, you really need to make up your own mind.

After the lackluster first sexual encounter with Martin, I was determined that it would indeed get better. After all, we are both attractive men in our mid 30s and we like each other, so there is nothing stopping us from having no-holds-barred-animalistic sex. Right? At least that is what I was hoping for. I like Martin, I really do and I want us to work. I don’t want you to get the wrong impression, but we all know that sex is a fairly large component in a new relationship.

I’m sure you know me well enough by know to know that I had a plan a brewin’. This what I finally decided upon: First, I would stop off and get two gourmet cupcakes. Who doesn’t love a good cupcake? Secondly, I would meet him at his apartment and I would say “First I want to ravage you. Then I want to ravage these.” Brilliant. Sexy. Fun. Sweet.

Ok, ok, ok, ok, maybe I stole that from an episode of ‘Sex and the City’ where the jazz player says to Ms. Bradshaw “I want a bourbon and I want to go down on you.”

Only the execution of my plan wasn’t so brilliant, sexy, or fun. I picked up the cupcakes. One double chocolate with caramel and chocolate ganache and one red velvet with cream cheese frosting. So there I was waiting for him outside of his apartment with cupcakes, all amped up… and he texts to tell me he was going to be late.

Damnit!  I was on a mission and I was quickly loosing my resolve!  About twenty minutes later he finally shows up and I was swiftly back in the game. He kissed me and I coyly said, “First I want to ravage you. Then I want to ravage these.” and he said “What?” He didn’t say this out of confusion, he genuinely didn’t hear me. I repeated myself, but lost all of my tenacity.

Regardless, my second attempt did the trick. He kissed me hard and led me to his apartment. We quickly tore off each other’s clothes and jumped into bed. The fire between us died as quickly as our clothes came off. I was dumbfounded. As I laid there and ate a cupcake, I couldn’t help thinking that it was incredibly sad that those cupcakes were the best part of the evening. They were great cupcakes but, come on!

The next day or so we exchanged a couple emails and Martin told me that he was back in his head and that it would be best if we cooled things off. He said that it had nothing to do with my HIV status, it was him. Blah. Blah. Blah.

Two weeks later and without even seeing me, he decided that his emotions weren’t “growing” for me and it would be best if we stopped seeing each other. I wasn’t crushed. I wasn’t even a little hurt. This is so uncharacteristic of me. I mean, I usually lock myself in my apartment and have mini breakdowns after every bad date singing “Could’ve Been” by the mall queen, Tiffany. This lack of a brokenhearted feeling made me realize that I wasn’t really in love with Martin.

Apparently, I was just in love with the thought of being in love.

And just as ceremoniously as I deleted it I poured myself a glass of wine and again downloaded Grindr to my phone. (Well, Grindr, Manhunt, and Adam4adam – I’m playing the odds). 

Antiretroviral medications, or ARVs - the miracle cocktail of pills that could save your life, aren’t without their faults. The problems are widely reported and often discussed – nausea, diarrhoea, lipodystrophy. Even the occasional perk of a nightly high/lucid-dreaming-state, which can get relentlessly tiresome after a while.

It’s the ‘take’ part to the pills that ‘give’ so much. With all that raining on the parade, when I was cautioned (I’m sure he meant to reassure, but this was not the assurance I was looking for at the time) by the supplier of my antiretroviral medications that my libido would rise from the dead - I took it with a generous dollop of sodium chloride.

I mean, come on, after my 2-month-long-stint in a hospital bed, having only been diagnosed mere weeks prior, my sex drive was the last thing on my mind. The only commuting I had in mind was to ride to the nearest retirement home, to spend my days in solitude. I was, in all honesty, all prepped for relegating myself to a life of chastity.

A few months later, my CD4 levels crept back to normal territory, and had my sex drive in tow. Foretold words of caution reared itself, the hard way. As most would feel with a prophecy fulfilled against their own expectations, due to what seemed like insurmountable odds, I was actually surprised.

Surprise also came with a friend, worry. The whirlwind that was my diagnosis and the quick succession of events that followed and that had left me really sexless for over half a year was as fresh as my sex life was rotten. The concern however, was not so much as “could I” since junior was quite obviously eager to go, but “should I?”

I tended to avoid men during this transitional period. That included not seeking out and turning away men who would come onto me. Admittedly, while I avoided the individual man, I found no wrong in frequenting clubs or bars where there were throngs of them (I was never really into groups anyway). I never actually said I would go so far as to deny myself from lookin, and, I thought, sleeping with them in my mind is the safest way anyway.

You know the saying, ‘avoiding is better than meeting a dick face on?’ Probably not, since I made it up, but it was something I found myself thinking a lot. I’ve gone this long without schlong, so as long as I avoid the dong, I should stay strong and get along. Unfortunately, I was dead wrong.

Egged on in part by the visual stimuli, my thoughts began to often gravitate to sex. Of course, I was too proud to admit this to my friends, who I thought saw me as some kind of walking miracle. The sexual megalomaniac – humbled. I figured they mistook my forced suppression for humility, as did I.

So in secret, I relented and started frequenting Grindr. The first hook-up came quick. So quick, I didn’t even see him come. No, really, he didn’t. I had backed out of my first romp faster than I hopped into it. In apprehension and guilt, my conscience was a mess. It was torn between satisfying my mortality and my morality.

I called a friend that night, and confided in tears my confusion. He assured me, as long as there was a condom, I can hump like an Energizer Bunny for all he cared. He did not expect me to become a saint after my diagnosis. I suspect, neither did my medications. 

Slowly, I opened up my legs and came to accept that intercourse can still be had guilt free, with proper precautions of course.

Fate, being ever so funny, would have it that the first person I would have all-out proper sex with would be the same person whom I now suspect knowingly infected me. I figured, if I’m too nice (or find him too sexually irresistible) to tell him to go to hell for the hell he’s put me through, then what the hell.  But I’ll save this for another story......

The word mafia means “a bold man.”

The idea that we might need a ‘Gay’ Mafia emerged from a group of grassroots activists who were trying to imagine new ways to engage communities of men who have sex with men. Institutions that support and inform gay men’s health and wellness have certain limitations, especially since we rely on the public purse. When I envisioned a video blog from a bathhouse with performers eroticizing safer sex negotiation, funders graciously turned down the idea. After all, we are not here to offend Joe Q. Public. Being polite and sanitizing sex however, has been indicative of much of our HIV/STD prevention history and the Gay Mafia felt like it was time for something bolder . . . and more risk-tolerant. So we partnered up with the Gay Mafia, an emerging group of man lovin’ man activists, to step in to help Victoria’s gay men to re-imagine who we can be in today’s climate of political and financial uncertainty.

For our first outing we brought a select group together to watch the extraordinary film, “We Were Here: the AIDS Years in San Francisco.” (Director David Weissman is seen below right.) The documentary depicts gay men and their allies rallying to the call, by all means necessary, to counteract and respond to an unimaginable crisis. In the early 80’s, governments turned their backs on us (as they still do in many parts of the world). It was local activism that changed the world. While under siege, men and women, many of them already sick, declared, “GLBT and HIV+ lives matter.”

The San Francisco model of public-private partnership for prevention inspired successful programs elsewhere and showed the world how loving we can be. Members of Act Up! fought the social order of the day and showed the world how fierce we can be. Angry, community-loving AIDS activists put queer lives on the world map.

So earlier this year the Gay Mafia printed souvenir tickets that read, Gay Mafia presents…We Were Here. On the back of each ticket, against a smudge of 80’s gritty grey, written in sparkling pink, are the words, “We’re recruiting.” We know we need to connect younger queer men with their elders, those who lived through the nightmare years. As an educational release, we were only allowed 50 seats. 105 more people wanted to come see the film. A third of the audience were men over fifty, a third were men under thirty and the rest were women, mostly lesbian allies who knew their herstory was also woven into the story of AIDS.

International AIDS educator, Ed Wolf, one of the five subjects of the film (see previous article) introduced the film and hosted the Q&A afterwards. We were curious to see how viewers would react. Can the genius of this 2011 documentary break through the seal of frozen grief to help today’s generation reclaim the treasure of who we are as a ferociously loving LBGTQ2S movement?

When the film ended and the lights came up, one long-term survivor stood and shared his gratitude for the many men who risked their lives in the early clinical HIV treatment clinical trials. Viewers acknowledged the role of women in the crisis and how they longed for a deeper re-connection with the womyn’s community. Andrew Shopland, a 24-year-old practicum student with our prevention program gave Ed Wolf a gift and said, “Thank you for touching our lives, for being here tonight and for all the work you have done over the decades. Having seen the film and heard you speak I have a much richer understanding of what happened.” Then he added, “I still don’t know if I’ll ever really understand what it was like.” To which Ed responded, “You don’t need to completely understand. Thank God you don’t have to have that experience in your body. The important thing is that you are here to pass our history on to. That is what you need to know.”

Do today’s young queer men and women need to more intimately know about the AIDS crisis? When nearly a quarter of those infected don’t yet know it, when 1 out of every 129 Torontonians now live with HIV, I say, ‘Hell, yes!’ However, when I look back on how Boomers were silently impacted by their parent’s experiences of WWII, I begin to comprehend why smart, caring men like Andrew and his cohort will never fully get the hugeness and horror of the AIDS epidemic. At 45, I feel as if I am just waking up. Population trauma takes generations to heal.

Perhaps the best we can do is draw lines of connection and communication between the past and present. My work as a middle-aged cocksucker is to make cultural and historical connections and in-roads to more resilient sex positive futures. As the GLBT2SQ movement steers toward mainstream assimilation, the need to reclaim our queer history feels acute and urgent. Now I’ve begun to see, like the Russian dolls of old, where yesterday’s stories fit inside todays’.

I’ve begun interviewing older and younger men about their experience of the documentary, asking them how the themes in the film interconnect with their lives today? Here’s one of the interviews.

Recruit: Dan, age 29

Daniel is bi-curious. He’s never had sex with a man. He sat alone through the film. Afterwards he signed up for future events and then contacted me to make more of a connection to the queer community.

I asked him what made him want to see WWH?

“I knew it was something that happened that you know you should be part of…. I knew that it was a huge event in our recent history.  I know that I have a personal connection to it - that I can empathize to a certain degree with the people who were there. Parts of my sexuality or otherwise my politics have been on the fringe. I have an idea of what it means to be pushed out of society. Not being there, not knowing what it must have been to have a vast part of your community dying, without knowing what the cause of it was, I can’t imagine how hard that would have been. I have a gay uncle living in SF, estranged from the family, he was there….

I also came to the film to explore my identity. Knowing history, all of our cultural history, of what happened to our brother and sisters…we learn about the world war, why not about this very tragic event?”

How did the film impact you?

“Hearing these guys stories, the feeling of loss, oh my god, that people can have lost so much. What would it have been like to have your friends and your partners dying all around you? I just felt like fucking crying. The film helped me appreciate the politics around the struggles queer people have gone through over time, like the Stonewall riots, how queer people have been purposefully ignored.”

From your perspective, what was the ‘invitation’ of the film?

“Recognize this! The film spoke to the desire for recognition. We invite you to come here to this story because it is important. The fucking resilience, it was a wild time, incredibly tragic, but we made it through and we’re doing good.  It gave me hope. Ed talked about today’s kids committing suicide, their feelings of despair, is this directly linked? Resilience and hope go together and for generations we have stood up against oppression to the benefit of everyone.”

At the end of the interview we hugged and promised to keep in touch. I walked away uplifted. And yet doubt lingered. I wondered if those of us who survived the AIDS years could really inspire a new generation of queer activists? Then I thought of We Were Here and said to myself, “Bet your well-lubed, condom-loving ass we can.” But how? By being bold. By telling our tales. By actively listening to one another and showing interest in who we are we change the plot line. Let’s make that our gay agenda. 

As we build more generational bridges, we may discern what is needed today and what work is yet to be finished from ‘way back when.’ The past holds secrets necessary to the health of our queer future. As Daniel and I parted, I felt such gratitude for the power of sharing stories. Next time I see him, I’ll tell him that he would make a great addition to Vitoria’s growing gay mafia. I stepped out into the night sky and thought for the first time, “Survival is sexy.”