Subscribe to TrevorHoppe.com





Creative Commons License
This work is licensed under a
Creative Commons License


November 3, 2009

Refusing to Have Sex With HIV-Positive People: Why It's Not a Prevention Strategy, and Why It's Harmful to Our Communities
FILED UNDER: "Gay Men's Health & Culture"
TAGS: gay men's healthHIV PreventionHIV-positivepublic healthserosorting
By Trevor

serodiscordant_magnets.gif

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

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

Because of these important differences, I want to suggest that Patrick's comments cannot possibly be said to be purely a method of risk reduction. To explain why I think this is so, we need to evaluate whether or not there is actually any risk worth avoiding by excluding HIV-positive men from your pool of eligible partners. Thus, to help illustrate this, let's attempt to assess the risk of transmission between a known HIV-positive partner and an HIV-negative partner when condoms are used. There is no data to suggest that many HIV infections occur in these contexts, absent condom failure -- rates of which are outrageously low (between 0.4% and 2.3%, depending on who you ask). If we take a generous account, let's presume that rate is 2%. In a single incidence, then, the risk of potential exposure is 1:50.

But exposure does not equal transmission. You can be exposed to the virus and not actually seroconvert. Thus, we need to add into this equation the risk of transmission per sexual encounter in the absence of condoms,which vary depending on a number of factors: whether the poz guy is insertive or receptive, his viral load, genital ulcerations, etc. Let's say the poz guy is doing the fucking, for example's sake. The generic risk in this scenario for a receptive HIV-negative man is 1:122 -- that is, statistically speaking, there is a 1 in 122 risk of seroconversion after getting fucked once without a condom by an HIV-positive man (see here for a summary of this data). If we multiply these two risks together, we get something like a 1 in 6000 probability -- give or take. According to risks of death statistics, this puts a person's risk of seroconversion in this abstract, theoretical scenario somewhere between their risk of death by electrocution (1:5000) and their risk of death by drowning (1:8942). Obviously, this is a gross use of statistics -- but I think it helps illustrate the point: the risk of transmission between serodiscordant couples in one sexual encounter when using condoms is EXTREMELY low. Just about negligible. And this example likely grossly overestimates the risk, due to the fact that condom failure is not the same as sex without condoms. Many people will quickly realize the condom has broken, leading to a much smaller window of possibility for exposure. Thus, the 2% exposure rate included in this example is likely much, much smaller in practice.

Obviously, if we extend this risk over time, then we run into increased risk of transmission for a variety of reasons -- namely condom fatigue reported within serodiscordant couples. But if you use condoms, your risk of becoming infected from hooking up with a HIV-positive guy is probabilistically very low. Thus, excluding them from your dating pool cannot and should not be considered a risk reduction strategy -- unless you are having unprotected sex.

Now that we've established that there is no real prevention rationale for categorically excluding HIV-positive men from your pool of eligible partners, we need to seriously consider the ways in which doing so actually works to reinforce stigma against HIV-positive men. If you ask any HIV-positive man what kinds of difficulties come with seroconversion, many will immediately respond that stigma and the resulting fear of disclosure are today some of their most pressing concerns. New medications have alleviated what used to be a very immediate sense of death, and their adverse side-effects have been dramatically reduced with even more recent advances in treatment protocols. Rather than "purely" medical, the problems that men describe today with living with HIV are very much in the realm of the social.

Take for example a scenario another friend (we'll call him Matt here) described to me recently at a gay bar in Detroit. Matt was dancing with a cute young man, who curiously told him that "You should stay away from me. I'm dangerous." Matt asked him why, and he ambiguously answered that he was contaminated. Matt then asked him directly if he was HIV-positive, at which point the guy stiffened and gave a sheepish affirmative reply before running away. In this scenario, the young man had so internalized this harmful discourse of transmission that paints HIV-positive people as dirty and dangerous, that he himself did the running away. Matt has slept with HIV-positive men before -- this is not a problem for him. But he didn't even have to not reject him -- the HIV-positive man did the rejecting for him!

While this seems like a very contextual and bracketed example, I think it serves to illustrate the kind of emotional damage that stigmatizing discourses may be having on HIV-positive people's lives. I contend that Public Health -- in its ambiguous and contradictory uses of the term "serosorting" (a topic for another essay) -- is part of the problem here. By refusing to explain what this term means, and by remaining quiet in the way it gets practiced, Public Health is serving to reinforce stigma against HIV-positive people by allowing many men to use it as a rationale for their exclusionary practices. This essay is just a gloss on these issues -- it admittedly raises more questions than it answers -- but I desperately think we need to think critically about the way we (I mean both we as gay men, and we as people invested in promoting Public Health) allow stigma to continue operating in our communities through the lens of "health" and "risk reduction." Backed by medical logic, stigma seems rational, logical, and unproblematic. But we need to expose the ways in which these allegedly science-based logics are actually totally bunk in terms of their validity -- and are actually just forms of stigma veiled by scientific authority.

Author's Note: After publishing, I corrected the 1:122 risk of transmission per incidence for HIV-negative people engaging in unprotected receptive anal intercourse with HIV-positive men from the originally cited 1:132. I also added a link to Poz Magazine's summation of this theoretical risk data. Many people have emailed their frustrations with my gross misuse of statistics. I don't dispute this. Indeed, the kind of very sketchy analysis I engage in is problematic if you are interested in the actual, "real" statistical risk. I'm not really so interested in the precise number, and I don't think it matters much in making this argument. To my knowledge, even if we look at the outcomes here -- seroconversions reported when using condoms with HIV-positive partners -- we just don't see large numbers of transmissions. But I certainly welcome and encourage further research that is invested in precisely quantifying these risks -- and the variety of factors that are bound to contextualize them.

PERMALINK | Posted at 10:12 AM | Post a Comment (17)

17 Comments

The PEP guidelines we use in Australia (available at www.ashm.org.au) posit a 1:33 risk of infection for a known-positive insertive partner who comes inside. I guess I'm a bit skeptical about the Poz.com description of where they got their estimate, and I would call it an estimate rather than "data".

Like you, I'm troubled by the easy confidence of the neg guy who breezily announces he would never have sex with a poz guy due to his right to self-protection. But I explain it using the concept of stigma rather than risk calculation. You could step out the risk calculation -- risk of condom breaking times risk of infection times risk of PEP failure = 1 in 10,000 year risk at an average rate of partner change -- and he'll still insist that's too big a risk to take, and by that point he'll be really defensive too.

I think it's more effective if you can get him to acknowledge how he feels about the possibility of HIV infection, validate his right to protect himself, and express the hope he can act on that right without causing pain to any poz guy he might encounter along the way.

Author Profile Page Daniel Reeders User Profile | November 3, 2009 3:46 PM

Thanks Trevor, as always, in both your reaction to your friend's statement and following through with this essay.

This plain dismissal of an entire portion of our community based upon serostatus is an all too common one, both for myself and I'm sure for the many others that attempt to bridge the divide - for many different reasons.

If only rationality, reason, or even compassion were at play here, but alas that often doesn't seem to be the case. I see this as no different as being dismissed for being too old, or not being the right color. It's outright discrimination based upon fear, ignorance, and a lack of human compassion. One that is often wholly supported by many of our peers, institutions, and so-called community organizations as being at the least politically correct and at best justifiable. Unfortunately this is not relegated to any particular demographic and I have encountered flat refusals to even converse or have any kind of interaction solely based upon serostatus from many different individuals, no matter their education, experience, background, or geography.

The not-so-great irony and sad realization is that these are the same forms of discrimination based upon sickness, disease, and undesirability that have plagued and made our communities suffer for countless generations. I suffer each time I am flatly rejected with no recourse and we all suffer as a community by these falsely constructed barriers between us. I feel deep regret for the individuals who falsely believe and use these beliefs to discriminate actively, thinking that they are somehow protecting themselves by exorcising the sick and diseased from their "healthy" world. These same individuals when they perchance seroconvert or god forbid have their 30th, 40th, or 50th birthday, will they be that dancer on the dancefloor with Matt? If so, I'd much rather work on the sero-divide now rather than continue to suffer the ongoing consequences of decades of poor public health policies, little to no sexuality education, and social marketing campaigns and interventions that preach but don't educate!

Author Profile Page Larry User Profile | November 3, 2009 7:18 PM

In terms of risk of infection, for our work we use Vittinghof's per-contact estimates, here's what he says:

"Estimated per-contact infectivity of URA with HTVseropositive partners was 0.82 percent (table 3), while per-contact risk of URA with HIV-positive and unknown partners combined was 0.27 percent. In contrast, per-contact risk of PRA with HIV-positive or unknown partners was 0.18 percent, although a substantial proportion of this risk may be due to condom failure."

Which is a less than a one in 100 chance, hence Poz's quote of 1:122. It seems the Australians are quoting the upper-end of the 95% confidence interval for these estimates.

As usual these are generalized estimates and do not take into account such things as Trevor mentioned, such as the actual infectivity of the individual (are the virally suppressed), other STDs present, etc.

You can read the article here for free:

http://aje.oxfordjournals.org/cgi/reprint/150/3/306

Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K and Buchbinder SP. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. American Journal of Epidemiology 1999;150:306-11.

Author Profile Page Larry User Profile | November 3, 2009 7:44 PM


About Us
Trevorade is a community of people just like you who spend their days thinking about sex, gay men's health, and HIV/AIDS. Welcome!

We Need Your Support
We're supported almost exclusively by donations from generous souls like yourself. So please, if you enjoy the content here, shell out a few gay dollars to help us cover our hosting bills.













Clips N' Chips
Liberal-Minded. Antillean-American. Queer. Non-PC Feminist.
Joe. My. God.
Gay Culture, Short Stories, & More! NY-Based.
Kaleidoscope
 Fellow Ann Arborite and Gay Blogger. Sexuality & Human Rights focus.
Knucklecrack
Gay Activist Eric Levin's Fabulous NY-Based Blog.
Lifelube
Gay, Sexy, Healthy - Just Like You!
Pam's House Blend
She's a fabulous North Carolinian blogging about politics, LGBT and women's rights, the influence of the far Right, and race relations. What more can I say?


19th Century
ABC
abortion
abstinence
academia
Acapulco
ACLU
ACT UP
activism
Adam Lambert
Adam4Adam
Adrienne Rich
advertising
aesthetics
Africa
age of consent
AIDS in Culture
AIDS Inc
airlines
Alan Cumming
Alice Newton
Alix Olsen
Allan Berube
Amanda Blank
Amazon.com
Amber Hollibaugh
America's Next Top Model
American Idol
American Sexuality Magazine
Americans
anal queefing
anal sex
Ancient History
Anderson Cooper
Andre Cavalcante
Andrew Sullivan
Ann Arbor
Antiretrovirals
Apple
archival research
Argentina
Armed Forces
Art
art fair
astrology
atlanta
Australia
AutBar
bacon
Badlands
banned
bareback
barebacking
Barry Adams
bathhouse
Batman
Bay Area Reporter
BBC
Bea Arthur
bears
Berkeley
Bette Midler
Better World Advertising
Betty White
Beyonce
Beyond Masculinity
bi-curious
bigotry
bikes accidents
Bill Clinton
Bill Frist
Black gay men
BlackBerry
Blackness
blogging
blow job
body hair
body image
Boston
Bottom identity
bougie white people
Brazil
Brent Corrigan
Britney Spears
Broadway
Brokeback Mountain
Bruce LaBruce
bullying
Bush Administration
Butt Magazine
California
call for papers
Calpernia Addams
Cameron Diaz
Camille Paglia
camp
campaign financing
Canada
cancer
capital punishment
capitalism
Carribean
Castro
Catholic Church
Cathy Cohen
Cazwell
CDC
Celine Dion
censorship
charity
Charlize Theron
Charlotte
Che Guevara
Cher
Chicago
China
chlamydia
Chris Bartlett
Christina Aguilera
Christina Applegate
Christopher Columbus
Chronicle of Higher Education
CIA
circuit boys
circumcision
civil rights
class politics
clubbing
CNN
cocaine
coming out
commodification
community
Community HIV/AIDS Mobilization Project
condoms
Congress
Connecticut
conservatives
cooking
copyright laws
Cornell
corporate welfare
corruption
Cortland Review
counterpublic health
country crock
country music
Craigslist
Creating Change
criminal justice
cruise ship
crystal methamphetamine
CTOPS
Cuba
cultural studies
D&X Abortions
daddies
Daily Beast
DailyKos
Dan Savage
Daniel Reeders
Danny DeVito
David Halperin
David Kaufman
David Letterman
David Malebranche
democrats
Denmark
Desperate Housewives
Destiny's Child
Detroit
Deutsche AIDS-Hilfe
Dick Cheney
dieting
disclosure
disco
discrimination
disidentification
Disney
divas
DOMA
douche bags
douching
drag queens
drugs
DSM
eagle
Ebay
Economics
economy
Edmund White
elderly
elections
Elizabeth Pisani
Ellen DeGeneres
England
epidemiology
epistemology
Eric Leven
Eric Rofes
español
Ethan Suniewick
Ethel Merman
ethics
ethnocentrism
European Union
Eurovision
Evan Wolfson
exams
extreme boy butter
Facebook
facial
family
Family Guy
fascism
Fashion
Father's Day
fausto fernos
FDA
feastoffun
FEMA
femininity
feminism
Feminist men
Ferndale
Film studies
Fiona Apple
fiscal responsibility
fisting
fitness
Florida
flow
foreclosure
FOX News
Frameline
France
free speech
Frontiers
FTM
Ganymede
Gary Dowsett
gas prices
Gawker
gay bashing
Gay bitch
Gay City
gay college applications
gay gene
Gay icons
gay male culture
gay marriage
gay men
gay men's health
Gay Men's Health Leadership Academy
Gay Men's Health Summit
Gay Pride
gay sex
gay stuff
Gay.com
gayborhood
Gayle Rubin
geisha
gender identity
genderfuck
genetics
George W Bush
Germany
Gilbert Herdt
Giovanni's Room
GLAAD
GLBT Historical Society
GLBTSA
GLEE
Glenn Beck
GLF
global health
Gold Coast
Golden Girls
Golden Globes
golden showers
goldstar
Google
graduate school
Grindr
Guillermo del Toro
H1N1
Haiti
hanky code
Harlequin Superromance
harm reduction
Harry Potter
Harvard
Harvey Milk
hate crimes
HBO
health care
Heather Cassils
Helen Goddard
herpes
heteronormativity
heterosexism
high school
higher education
Hillary Clinton
hipsters
HIV
HIV / AIDS
HIV Panic
HIV Prevention
HIV testing
HIV-positive
Hollywood
homofobia
homophobia
Homophobia
hooking up online
hospitals
HPPC
HPV
Human Rights Campaign
Hurricane Katrina
identity politics
Illinois
IML
immigration
India
individualism
Indonesia
inequality
Inga Muscio
insomnia
Institutional Review Board
insurance companies
intergenerational intimacy
International Mr. Leather
Internet
intersex
Iowa
iPhone
Iran
Iraq
Islam
Israel
iTunes
Ivy League
Jackson Bowman
James Baldwin
James Schuyler
Janet Jackson
Japan
Jean Genet
Jim Pickett
Joe Lieberman
John D'Emilio
John McCain
Jon Stewart
journalism
Juanita More
Judith Butler
Julia Serano
juventud
Juventud
k.d. lang
Kane Race
Kansas
Kansas City
Kanye West
Karl Rove
katastrophe
Kathy Griffin
keith green
Kevin Jennings
Kim & Cookie
kitsch
Kylie Minogue
LA Gay & Lesbian Center
Lady Gaga
LAMBDA
Lambda Literary Foundation
lark ballinger
Larry Kramer
Las Vegas
latex condoms
latino
Lauryn Hill
lawyers
leadership
leather
Legends
Les Natali
lesbians
LGBT Cinema
LGBT culture
LGBT history
LGBT politics
LGBT youth
LGBTI Health Summit
lgbti health summit
libertarianism
Lifelube
Lisa Marie Presley
literary
Liza Minelli
LOGO
London
long term nonprogressors
Longtime Companion
Lord of the Rings
Los Angeles
Los Angeles Times
love
lube
Madonna
Magnet SF
Maine
malaria
Malaysia
man/boy love
ManAlive
Mandy Carter
Manhunt
marc felion
Marilyn Monroe
Marion Cotillard
Mark Snyder
Mark Wunderlich
Married Men
Martha Nussbaum
Martin Luther King Jr.
masculinity
Massachusetts
masturbation
Mattachine Society
Matthew Shepard
Medicine
mentorship
Meredith Vieira
methodology
Mexico
Michael Hurley
Michael Jackson
Michael Moore
Michael Petrelis
Michael Scarce
Michael Warner
Michel Foucault
Michelangelo Signorile
Michigan
Michigan Daily
Microsoft
Middle East
Mika
military
Million Dollar Bill
Minnesota
monogamy
moral panics
morality
Mormon Church
Moscow
Movable Type
Movimiento LGBTTT en México
MRSA
MTV
museveni
music
music videos
mythology
nair
NAMBLA
National Gay and Lesbian Task Force
National Sexuality Resource Center
NBC
Necto
needle exchange
Needles Jones
negative men
neo-nazi
neoliberalism
Netherlands
New York City
New York Times
New Zealand
newspapers
Newsweek
NGLTF
Nicole Kidman
No Doubt
North Carolina
Obama
obesity
okcupid
Olympics
Ongina
Oprah
oral sex
orgies
Original Plumbing
Out Magazine
Outfest
Outkast
Palestine
Pamela Conover
Pansy Division
parenting
Paris
Paris Hilton
Pat Califia
Pat Robertson
Patriot Act
Paul Newman
Peaches
Pedophilia
Perez Hilton
perfume
Peru
Peter Tatchell
pharmaceuticals
Philadelphia
Philippines
philosophy
photography
piercings
plagiarism
Planned Parenthood
pleasure
podcasting
poetry
police
police brutality
polyurethane condoms
poppers
pornography
positional identity
Post exposure prophylaxis
post-race
postmodernism
Powell's
Poz Magazine
Pre-Exposure Prophylaxis
PrEP
President Obama
Pride
Princeton
print media
Prison-industrial complex
progressive
Project Runway
Proposition 8
prospect theory
psychology
public health
public sex
Puebla
Puerto Rico
Queen Latifah
Queer as Folk
queer identity
queer politics
queer studies
queer theory
QueerToday.com
Question of the Day
Quotes from People's Profiles
Rachel Maddow
racialized desire
Racism
racism
Radical Faeries
radio
raid
Raleigh
Rape
recording industry
rectal microbicides
refreshing
religion
RENT
Rene Zellweger
reproductive health
Republican Bastards
Republican party
research
retreat
Richard Labonte
rimming
risky business
Rita Hayworth
Road Trip
Robert Novak
Robyn
Roe v. Wade
Rome
Romeo Void
Royal Oak
RuPaul
RussaYog
Russia
russian river
Saint Foucault
Salon.com
Sam Sparro
San Francisco
San Francisco AIDS Foundation
San Francisco State University
Sarah Palin
Sasha Baren Cohen
Saturday Night Live
Scarlet Johansson
School violence
Scissor Sisters
Scooter Libby
Scott's life
Search engines
Seattle
September 11th
seroadaptation
serosorting
Sex and the City
sex education
sex offenders
Sex Panic
sex work
sex-negativity
Sexism
sexology
SexPols
sexual ethics
sexual health
sexual scripting
Sexuality & LGBT Studies
Sexuality & LGBT Studies
SF Weekly
silver foxes
sissyphobia
Sisters of Perpetual Indulgence
size queens
smoking
social justice
social marketing
social networking
social science
socialism
Sociology
Sordid Lives
South Africa
South America
South Park
Spain
spanish
sports
Starbucks
statistics
Steamworks
stem cells
stereotypes
stigma
stock market
Stonewall
stop AIDS
straight people
suburbia
Sue Hyde
superinfection
Supreme Court
Susan Kippax
Susan Stryker
Suzanne Pharr
Switzerland
syphilis
Taiwan
taso
technology
Ted White
Telephone
television
terrorism
Thailand
Thanksgiving
The Advocate
The Anonymous Gay Sex Column
The Bottom Monologues
The Gayest Podcast in Michigan
The L Word
The Netherlands
The Onion
the South
The Today Show
The Vatican
The View from the Bottom
The Village People
threesomes
Time Magazine
Tina Fey
Toe up
Tom DeLay
Tony Valenzuela
tops
Toronto
Transamerican Love Story
transgender
transphobia
tricks
Troy Wood
Tucker Carlson
Twilight Series
twinks
Twitter
uganda
Ugly Betty
UNC Chapel Hill
unemployment
Union Square
United Kingdom
United Nations
Unity Conference
University of Michigan
UPenn
Urvashi Vaid
Utah
vacation
vaccine
Vagina Monologues
vaginas
Valentine's Day
vampires
Vermont
Veteran's Day
Viagra
Victoria Beckham
Village Voice
voting
Walmart
Washington DC
wax
Wendy Brown
Whitney Houston
Wicked
William Way
Wisconsin
women of color
Women's Studies
World Health Organization
Xtube
yoga
young gay men
youth
Youtube
Zimbabwe
zines
zoology
mile Durkheim