The PARTNER study doesn't just tell us that HIV-positive gay guys on treatment are pretty safe. It tells us that they're safer than a lot of 'HIV negative' guys.
The big news at last week's HIV conference in Boston was a thing that didn't happen. A trial, the PARTNER study, found that no one, gay or straight, who had HIV but was on successful treatment transmitted the virus to their partner over the two years the trial has so far lasted. And that's in people largely not using condoms. As Tyler Curry writes in his blog, this is big news.
One of the researchers said that they'd have expected 86 transmissions between partners, or thereabouts, if none of the HIV positive people was on treatment. It was no big surprise that instead they saw none, since successful HIV treatment reduces the amount of HIV in your system ten-thousandfold or more.
To those less acquainted with the workings of HIV, and more surprised by the news, you'd think this would be cause for celebration. In the gay community, however, the news was received by many with disbelief ("This is bullshit science" said one) or downright fear.
Take someone Tyler Curry quotes. "HIV undetectable (people) will use it as excuse to bareback" [Yes, but terms solely of HIV risk, the PARTNER study is telling us it won't matter if they bareback] "or skip their daily antiviral meds" [Why in God's name would they want to do that?] "Then become re-infected creating a super bug of HIV that current meds can't treat" [Run for the hills].
A couple of 'Yes, But's. Firstly, the reason the trial does need to be continued in gay men is because so far we only have relatively few people in it.
A proper scientist, unlike me, would say something like this: "Seeing zero transmissions allows us to estimate that the true risk of transmission lies somewhere between zero and 1% a year" - not that comforting if taken over ten years.
But that caveat is about the fuzziness of the picture we have, and not about the thing it shows, namely nothing. Researchers expect that with more people and time, and barring nasty surprises, the maximum estimate of risk will probably edge ever closer to zero.
A bigger 'Yes, But' is this: the PARTNER scientists are keeping another figure close to their chest: the number of HIV infections the negative guys actually got. They hinted there were quite a few, and probably a lot of other STIs too. A smidgeon of HIV may come from the 5% or so of positive partners who were unlucky enough to have treatment failure. But the vast majority will come from sex with guys outside the main relationship. Mainly, probably, guys who thought they were HIV negative.
And here we get to the heart of the meaning of the PARTNER study. It confirms that we gay men have to change our ideas about infectiousness and HIV radically if we are to stand a chance of reducing HIV infection in our community.
Valerie Delpech is one of British science's hidden treasures (except she's Australian), an epidemiologist who sifts through every shred of evidence from her lab at Public Health England (do epidemiologists have labs? I'm not sure).
Last September she showed a presentation at a conference - it's here. Now, readers, turn to slide 14. What this shows is that of HIV-positive guys you might encounter while dating, two-thirds will know they're positive but won't be infectious: but of the infectious ones, two thirds will think they're HIV-negative.
I'll repeat that. If you're a gay Brit, two-thirds of the guys who could give you HIV think they don't have it.
Given that in London one in seven gay men has HIV, this means that [taps calculator]:
- -one in every 32 men you may meet dating thinks he's HIV negative and can't give you HIV when, in fact, he can;
- -one in every 44 men you may meet dating knows he has HIV, and is infectious. The other poz guys aren't.
Ergo: Guys who tell you they're positive are safer than guys who tell you they're negative. QED.
So, with all this new-found knowledge, the way to avoid HIV is simple, eh?
[At this point someone usually says "Yes, use a condom every time," so I will interrupt this broadcast with this brief message. Ahem:
-CONDOM DISCLAIMER: Condoms are a jolly good idea. They protect against lot of other nasty diseases as well as HIV. If I had casual sex I'd use a condom. They should be widely available and cheap. Nothing in this article should be construed as hostility to condoms or undermining gay men's motivation to use them. If you use condoms 100% of the time, great. This isn't about you or for you. It's for the 40% or so of gay guys who have sex with new partners without condoms. Thank you.
Now back to our broadcast]:
So, with all this new-found knowledge, the way to avoid HIV is simple, eh? If you're an HIV negative guy and you don't use condoms every time with a new date, then just date HIV-positive guys on treatment. They're very unlikely to infect you.
Hahahahahah. Excuse me while I pick myself off the floor.
Because we all know how most HIV-negative guys who don't use condoms with new partners avoid HIV, don't we? They ask if you're 'clean' or 'disease free' and then won't touch you with sterilised tweezers if you fess up to being poz.
Don't take my word for it. Another study at last week's HIV conference looked at all the gay guys attending the Seattle HIV clinic who were at risk of HIV (meaning that they had buttsex but weren't monogamous and didn't always use condoms). Most of these tried to take steps avoid HIV in other ways.
By far the most popular way - a strategy adopted by 42% of all the HIV negative men in the survey - was to never, ever have sex with a poz guy, period.
I'm not saying that HIV-negative guys aren't allowed to think twice and ask questions if someone discloses HIV. No-one's entitled to sex, least of all this greying 57-year-old here.
But I do wish the message would get across that if I say I'm vanishingly unlikely to infect you because I'm on the pills, I'm telling you the simple truth, not using my evil seductive wiles to get you into the poz club.
A lot of poz guys do lie about their status - because they're afraid of rejection. The saddest study at the conference was a German one. It asked poz guys if they believed their undetectable viral load made them non-infectious and if so, whether they based condom decisions on it.
Only 10% admitted to doing this but that 10% were far more likely to have condomless sex (natch - they don't think they're infectious). But they were also far less likely to disclose they had HIV, far less likely to raise the subject at all, far more likely to have anonymous sex.
'Undetectable=uninfectious' wasn't, for them, a belief that spurred discussion about HIV status and viral load. It was an excuse to avoid any discussion at all, and the rejection that comes with it.
When the first study came out showing the power of HIV treatment to reduce infectiousness, the hope was expressed that it might reduce the stigma against people with HIV. It hasn't happened. It's just so much easier to avoid visible people than an invisible virus.
The real danger of the Reject All Poz Guys strategy is not so much the 'serodivide' it perpetuates in the gay community - though that's damaging enough - but more that it reinforces the idea 'If he says he's negative he's safe'.
In an HIV epidemic where half of those who pass on HIV have themselves had it for less than six months, basing your dating decisions on someone assuring you they don't have HIV is downright daft. The price of that strategy may be what we see: a undiminished rate of infection in gay men.
You might call it Dangerouser Sex.