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March 11th, 2014

Will HIV Ever Be Safe Enough for You?

There is a classic episode of Oprah from 1987 that can still raise my blood pressure. That year, the tiny town of Williamson, West Virginia, became part of a national discussion about AIDS when Mike Sisco, who had returned to his home town to die of the disease, dared to step into a public pool.

Scary nightmareThe community freakout was immediate. Sisco was quickly labeled a psychopath (rumors emerged accusing him of spitting into food at the grocery store), and the town pool was closed the next day to begin a Silkwood-style pressurized cleaning.

Soon thereafter, Oprah Winfrey arrived with cameras for a town hall forum about the incident.  Fear was the order of the day. “If there’s just one chance in a million that somebody could catch that virus from a swimming pool,” the town’s mayor told Winfrey’s worldwide audience, “I think I did the right thing.”

Sure. Why not react in the most extreme way possible, if there is a chance in a million?

Williamson citizens were not swayed by health officials who calmly explained the established routes of HIV transmission and the impossibility of infection from a pool. “The doctors can say you can’t get it this way,” a woman countered, “but what if they come back someday and say, ‘We were wrong?’”

Indeed. What if? If there’s a chance in a million…?

That broadcast might have remained a sad footnote in HIV/AIDS history, an instructive example of people ignoring scientific fact to protect a satisfying fear, if history didn’t enjoy repeating itself so much. Today, though, the willful ignorance isn’t coming from uneducated residents of a southern town you can barely find on a map.

It’s coming from gay men. And they are just as threatened, frightened, and dismissive of science as the townsfolk of Williamson were thirty years ago.

Recently, research known as The PARTNER Study was presented at the prestigious Conference on Retroviruses and Opportunistic Infections (CROI). PARTNER proved something HIV advocates have long suspected: people with HIV with an undetectable viral load are not transmitting the virus to their partners. The study included nearly 800 couples, all involved in an HIV positive/negative relationship, gay and straight, with the positive partner maintaining an undetectable viral load. Over the course of two years, more than 30,000 sex acts were reported and documented (couples were chosen based on their tendency to have sex without condoms).

Not a single HIV transmission occurred during the study from someone with an undetectable viral load. If PARTNER had been researching a new medication, they would have stopped the trial and dispensed the drug immediately.

The PARTNER results bolster the prevention strategy known as “Treatment as Prevention” (TasP), meaning, a positive person on successful treatment prevents new infections. To date, there is not a single confirmed report of someone with an undetectable viral load infecting someone else, in studies or in real life.

Just don’t tell that to a sizable contingent of skeptical gay men, many of whom took to their keyboards to dismiss the PARTNER findings. Phrases like “false sense of security,” “positive guys lie,” “junk science,” and “if there’s even a small risk” appeared on Facebook postings and in web site comment sections. The people of Williamson must be slowly nodding their heads.

Resistance to the PARTNER study corresponds with stubborn doubts about PrEP (pre-exposure prophylaxis, or HIV negative people taking the drug Truvada to prevent infection). Although virtually every nervous argument against PrEP has been overruled by the facts, naysayers continue to either reject the evidence outright or make moral judgments about the sex lives of HIV negative gay men on PrEP.

Yes, there are unknowns. There always are when scientific studies meet the real world. And every strategy will not work for every person. But the vehement rejection of such profound breakthroughs suggests there is something more, something deeper, going on in the minds of gay men. What is it?

Our collective memories of AIDS horror are hard to shake, and that’s a good place to start. On a gut level, any study suggesting that HIV could be neutralized is met with a weary doubt. Good news is no match for the enduring grief that has shadowed us for 30 years.

The PARTNER study also threatens the view that positive men are nothing more than risks that must be managed. The study kills the HIV positive boogeyman. It means positive gay men who know their status might actually care enough about their health to seek out care, get on treatment, and become undetectable. And, once the positive partner is no longer a particular danger, both partners would bear responsibility for their actions. What an enormous psychic change that would require in our community.

It’s tough to do that when fear creeps in and “what if?” fantasy scenarios take hold. What if my partner missed a dose yesterday and, even though HIV meds stay in the bloodstream for extended periods, his viral load has inexplicably shot up? What if he isn’t being truthful about his viral load? What if he doesn’t know?

The greater threat, folks, isn’t positive guys who think they are undetectable but are not. It’s men who think they are HIV negative but are not. But we’d rather stay focused on the positive person being at fault, because, well, people with HIV lie a lot. We miss doses constantly because we have a death wish or we’re too busy finding our next victim.

I have some “what if?” questions of my own. What if these unrealistic fears were meant to stigmatize and isolate HIV positive people? What if I am undetectable and feel no responsibility to discuss my status with a sex partner because I don’t care to engage in a science lesson? What if everyone availed themselves to prevention options that worked best for them? What if my HIV status were none of your damn business?

These risks could be alleviated, of course, if everyone simply protected their own bodies when having sex with people they don’t know or trust. But that would place an equal burden on negative men, and what a bother that is.  Better to leave that discomfort to those with HIV, vectors of disease that we are. Just consider us criminals, lying to you about our viral loads and spitting in the food in Williamson, just waiting to infect you when we get the chance.

 

As long as we’re giving undue attention to fantasy scenarios we’re not focused on the real threats. The rates of STD’s are up. Young gay black men in the United States don’t have proper access to healthcare and have infection rates worse than any developed country. Our community is plagued by  alcoholism, addiction, and mental illness. Do we want to debate established science or should we devote that energy to other challenges to gay men’s health?

If you still have the arrogance to believe you could win the HIV Powerball Lottery and be the one person who gets infected in ways science has disproven, you’re perfectly entitled to that point of view.

Here are some helpful instructions, however. Carefully step away from your computer and don’t touch the cords because 50 people die of product related electrocutions each year. Walk slowly to your bedroom, being mindful of debris in your path because slip-and-falls kill 55 people every single day. Once there, refuse food or water because, well, you never know. Now slip into your bed of willful ignorance and try to make yourself comfortable.

The good people of Williamson are keeping a spot warm just for you.

Mark

p.s. In the time it took you to read this article, the number of people who were infected by someone with HIV who had no viral load was zero.

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38 Responses to “Will HIV Ever Be Safe Enough for You?”

  1. J. Wesley Thompson Says:

    March 11th, 2014 at 3:06 pm

    Mark,

    Excellent article. Well said; succinct and accurate.

    Wesley

  2. Charles Says:

    March 11th, 2014 at 3:22 pm

    Oh Lord! I predict this is gonna be your most controversial posting since your “You’re Mother Liked it Bareback.” Powerful thoughts here. And the helpful instructions are icing on your cake of controvery.

  3. Vickie Says:

    March 11th, 2014 at 3:49 pm

    I absolutely love YOU!

  4. Michael Buitron Says:

    March 11th, 2014 at 4:08 pm

    Hey Mark,

    I like how your posts pull a moment from the recent past, and then show us how we’re making the same mistakes all over again. In your post on PrEP (and The Pill) you point out how the number of new infections has remained consistent over the past thirty years. This makes me wonder why (as HIV treatment has become more commonplace, easier to tolerate, and more of us have achieve undetectable viral loads), the new infection rate doesn’t seem to waver.

    My guess is that as HIV has become less deadly and more easily managed for most, it has also led to a perceptible increase in risk taking among gay men. Though it doesn’t prove anything, the increase in syphilis and other STDs certainly doesn’t refute an increase in riskier behaviors.

    The results of the PARTNER study don’t surprise me. I’ve been testing the negative partners of the positive clients who come into the HIV clinic where I work, and I’ve never seen a negative partner test positive when our client is on medication. And from my one-on-one with the negative partners, consistent condom use isn’t happening. My anecdotal evidence supports the results of the study: an undetectable viral load protects the negative partner in a relationship.

    My main concern is how that data get extrapolated to a single gay man who may or may not use meth, patronizes his local bathhouse or sex club, or finds casual sex partners at a bar or on line. We know from other studies that positive persons on medication will show transient viremia when they have an STD. When “condoms are unnecessary for couples” slides into “condoms are unnecessary for sex partners,” I expect we’ll see enough additional risk taking that we can keep up the 50,000 new infections per year, well into the future.

    My second point is that I have trouble making my own personal psychology jibe with the data from the study. When I’ve been in anonymous hook-up situations, it’s much easier for my internal voice to rationalize my behavior. Mr. No Name needs to accept some responsibility for the unprotected sex he’s engaging in, I’m undetectable, etc.

    Now that I’m in a relationship with a negative partner, my sense of responsibility and commitment has grown exponentially. He may be laissez faire about condom use, but I don’t want to imagine what a shit I’d feel like if I gave HIV to someone I love, when there were simple things I could have done to protect him.

    Sex and fear have always gone hand-in-hand; I don’t expect one pill (or one study) to untangle that mess.

  5. Timothy Ray Brown Says:

    March 11th, 2014 at 4:17 pm

    Great article Mark! I love you too! I think we need to get rid of these fears!

  6. chuck jarvis Says:

    March 11th, 2014 at 4:34 pm

    Does anyone know—i am looking for just observations at the gay bars and gay hook up places these days if this kind of information is as prominently displayed or/otherwise available like it was in mid to too late 80′s??? This is example of not only very helpful information but also helpful ways to discuss these things. Thanks, Mark.

  7. Marc Paige Says:

    March 11th, 2014 at 5:11 pm

    The study also found that in the couples studied, there were gay men who did seroconvert to HIV positive, when they had anal intercourse without a condom outside their relationship. So to read the study properly, if you are in a sero-discordant relationship, with the HIV positive partner on medications giving him an undetectable viral load, the chance for the negative partner to seroconvert is negligible, even if condoms are not used. However, if you are not monogamous, condoms remain vital for anal intercourse with partners of unknown medical history, to prevent infection with HIV or other STD’s.

    This study is great news…HIV positive people on meds giving them an undetectable viral load are basically not infectious! But, we still have a virus (that’s the enemy!) that infects over 50,000 Americans each year, and the vast majority of new infections are in gay/bi men through unprotected anal intercourse.

    (Yes, some negative people in the study got infected, which is why they say there is a chance for infection. But not from the positive partner! The negative guys were infected through sex with someone else outside the relationship. — Mark)

  8. Jim Pickett Says:

    March 11th, 2014 at 5:22 pm

    Love this Mark S. King! Once again, nailed it nailed it nailed it. Thank you!! Marc Paige makes very important points. I would just add a friendly amendment to his recommendation for HIV negative men to use condoms for anal intercourse with partner of unknown HIV status or unknown viral load – PrEP! Condoms are not the only tool HIV-negative people can use to protect themselves – thankfully. We also have PrEP – which means taking the drug Truvada every day. It works really, really well at preventing HIV. For people who don’t use condoms consistently, for whatever reason, and want to stay HIV-negative, PrEP is an option worth seriously considering.

  9. Wayne Says:

    March 11th, 2014 at 5:27 pm

    So in the PrEP study, HIV transmission was reduced by 44% in the men who were given PrEP as opposed to placebo, right? That’s fantastic, reduced by ALMOST half. Not quite half but almost.

    (Nope, not quite right. The 44% figure refers to everyone in the entire study who was offered to take the pill – all 2,499 individuals. Only about half of the participants actually took their pills – so the 44% figure is based on the efficacy rate for everyone in the trial – whether they took it or not. This is the “intention to treat” analysis – everyone screened into the study.

    For people who actually did take their pills, based on blood detection, their rate of protection was upwards of 90% – as high as 96%. Moral: it works if you take it. — Mark)

  10. Jose Sousa Says:

    March 11th, 2014 at 6:03 pm

    Well done Mark. It’s unfortunate that people will concentrate on the 4% that get infected, not realizing that it was due to unsafe sex outside the relationship with someone who had a detectable viral load. I hope that someone does a mathematical model of the chances of getting HIV from someone who does not know their status vs someone who knows and is undetectable. Even if someone has been tested in the past year, he could be positive today without knowing it. Since some studies have shown that most forward transmissions occur during primary infection and most people only find out their status when their CD4′s are below 500 which means that they have been infected for a few years. My belief is that you have less of a chance of getting infected by having unsafe sex with someone who is undetectable vs someone who tested negative one year before having sex. But of course you would be better off having safer sex, but that doesn’t always happen.

  11. Andy Says:

    March 11th, 2014 at 7:31 pm

    If people in treatment aren’t infectious then why have infections gone up since effective treatment started? Elizabeth Pisani has the answer,”In gay men, you’ve got quite a dramatic rise of new infections starting in the years since treatments became widely available. This means that the combined effect of being less worried [about HIV], and having more virus out there in the population — more people living longer, healthier lives, more likely to be getting laid, with HIV — is outweighing the [beneficial] effects of lower viral load.”
    The addition of TasP as a prevention method has made infections INCREASE over the just condoms, non-penetrative sex, and abstinence message.

    (That’s a strange and incorrect leap in logic. The fact that gay men are less worried about HIV, and therefore less likely to get tested regularly, for instance, does in no way mean that HIV positive guys who are on treatment are infecting anyone. New infections are the result of people with HIV who are NOT on successful treatment, including the ones who don’t even know they are infected. — Mark)

  12. Andy Says:

    March 11th, 2014 at 10:01 pm

    We’ve never had more testing and less stigma. But I’m sure a failed actor and blogger that wasn’t able to keep himself negative knows more than an epidemiologist with decades of experience in HIV/AIDS. Go straight to 9:25 since you can’t seem to understand the logic.

    https://www.youtube.com/watch?v=LoXAAEy6YQU

    (I will have you know, sir, that I sang and danced in a Popeye’s Fried Chicken commercial in 1983! Why I wasn’t given an honorary Emmy by now, I’ll never know. Furthermore, I managed to “keep myself negative” all the way to 1985, when the HIV test came out and I tested positive. I know. How stupid of me. — Mark)

  13. pozmonaut Says:

    March 11th, 2014 at 11:16 pm

    I think you’ve hit the exact issue behind the “any degree of hypothetical danger is too much risk (but only when talking about HIV)” thinking of many gay men. I couldn’t have said it better myself.

    And I have!

  14. OrwellIsDead Says:

    March 12th, 2014 at 12:45 am

    Gay men will always be nervous about HIV, in much the same way that people will always be nervous about air travel. It’s a one in a million chance that the plane might come down, but it does happen. Cheerily telling people about your viral load and school-marming them about “stigma” is about as effective as the safety demonstration before take off. Quit trying to turn HIV into something that is only feared by the neurotic – in doing so, you create an alienating form of stigma all of your own.

  15. Bradley Says:

    March 12th, 2014 at 1:29 am

    @Andy – no need to act like a petulant child just because your illogical leap of facts was refutted by Mark. If you knew anything about him, you would know how sad and snarky your last comment was.

    The fact is even epidomologist with years of experience can be held back by that ‘knowledge’ when newer facts arise. Many folks speculate that the increase in infections is happening not because we have more men and women on treatment who are undetectable having barrier free sex. It is because we have a lot of men and women who are having barrier free sex with a partner or partners(yes Virgina, women swing too) who don’t know they are positive or are not on medication for a variety of reasons.

    I work in the field of human sexuality – I cannot tell you how many folks, young and older – who still think that HIV is an infection for gay guys; or that they can tell by eyeballing someone if they are postive or not – or even scarier… Folks who only get tested every 6 months or so.

    These are the ones who show up with an STI for treatment and when you suggest an HIV test, they respond ‘oh no, she doesn’t HIV or he didn’t look sick.’

    The Partner survey indicates what we have been seeing in the field for years now.
    Those on medication, who are undetectable and are having barrier free sex with others who are either negative and or undectable are not infecting and or re-infecting themselves or others. The infections are coming from those unaware of true status or are not on treatment.

    We need more research to continue, yes. Yet we need to pay attention to what is really happening — Not what we thought would happen of what did happen in the past.

  16. Helle Andersen Says:

    March 12th, 2014 at 6:17 am

    Dear Mark
    I have been following your posts for quite a while and want to thank you for your clear reflections and solid information. In Denmark we (Hiv-Danmark) in 2013 launched a campaign: More sex with hiv+ because welltreated hiv is not infectious. We went on the Pride in Copenhagen with this message on T-shirts and posters/ banners and Heath officials supported the message from the stage. We were wellcomed by everybody on the route and people congratulated us and cheered the message. Some even told us they already knew about this. We are still working on spreading this information wider in society and it takes time for all to know but we will eventualitet get there. Just to cheer you up and salute you for your good work. Best wishes Helle

  17. Gus Cairns Says:

    March 12th, 2014 at 6:54 am

    Dear all,
    I wrote the story on Aidsmap that reported the PARTNER results. For me the crucial thing is what someone already said above: “When “condoms are unnecessary for couples” slides into “condoms are unnecessary for sex partners,” I expect we’ll see enough additional risk taking that we can keep up the 50,000 new infections per year, well into the future.”

    There’s more on this at http://www.aidsmap.com/Rejecting-serodiscordant-partners-is-HIV-prevention-strategy-of-choice-for-40-of-gay-men/page/2835100/#item2835103 – which I also wrote.

    The German study makes the point that the new knowledge about undetectable viral load, instead of being used in discussions between partners bout HIV status and infectiouness, is being used as a justification for NOT talking and NOT disclosing – it’s being used by HIV+ men to salve their conscience when they don’t talk. While this strategy of silence may not be a cause of increased HIV infections in itself, it perpetuates the stigma of HIV, makes relationships more rather than less difficult, and certainly contributes to the spread of other STDs.

    However as I also say in this story, since the lesson of the previou study from Seatlle is that for 40% of HIV-negative men, their safer-sex strategy is to flatly reject sex with any HIV-positive man, regardless of circumstances…where’s the incentive to talk? So while I hail the PARTNER results as significant, in prctical terms they will be useless unless they are accompanied with a really strong anti-stigma message, especially for HIV negative guys, and the continued encouragement, especially for HIV positive guys, to “always talk- always disclose – always negotiate”.

    ACT-UP coined the phrase ‘Silence = death’. I think we need to revive this slogan in the form of “Silence = HIV”.

  18. Simon Collins Says:

    March 12th, 2014 at 9:28 am

    Thanks – this was a nice article from a good perspective – and a good set of comments.

    One of the cautions, which I add as a comment in my i-Base article, and which the researchers are cautious about, is that most people had already stopped using condoms a long time before they entered the study.

    While this is great from an ethical point of view – the study itself isn’t driving or asking for people to change their behaviour – it is an important caveat with the results.

    This is because any partners who were especially susceptible to catching HIV – there are lots of genetic factors that we can’t measure but that affect individual risk – would not be captured in this data set. The results so far really mean that if you are lucky and don’t catch HIV from your partner when you first stop using condoms, then you are likely to be okay later on.

    The study design including study numbers to be adequately powered to answer the question – was based on no transmissions occuring. If one transmission does occur during later flow-up, this will change everything – but we think this is a very low risk.

    One small detail is that the number of exposures was close to 44,500 rather than 30,000 – maybe you got data from aidsmap who got this and a few other things wrong.

    Also, no details have been given about the negative partners who caught HIV from outside the relationship. The study has been really careful not to report anything about this cases – and the study steering committee doesn’t even know how many cases there are. So nothing has been said about whether these were gay/straight or men /women etc.

  19. pozmonaut Says:

    March 12th, 2014 at 9:59 am

    OrwellIsDead’s analogy to air travel proves too much. Yes, there’s a one in a million chance (or less) that the plane will come down – or will disappear somewhere in Southeast Asia and elude discovery for day – and yet PEOPLE STILL GET ON PLANES.

    “Gay men will always be nervous about HIV, in much the same way that people will always be nervous about air travel. It’s a one in a million chance that the plane might come down, but it does happen. Cheerily telling people about your viral load and school-marming them about “stigma” is about as effective as the safety demonstration before take off.”

  20. Gus Cairns Says:

    March 12th, 2014 at 2:10 pm

    Re Simon above: quote from my piece:
    “The main news is that in PARTNER so far there have been no transmissions within couples from a partner with an undetectable viral load, in what was estimated as 16,400 occasions of sex in the gay men and 28,000 in the heterosexuals.”
    …I make that 44,400.

  21. Gus Cairns Says:

    March 12th, 2014 at 2:29 pm

    One more thing: we also don’t know if the 5% or so of HIV positive partners who had or developed a viral load over 200 transmitted.
    Re length of prior condom use: as long as you don’t stop using condoms before your partner becomes undetectable, I don’t see how length of condom use would affect the result, whether people stopped using then 5 years or 5 days before the start of the study. Genetic susceptibility to HIV matters a lot if your partner is infectious, but if you’re virally suppressed genetic susceptibility or acquired immunity probably make very little difference: no virus is no virus.

  22. Robert Says:

    March 12th, 2014 at 5:23 pm

    intrigued by the article and conversation because I have a relationship with a Poz man top, and I started taking Truvada in January. I never barebacked for the 8 years I’ve been active, and even now we’re not going all the way.

    My main questions: Is undetectable specifically defined as not having a number that can be read? and why are there two thresholds depending on test?

    I have read in several places that viral loads can fluctuate between tests. He goes every three months but suppose he gets a cold on virus? Thanks

    (What is considered undetectable is a moving target, because tests continue to improve and “find” smaller and smaller portions of virus in the blood. For the purposes of the PARTNER study, undetectable was defined as a viral load less than 200, that is, 200 copies per ml. — Mark)

  23. Jeremy Says:

    March 12th, 2014 at 6:40 pm

    To Robert: Congrats on your relationship! I’ve been undetectable for more than five years. My lab just started using a new test which detects any viral load above 25 copies per ml (previously the threshold was 75 copies). I’m still undetectable based on the new test. Given five years of testing, my viral load does not vary in any measurable sense. Hope this info helps.

  24. Matthew Steiner Says:

    March 12th, 2014 at 10:20 pm

    Great article Mark!

  25. Brian Says:

    March 12th, 2014 at 11:06 pm

    Mark, this article is outstanding! Spot on brother.

  26. Eric Glare Says:

    March 13th, 2014 at 2:30 am

    Simon Collins is suggesting that genetically susceptible individuals will not be in the study because they would already have been infected as “most people had already stopped using condoms a long time before they entered the study” but the lower quartile for this was 0.5 yr. So a quarter had not being using condoms for less than 6 months – relatively short with respect to risk. Given the study is selective for relationships, for those who have spent much of their non-condom time in treated discordant relationships their risk will have been close to zero even thought they are relatively ‘genetically susceptible’. It is going way too far to say these people “would not be captured in this data set”.

    A good test of the probability that is risk is to ask does it make sense for gambling: “if you are lucky and don’t catch HIV from your partner when you first stop using condoms, then you are likely to be okay later on”. Nothing like a bit of early luck to ’cause’ a gambler to lose all their money.

  27. Renee Malick Says:

    March 13th, 2014 at 12:36 pm

    I am always amazed at the clarity of your thoughts on what it really means to be a positive person now as compared to the “early” years. Really glad that people are even around to be having this discussion! Keep up the good work, Mark!

  28. sobedoug Says:

    March 13th, 2014 at 6:23 pm

    “Does this mean that discordant couples (or ‘serodifferent couples,’ as the author called them) can dispense with condoms altogether? Not necessarily. While the transmission rate was zero in this study, the presenter made a point of discussing the uncertainty around that number. She pointed out that while their best estimate for the transmission rate is zero, they can’t exclude the possibility, with 95% certainty, that the true overall transmission rate was up to 4% over 10 years, and that the true transmission rate for receptive anal sex with ejaculation was up to 10% over 10 years.” http://hivforum.tumblr.com/post/79078620695/news-from-croi-does-zero-infections-mean-zero-risk

    (The article goes on to say, “As the study accumulates more couples, the statistical uncertainty will diminish, and if they continue to see no transmissions, they will be able to say with greater certainty that the estimated risk is zero.” Parsed research vocabulary aside, we’re still waiting for a single confirmed case of anyone being infected by someone with an undetectable viral load. Maybe God himself will appear with “zero” written on stone tablets? — Mark)

  29. Mark Hubbard Says:

    March 15th, 2014 at 1:28 pm

    Great article, Mark.

    The following comparison, however, isn’t valid:

    “If PARTNER had been researching a new medication, they would have stopped the trial and dispensed the drug immediately.”

    The fact is, this is an observational trial that is not dispensing medication or prospective intervention. In fact it isn’t randomized, placebo controlled, or blinded. There is no comparison arm.

    The concept of stopping a trial (and/or unblinding or offering an intervention – which is a separate decision that depends on the study design) is simply not relevant to this trial.

    The most important point here is that this trial is not randomized and that this is early data.

    While I recognize the data as incredibly important and that this “early” data bolsters what we’ve believed for some time about the prevention benefits of treatment, this trial design is fundamentally less stringent than a randomized trial. That’s all the more reason we must demand that it and the Australian “Opposites Attract” study be fully funded and completed.

  30. Mark Hubbard Says:

    March 15th, 2014 at 2:32 pm

    “Parsed research vocabulary aside, we’re still waiting for a single confirmed case of anyone being infected by someone with an undetectable viral load.”

    Actually, there is one transmission documented well enough to be published. I’ll concede that some have questioned it, and that one would have expected to see more cases reported in the three decades since the disease has been studied.

    I think it’s important to remember that the absence of data doesn’t always constitute proof. It can either mean that a phenomenon occurs rarely or it can mean that it’s difficult (and therefore rare) for such phenomenon to be documented. That’s why these studies must be done.

  31. W. Biggs Says:

    March 15th, 2014 at 8:26 pm

    In order to put the brakes on HIV infection, our health department should provide medallions with each UNDET checkup, indicating the month and year of that checkup, and the number of years of consistent UNDET VLs indicated by the color of the medallion and also marked on it. Gay men (or other persons) would be told the truth about transmission rates and advised to be wary of having unprotected sex with persons who do not have an impressive medallion. Let’s get real here. It might be useful to refer to Donald Rumsfeld’s discussion about known unknowns and unknown unknowns.

  32. Random John. Says:

    March 16th, 2014 at 12:23 pm

    “To date, there is not a single confirmed report of someone with an undetectable viral load infecting someone else, in studies or in real life.”

    DID YOU SERIOUSLY TYPE THIS?

    When I got infected, I contacted everyone I fucked with SIX MONTHS back (yes, I keep records). ONE person claimed to be “undetectable”. The others claimed to get tested/have gotten tested within a short window of then I last saw them. All them tested NEGATIVE. EXPLAIN THAT.

    Yes, people may lie, yes he may not have been undetectable…but to say a sterile isolated study that may be true about not being able to infect other guys with an undetectable viral load means that in this real world of lies, random viral blips, etc., that we can go on finding comfort in this isolated clinical information is all too convenient. You may be providing comfort, but you are also providing DANGEROUS fuel for rationalizations of just how to be a more careless slut again.

    (Not only did I type that, I will type it again: there are no confirmed cases of someone with an undetectable viral load transmitting HIV. Your own infection scenario hardly stands up to close scrutiny, considering those that claimed they were HIV negative may not have known the truth (a popular scenario responsible for many infections), and/or the positive person might not have been all that undetectable after all. I’m far more interested in discussing the truth than labeling sexually active men as “careless sluts.” Is that how you feel about yourself? — Mark)

  33. Simon Collins Says:

    March 17th, 2014 at 5:47 am

    Great discussion – and it shows the complexity of both measuring and then reporting this that are generally likely to be a low risk.

    So the Eric, it is great that about 25% of couples only recently stopped using condoms. It means we have some results from people in this situation. But because it is only a relatively small group of people compared to the whole study, it is reasonable to allow for this when interpreting the results. Nothing is clear cut and this is a caution.

    There has been a reported case case of transmission between gay men when the positive partner was undetectable and on treatment. I find this report frustrating though because it has few details about the couple and their risks.
    http://www.intmedpress.com/journals/avt/abstract.cfm?id=168&pid=88

    This should not be a surprise. Given enough chances, this is actually pretty likely. PARTNER is trying to put a more accurate estimate on how likely in terms that are easier to understand – such as x% chance from one exposure or x% chance over one year if you have sex 50 times a year etc. This is the data people need when deciding what is acceptable for their own level of risk. This case shows that with enough exposures, transmissions could occur, but this might, for example, need 100,000 or 1,000,000 or higher. This sort of risk probably become similar to catching HIV from oral sex from someone with very high viral load.

    http://www.intmedpress.com/journals/avt/abstract.cfm?id=168&pid=88

    To Gus, my comment on the aidsmap article was based on your first report when you quoted 14,000 heterosexual exposures instead of 28,000, so good if the online version now has been corrected.

    On a related subject, at a meeting last week in Barcelona I hear that last year (I think) about an interesting law change in Sweden. This said that an HIV positive person did not need to inform new sexual partners about their HIV status, if their viral load was <20 copies/mL on treatment.

  34. Jeton Ademaj Says:

    March 18th, 2014 at 3:52 pm

    i’m intrigued that “W Biggs” refers to a similar idea to one i have been structuring for implementation in New York. however, i dont think physical medallions are possible or practical (even if Mark King rather absent-mindedly referred to such in “appraising” my idea on the IRMA list).

    what will prove quite doable is, in those districts with quarterly or more frequent data gathering of names, tcells and viral loads, to enable a “digital certificates of undetectable viral load test results”, for voluntary use by program participants to advertise their suppressed viremia on participating websites…as well as the ability to send viewers to a personal, digitally secure webpage presenting one’s health status and testing history to individuals of a participant’s choosing. that latter part would enable A) PRIVACY and B) be portable outside of any specific website or app.

    “yea i have no reception down here in the dungeon, let’s go upstairs for a bit so i can log into my own personal Dept Of Health-secured health records page!”

    sorry you can’t see it Mark, but holding a yellow paint brush and crying about stigma will never dispel a tiny fraction of the HIV stigma many face…what HIV- people (and those who simply think they are) really want is cold assurance of levels of biohazardous risk.

    THAT is why the PARTNERS study is so important, and why i’m amused and pleased to see you and others (Gus, Jim) slowly waking up to the fact that all these caveats are coming from an essentially religious perspective.

    condom nazis are by definition not very rational, neither are grammar nazis or soup nazis or rules-nazis…too bad those offended by the vernacular use of “small-n ‘nazi’” waited so very long to voice their deep, heartfelt-and-NOT-exploitative-or-opportunistic offense at being called a *cOnDoM nAzI*. people only ever bust out the “n-word” when the strident advocate in question presume to impose their position on others.

    the cold truth is simply this: the underlying emotional reflex of just about every last caveat offered against PARTNERS or HPTN052 or the UK Statement of 2013 or the Swiss Statement of 2008 has simply been that we are somehow trading a valuable known (condom use AS AN OVERALL STRATEGY rather than as a powerful tactic) for an unknown of what they erroneously assess to be of probably lesser value.

    that comparison is simply not justified by evidence…only a tiny subset of condom users of any orientation have used them with the diligence and consistency needed to have a serious risk reduction benefit…most HIV- people have remained so thru a combination of sheer luck, and the one thing that has always worked best, COMBINATION PREVENTION. condoms and/or serostrategizing (seropositioning, serosorting, seroguessing) and/or partner limitation and/or sex-act-restriction and/or abstinence and/or ARV drugs.

  35. Dan, United Kingdom Says:

    March 19th, 2014 at 12:47 pm

    Wow Mark, Thank you so much. Such a powerful and succinct article. This is a problem that exists everywhere – including the U.K. its a sad reflection that after 30 years, ignorance can be as strong and virulent as it was then. I have been undetectable for more years than I can remember but once I cut myself with what I believed were my friends (not anymore!) and immediately there was a ten foot exclusion zone whilst some one donned gloves so that they could administer a plaster for me (I was simply not allowed to do this myself) There is no evidence of any pro advertising of the facts where no detectable viral loads as concerned – as far as I can see – in my country so I’m guessing sadly the same is true in yours. Always thinking of you guys across the pond, love.

  36. Eric Plamondon Says:

    March 23rd, 2014 at 8:43 am

    I really dont think Mr King is doing ANYTHING good for the younger or newly infected POZ people. In fact one article of his was so damaging to me and my goals to raise money for cure research that I almost left the sector completely. King. The newly infected, these young gay men need our support and education. Not to be further stigmatized by people living with the same disease as them. They were no more careless then you. I contracted HIV from a rape you jerk and I’m only 27. I’ve put everything i had left into fighting this and raising money. You need to go back to the drawing board. Your hurting people with your “controversy.”

    (I can relate to your frustrations. When I was your age I’d been positive for a number of years and your anger is really familiar to me. Please take care of yourself, first and foremost. You might appreciate my video blog on cure research; it’s been used by agencies to help raise funds for that effort. — Mark)

  37. Thomas Simmons Says:

    April 6th, 2014 at 9:04 am

    You are my hero, and the #1 most important voice in HIV discussions today. Thank you.

    (Oh my. Thanks very much, Thomas! And allow me to direct your attention to some terrific writers in my Favorites list on the right column! — Mark)

  38. Skyline Says:

    June 1st, 2014 at 11:21 pm

    Maybe we should all agree that condom use = safer sex. And poz guys being undetectable because of being compliant with improved meds = less likelihood of HIV transmission. And neg guys on PrEP = another layer of defense.

    And…wait for it…condom use paired with a poz guy being undetectable along with PrEP = a win/win/win strategy for reducing the current staggering rate of increased HIV transmission, especially among younger gay males and gay males of color.

    Why do we talk about REPLACING strategies we know work if we’re being diligent, with the newer breakthroughs? The newer breakthroughs ADDED TO the old strategies are what we should be promoting!

    And still being diligent.

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