After more than a decade of safe sex campaigns to prevent the spread of HIV and AIDS through the use of condoms, an increasing number of HIV-positive gay men are questioning the need for them when having sex with others who are HIV-positive.
Among the rationales: that their viral loads have been reduced beyond detection by the new protease inhibitor “cocktails,” that there is no evidence that reinfection can occur, or, most simply, that the worst that could happen to them already has.
The health consequences of this behavior are not fully known. And what little is known is not being passed on to HIV-positive men, who figure low in anti-AIDS education priorities. They continue to receive the standard absolutist proscription: No unprotected sex, anywhere, any time, with anyone.
But as death rates for HIV-positive men fall, and those men become a larger portion of the gay population (40 to 45 percent of the city's gay and bisexual men are estimated to be HIV-positive), such simplistic advice seems inadequate at best.
There's no hard data about positive-to-positive unsafe sex, says Paul O'Malley, HIV research program manager at the San Francisco Department of Public Health, but he's seen anecdotal evidence that supports the assumption that it's happening more. “With protease inhibitors causing viral loads to be undetectable, and the new 'morning after' exposure treatments coming out, it's easy to conclude this is happening,” he says.
But positive-to-positive sex is virtually excluded from consideration by medical research into and public discussion about safer sex. As a result, HIV-positive gay couples are deciding whether to have unprotected sex under a shroud of misinformation, secrecy, and guilt.
Jonathan, a 45-year-old San Francisco businessman who asked that his last name not be used (as did other sources for this story), says he knows “lots of positive people” having unprotected sex with positive partners. “And there's no indication they're any worse off than guys who faithfully had protected sex or are celibate,” Jonathan says. “At this point, reinfection is just a theory.”
He's chosen to follow suit and now has “a couple of [HIV-positive] sex partners who I regularly have unprotected sex with by mutual agreement.”
Behavior like Jonathan's poses important health questions: Could HIV-positive people be infected with a second, more virulent strain of HIV, possibly accelerating the course of the disease? Could they contract a drug-resistant version? Or, in the best case, could they turn out to be immune to any additional HIV infection after their first infection?
Researchers don't know the answers to any of these questions. They're “germane,” says Dr. Marcus Conant, medical director of the Conant Medical Group, which cares for about 5,000 HIV-positive patients. “But they are ahead of their time.”
No clinical proof exists that once infected, a person can contract a second, different version of the virus. A process known as “viral interference” seems to prevent infected cells from becoming infected with any additional related retroviruses. Nevertheless, most doctors, even those with large AIDS practices, prefer to err on the side of prudence, recommending protection for the HIV-positive.
George and Craig, both in their early 40s, have been HIV-positive since the early 1980s. Both are taking protease inhibitors, though not in identical drug combinations. Two years ago they met, fell in love, and after several months stopped using condoms.
George, a registered nurse who works with AIDS patients, knows he's violating the advice he gives out to his own clients. It seems as if “HIV has taken everything from me,” he says. “And I'm not letting it rob me of my enjoyment of sex and of making love with my husband without a condom. Besides, I think that by now we've probably been exposed to every strain there is.”
The Stop AIDS Project, a community-based organization focusing on HIV prevention among gay and bisexual men, addresses the epidemiological implications of positive-to-positive unprotected sex the same way it addresses other risk factors: It disseminates the latest information and leaves the final decision to its clients.
Dan Wohlfeiler, education director at the Stop AIDS Project, likens the reinfection quandary to the uncertainty over the risks of contracting HIV through oral sex. “Only a few people have gotten HIV through oral sex,” he says. “But people make decisions based on their own personal history of risk-taking.”
With the advent of protease inhibitors, a new factor must be calculated into the equation: Could a person be reinfected with a strain resistant to different drugs in the regimen, thus reducing his treatment options?
For Jim, a 43-year-old psychotherapist who has been positive since 1987, the fear that the answer is yes has led him to recently re-evaluate his sexual choices. He argues it's not realistic to expect gay men to refrain from unprotected anal sex for the rest of their lives. “The concept of negotiated risk must be included,” he says.
Now that he's on protease inhibitors, however, the risk-factor equation has changed. His doctor advised him against unprotected sex for fear he'd get reinfected with a drug-resistant strain. To have unprotected sex with a positive man would be “shooting myself in the foot by closing off options,” Jim says. (His current lover is negative.)
Jim found scant information when he tried to research the subject of reinfection before making his decision. He has his suspicions why that was the case. He blames homophobia, for one. “No professional wants to put their name behind that kind of research because they don't want to be seen as encouraging gay sex,” he says, barely containing his anger. “They're also afraid that people will misinterpret it and run off and have unprotected sex.”
The Department of Public Health's O'Malley says homophobia might be an element in the more conservative confines of the Legislature in Sacramento or in Washington. More important, though, researchers don't have enough money to spend on everything they'd like. “Many feel that there are more important spending priorities like finding a vaccine, anti-viral research, and education efforts to keep people negative,” O'Malley says.
Another question left begging involves viral load. Protease inhibitors can force the viral load below detectable levels; when that happens, the question arises whether unprotected sex might be safe.
But viral load tests don't measure the virus in all its forms, explains Lee Hardy, executive director of the AIDS Information Research Center in Baltimore. And a low viral load doesn't mean that the virus has disappeared. He counsels patients to use condoms no matter how low their viral loads. If nothing else, condoms protect against exposure to sexually transmitted diseases such as hepatitis, herpes simplex, and gonorrhea, which can wreak havoc on weakened immune systems.
The most hopeful theory, that HIV infection confers immunity against being infected with other strains of the virus, is still unproven. “Until we understand what is protective immunity regarding HIV, it's cavalier to think 'once infected, never re-infected,' ” says Dr. Stephen Follansbee at the Infectious Diseases Associates Medical Group.
Jim and others like him aren't content with that answer. “The medical community must realize that reinfection is a legitimate concern which needs research funding,” concludes Jim. “By now there's a tremendous amount known about the virus, and there's no reason why research isn't being done. The real question that needs to asked by AIDS activists is: Why hasn't it been done? And how can we make it happen?