From San Francisco to New York and now London, cities with large gay male populations are beginning to see major drops in new HIV infections. What do these three and others like them all have in common? PrEP.
To be clear, this does not put the USA cities past the goal post of the UNAIDS 90/90/90 plan but it does get them very close. Take New York City, the hometown our non-profit shares with Prevention Access Campaign and #ueuqualsu founder Bruce Richman, for example:
“The City presented estimates for 2018 in its annual HIV surveillance report, which was released on November 22, it calculated that 93 percent of the 90,800 people living with HIV in New York City had been diagnosed in 2018 or earlier, 87 percent of the 90,800 were “retained in care,” 83 percent of the 90,800 were taking anti-HIV drugs, and 77 percent of the 90,800 were virally suppressed. “
The United States as a whole has embarrassing numbers regarding HIV. Of the people with HIV (diagnosed and undiagnosed) in 2016, about 67% have received some HIV care, 49% were retained in care, and 53% were virally suppressed or undetectable. (Note: virally suppressed IS NOT THE SAME as undetectable)
The UK, is a different story though.
“Of the estimated 103,800 people living with HIV in the UK in 2018, 93% have been diagnosed with the virus. Of these, 97% are receiving treatment. and of these, 97% are, as a result, undetectable, meaning they cannot transmit the virus.” Reports OUTINPERTH.com.
The GLBT newspaper went on to state that,” the introduction of Pre-exposure Prophylaxis (PrEP) and rapid HIV testing have resulted in a significant downturn in the number of new cases of HIV. Combined with medical improvements that see people who do have the virus maintaining undetectable viral loads. Medication now makes the virus so dormant in people’s cells that they are unable to pass it on to other people.”
To us, this reads like great and exciting news. A three pronged approach to combating HIV that actually works. But, Mr. Richman didn’t quite agree. Stating in a tweet:
“(angry emoji) Another article that exaggerates the role of Prep and devalues the role of effective treatment for people w/HIV in the UK’s reduction in new transmissions. Let’s stop this BS. It’s not true & it could harm efforts to expand treatment.”
And here lays a significant issue with the U=U movement; it’s seen as the be-all-end-all for the end of HIV infections or followers, including the founder will flame you across the internet.
The simple fact is, PrEP does work, and people are using it. Uequalsu is amazing factual information that should be shared and taken on board by everyone but it will not solve every issue for everybody, and that’s not something to be angry about.
But, we are not the only ones who believe this. A reply tweet to Mr. Richman asked an interesting question that went unanswered:
“Bruce, do you seriously believe that a large percentage of non-poz men suddenly chose to fuck only guys with suppressed viral loads? Or that community viral load which is referenced changed so much so quickly? Have you looked at the underlying methodology and metrics?”
U=U does have one very large and glaring fault; its growing cult like following that does not allow room or space for critique, criticism or disagreement.
But, we never fall to bullying about the direction of HIV prevention and/or treatment campaigns, especially not by those who have never been given an AIDS diagnosis and given three months to live, like we have.
Dissent can be a great motivator for change and improvement. Here are our greatest concerns about this new movement and ways they can be addressed.
creates 3rd class citizens
Of the estimated 1.1 million people living with HIV in the United States, about half (50 percent) had the virus under control through HIV treatment, according to new CDC estimates based on the most recent national data from 2016. CDC previously estimated that in 2010, 28 percent of people living with HIV in America had the virus under control. This is the latest data, released in March of 2019.
Although almost half of those living with HIV don’t have the virus under control through treatment, the bad news about U=U is that it’s already being used as a badge of honour within the gay male community. This is akin to those who are HIV negative stating they are “clean” or posting their last HIV anti-body test results.
Many dating apps give the option of checking “undetectable” in the space for HIV status. As the knowledge of U=U increases, and more accept the science as fact, there will also be an increasing number of guys who hear “HIV positive” and assume the speaker is also “undetectable” and thus “safe to have sex with”.
What happens to the 50 percent that don’t have this golden ticket? How will they be treated by a community that already is plagued by a large amount of HIV stigma?
Finally, getting to undetectable and maintaining this status are not the same thing. For a variety of reasons, some guys are not always able to stay inside this bubble. Knowing and even having the privilege that goes along with being undetectable and then losing it, sometimes without the hopes of return, could be emotionally and mentally devesting. Not to mention the effects it could have on one’s HIV negative partner and their relationship.
it does not reduce HIV infection rates
Many people, but especially those at Prevention Access Campaign and their founder Bruce Richman, enjoy repeating the unsubstantiated non-fact that U=U can and will reduce HIV infection rates. Not only is this flawed logic but the result could lead many who do believe in the facts of this message to begin to doubt it. Here is why.
Those who are living with HIV and undetectable can not now, nor in the past, pass the virus on to their sexual partners. The fact that this is new information to many doesn’t change the science. Learning you can’t transmit HIV once learning of U=U doesn’t mean you could, before you knew. So, none of your prior sexual acts without condoms put anyone at risk for infection. And the rate of HIV infections did not increase because of any of the sexual acts of those who are undetectable.
If, as if claimed, U=U has the ability to inspire testing, treatment and maintenance of HIV, then the logical outgrowth would be an increase in the HIV infection rate, at least for the foreseeable future. Countries like the USA that have not come anywhere the UNAIDS 90/90/90 goal need to see a major increase in testing considering that an estimated 1.1 million people are living with HIV but as many as 14% or 1 in 7 don’t know they are infected.
- About 55% of adults aged 18–64 have never been tested for HIV. Even among people at higher risk for HIV infection, 28% have never been tested.
- Young people are the most likely to be unaware of their infection. According to a CDC analysis, in 2017, an estimated 54.6% of young people aged 13-24 who were living with HIV, were unaware of their infection.
If uequalsu is able to entice people to get tested and thus begin treatment and hopefully become undetectable, the HIV infection rates will rise. Which in the short term, is a good thing.
it does not increase access to care
Not only is this concept insulting, it is nonsensical. Healthcare in the USA is a complex and often expensive affair. If you have a high level of employment, health insurance will be part of your benefits package. But from part-time and underemployed workers to those without a job, healthcare insurance is usually unaffordable.
Statements about U=U increasing access to healthcare are borne from a point of privilege where the speaker believes not having healthcare is a choice. Some even equate not taking HIV medications to a choice, rather than attribute them to financial, housing and even mental and emotional health reasons.
Beyond basic health coverage, there is the issue of resources. Sexual orientation minorities currently make up 4.5% of the American population but in comparison to our straight siblings we have higher:
- unemployment 9%, vs 5%
- numbers of uninsured 15% vs 12%
- major issues with food insecurity 27% vs 15%
- greater population number with yearly income under 24k, 25% vs 18%
Finally, we face substantial challenges gaining access to proper medical providers and information. A significant percentage of us live in the South and Mid West. Areas that are not known for their hospitality to gays. These states were also the first to introduce Religious Freedom bills that give cover to providers, EMT workers and even pharmacies for not servicing us.
How could knowing that being undetectable means that you cannot pass on the HIV virus change any of these factors that are usually out of the control of the individual?
It does not make doctors gay friendly. It does not create more clinics or offices in rural areas. It does not increase the level of care we receive inside of these institutions and it does not increase the level of knowledge and education needed to properly assist us in our overall healthcare needs.
We think that this is fine. Other movements, laws and policies can address these issues. But, when #Uequalsu claims it can and will do it, it is lying!
no one begins or stays on treatment because of it
Hey Joe, I know that you aren’t taking your HIV medications but did you know that if you did successfully, you could become undetectable and not be able to pass on the virus to your sexual partners?
No, I didn’t know that. Thanks for telling me. From this moment on, I will take my meds as directed by my provider without fail.
See how ridiculous that exchange sounds? Again, there are a myriad of reasons why a guy is not taking his meds, and none of them will be solved by telling him that he can safely have sex with neg guys, without worry.
Another issue is how and why some are able to obtain an undetectable viral load count within their bloodstream, and others cannot. The CDC provides tips to assist those living with HIV in gaining and maintaining an undetectable viral load.
Time to viral suppression: Most people will achieve an undetectable viral load within 6 months of starting ART. Many will become undetectable very quickly, but it could take more time for a small portion of people just starting ART.
Adherence to daily treatment: Taking HIV medicine as prescribed is the best way to achieve and maintain an undetectable viral load. Poor adherence, such as missing multiple doses in a month, could increase a person’s viral load and their risk for transmitting HIV. People who are having trouble taking their HIV medicine as prescribed can work with health care providers to improve their adherence. If an individual is experiencing adherence challenges, other prevention strategies could provide additional protection until the individual’s viral load is confirmed to be undetectable.
Knowledge of viral load: Regular viral load testing is critical to confirm that an individual has achieved and is maintaining an undetectable viral load. It is not known if viral load testing should be conducted more frequently than currently recommended for treatment if someone is relying on treatment and viral suppression as a prevention strategy. Data show a discordance between some people’s self-report of their viral load status and laboratory measurements, suggesting that people may not know or be able to accurately report their viral load level. Just because someone was virally suppressed in the past does not guarantee they are still virally suppressed. However, the good news is the longer someone is virally suppressed, the more likely they will remain virally suppressed if they continue to take HIV medicine as prescribed.
Stopping HIV medication: If an individual stops taking their HIV medicine, their viral load will increase, in some cases within a few days, and eventually return to around the same level it was before starting their HIV medicine. People who have stopped taking their HIV medicine should talk to their health care provider as soon as possible about their own health and use other strategies to prevent sexual HIV transmission.
Protection against other STIs: Taking HIV medicine and achieving and maintaining an undetectable viral load does not protect either partner from getting other sexually transmitted infections (STI). Other prevention strategies, such as condoms, are needed to provide protection from STIs.
Barriers to treatment
Gay and bisexual men are the population most affected by HIV. In 2018:
- Gay and bisexual men accounted for 69% of all HIV diagnoses in the United States and 86% of diagnoses among males.
- Black/African American gay and bisexual men accounted for the largest number of HIV diagnoses (9,499), followed by Hispanic/Latinos (7,543) and whites (6,423).
Among all gay and bisexual men, HIV diagnoses remained stable from 2010 to 2017, but trends varied by race/ethnicity:
- HIV diagnoses among Black/African American gay and bisexual men remained stable.
- HIV diagnoses among white gay and bisexual men decreased 19%.
- HIV diagnoses among Hispanics/Latino gay and bisexual men increased 17%.
The majority of PLHA in the US are from African-American and Latino/Hispanic backgrounds (approximately 60%), and likewise, the majority of PLHA-NOA is from racial/ethnic minority backgrounds Indeed, the racial and ethnic background of PLHA-NOA is relevant because barriers to ART tend to vary across racial/ethnic groups, and interventions to reduce barriers to health can be culturally targeted to the factors with the greatest relevance to various subgroups of PLHA.
- At the individual/attitudinal level of influence, poor understanding of HIV treatment as well as misconceptions about ART appears to contribute to PLHA-NOA.
- PLHA may not perceive the need for ART, particularly when they feel healthy.
- African-American and Latino/Hispanic PLHA evidence a number of HIV- and health care-related attitudes and beliefs rooted in culture and U.S. history. Specifically, these beliefs are partly grounded in the history of past abuses of people from racial/ethnic minority backgrounds by medical research, the medical establishment, and larger society, which have been described as resonating with present-day exclusion, discrimination, and structural racism.
- The Tuskegee Syphilis study is perhaps the most emblematic example of past abuses, and this and other examples of maltreatment contribute to fear and distrust, not only of ART, but also the HIV care system, health care providers, and other larger societal structures
- Further, negative perceptions of ART, particularly fear of side effects, are common and can impede acceptance of ART, as do negative outcome expectancies, that is, the belief ART is ineffective and/or toxic
- Moreover, low self-efficacy for managing and adhering to ART may reduce ART initiation.
- These attitudes and intentions appear to interact to contribute to a belief that ART is unnecessary or even harmful that it cannot be tolerated or successfully managed, and/or create fears that one is not “ready” to manage an ART regimen.
- Indeed, a number of studies have argued that readiness for ART is an important latent construct that influences both adherence and treatment outcomes, which can therefore be targeted in behavioral interventions to improve ART outcomes.
- Yet fears and negative health beliefs do not preclude interest in ART or even ART initiation. PLHA, including those from racial/ethnic minority backgrounds, can simultaneously evidence curiosity about and willingness to initiate treatment options, along with fear and negative health beliefs.
- Persons living with HIV/AIDS’ health status can impede uptake of ART.
- PLHA face challenges accessing HIV health care and sub-optimal engagement in care is common.
- Those attending fewer health care visits are less likely to initiate ART, suggesting that those with poor access to care are less likely to use ART, those who do not wish to initiate ART elect to attend fewer health care appointments in order to avoid such discussions with providers, and that barriers to ART also impede access to care.
- Moreover “competing priorities” interfere with initiation of ART, primary among them are alcohol and non-injection drug use problems, injection drug use in some studies, mental health symptoms, and unstable housing.
- Yet competing priorities, while serious, do not necessarily preclude individuals from initiating and sustaining ART with high adherence. Past studies have shown these types of barriers can be ameliorated through interventions, and that among populations with competing priorities, rates of ART initiation with high adherence improve with clinical care, behavioral interventions, and support.
- Social-level barriers include fear of HIV-related stigma that might arise if others were aware of their HIV diagnosis.
- Moreover, PLHA who perceive negative peer norms regarding ART, that is, that their peers tend to avoid ART or view ART negatively, or would view the PLHA negatively if he/she took ART, may be less likely to initiate and sustain these regimens.
- PLHA’s relationships with health care providers play a critical role in ART initiation. National HIV treatment guidelines recommend that providers evaluate and manage factors that might impede adherence to ART.
- Yet some studies suggest that providers may delay recommending ART to patients because of concerns that patients will be unable to benefit from or adhere to ART.
- Wong and colleagues found that African-Americans initiate ART later than Whites regardless of providers’ attitude toward prescribing ART, but that provider beliefs led to delayed prescribing of ART to Latinos/Hispanics, women, and those with low socioeconomic status.
- The problem of PLHA-NOA is complicated by the fact that some patients are hesitant to tell their providers that they are not taking ART, for example in cases when providers have prescribed ART and assume patients have initiated it.
- Structural barriers are features of the external environment (economic, geographic, policy, organizational or other) that limit individuals’ options.
- Aspects of the HIV care setting including its location, structure, policies, and quality of care can promote or impede access to ART.
- While few studies have compared the initiation of ART, adherence, or retention in care between patients in comprehensive hospital HIV clinics vs. those in community care settings, recent work suggests that rates of initiation of ART are similar between the two settings, although community-based clinics may see patients earlier in their HIV disease as a result of outreach efforts.
- Yet another recent study suggests that patients in community-based clinics have better health care retention but those in hospital-based clinics are more likely to be virally suppressed.
- Thus the setting where PLHA receive care may influence patterns of ART initiation.
- A second structural barrier to ART may be the short health care encounter, which is not well designed to overcome multiple, intersecting barriers to ART.
- Last, in some locations, vulnerable PLHA are offered the chance to sell medications back to a pharmacy, an illegal activity that thereby decreases uptake of ART.
We provided this very extensive list to illustrate that the issues around why, and why not, someone takes HIV medication is much more complex than they didn’t know that if they achieved an undetectable viral load they couldn’t pass the virus on to their sexual partners. Demeaning statements like this help no one.
little to no outreach to gay males of colour
We refuse to post the dire warnings and predictions about the future infection rates for gay males of colour, but we would like to provide some statistics from our home city, which is also the home of Bruce Richman and Prevention Access Campaign. The following was reported by The Gay City News on Dec. 10, 2019.
“Using one number for estimated new HIV infections suggests that those infections are distributed evenly among different demographic groups. They are not.
Among the 1,917 new HIV diagnoses in 2018, 1,487, or 77 percent, occurred among men. Forty-one percent of the new HIV diagnoses among men were among African-American men, 39 percent were among Latino men, and 67 percent of the new HIV diagnoses among men were attributable to men who have sex with men (though 25 percent of the total diagnoses among men had an unknown transmission risk). Insofar as new diagnoses are a surrogate for new HIV infections, the new HIV infections are occurring disproportionately among African-American and Latino men who have sex with men. “
The above shows that just like in the early days of AIDS, Black and Latino gay males are at the center of the HIV storm. And just like during those days, our issues, needs and even lives are never given priority.
During the past year, a few notable HIV orgs in the Western World have been bending over backwards, praising themselves for creating outreach campaigns by and for gay males of colour. These astounding achievements are first of kind and lauded because after almost 40 years of HIV, this is a brand new concept to many of these orgs. The notion that if you actually hire gay males of colour in policy and program direction, we will be able to effectively reach our communities. It only took four decades, hundreds of thousands of infections and far too many lives for them to learn exactly what they have been saying about themselves: representation matters. But, none of these positions were permanent ones, just for the one campaign.
The HIV community has a great deal of comfort with women of colour. Not to say that they are seen or treated equally, rather in comparison to gay males of colour, cis and transgender women are held in high regard and protected. It is not uncommon for them to hold executive positions within these organizations, receive large funding for their programs as well as increased outreach to their community. They also provide support and shielding from criticism around racism.
Gay males of colour are on the exact opposite end of the spectrum. Even though we were one of the hardest hit communities by AIDS, we were never given a voice in the movement. We had to take it! We had to forge our own path, usually outside of the mainstream and congregate with other Black and Latino gay male orgs to gain strength in numbers. Our agencies are called, first and foremost, BLACK as a method of demeaning our work and progress. Even though all of us are able to do much more, with a fraction of the resources.
Anyone who lives in the USA or UK know this to be true. But the issue is that this deaf ear to our cultural issues is costing us our lives. No other group is told that they can be properly represented by outsiders, except us. Our representatives raily share our gender, sexual orientation, race or even have cultural awareness and participation. And we are told to just accept this.
Now, there is a new movement with U=U that is attempting to shut-out those of us who have been diagnosed with actual AIDS in the past, and long term survivors that are still standing strong, from the conversation. Our education, career experience and ability to keep ourselves alive is thrown aside for literally anyone else that shows up on the door step.
There is no outreach to gay male communities of colour. Period. We are still living in the 1980’s effectively where fear and stigma rules. The facts are the facts. Black and Latino gay and bisexual males continue to have the highest HIV infection rate of any demographic. We have the least access to proper care and treatment. The least knowledge and access to PrEP and the worst level of representation inside of HIV organizations policy, program development and leadership hierarchy.
An example of this lays within the U=U governing office. Prevention Access Campaign has hired Cameron Kinker as their Community Engagement Coordinator. Cameron graduated cum laude from Washington University in St. Louis in 2016 with a degree in Anthropology: Global Health & the Environment and Women, Gender, and Sexuality Studies. He wrote his honors thesis on transgender healthcare access in the St. Louis region. Cameron is HIV-negative (this is all from the Prevention Access Campaign website. We don’t believe in exposing anyone’s HIV status without permission)
There is literally NOTHING within his background, race, education or experience to state that any outreach from him towards gay males of colour would be created, or received well by this population.
Three cis gender, privileged gay white males run this huge new movement, but no one thought hiring a Black or Latino gay male of colour with the proper amount of experience, education and community participation to run policy or outreach was a good idea. Not one of them, or their entire governing body. Even as 1 out of every 2 of us is expected to be infected with HIV in our life times!
Before you say qualified gay males of colour don’t exist, remember, they travelled to the midwest to find Cameron but won’t take the subway to find someone from our community in New York City.
inability to provide criticism without backlash
As gay males of colour, some of whom are long term survivors living with HIV, and all with over 2 decades within this field, we know the importance of the facts behind U=U, but there is an almost cult like following that does not allow for any level of critique or criticism of the way this message is disseminated to those most in need. Especially cruel has been blowback from cis white gay males from Western Countries.
On 1/21/2020, George M. Johnson, an award-winning journalist, consultant, and activist located in Brooklyn NY, who also happens to be a gay man of colour, tweeted that he was going to write about the “U=U” movement in HIV work. Suffice to say, I don’t like it at all“. Almost immediately he was met with not only resistance but a hive mind reaction that included large amounts of racism. One of Prevention Access Campaign and Bruce Richman’s largest supporters Mark S. King, a cis gay white male blogger at My Fabulous Disease, tweeted “an editor once advised me, find a topic that everyone loves and then shit on it. Ill withhold my opinion on your beef with #uequalsu until I read your piece, but it certainly follows that formula”.
Not only did the founder of this movement not stop the barrage of attacks upon Mr. Johnson, he compounded and possibly initiated them by creating a pile on effect by tagging as many white people as he could. This was after telling Mr. Johnson that he looked forward to his critique, but then quickly unfollowed him.
In a reply tweet Johnson wrote “tagging people while never once reaching out to me or stating an opinion is throwing rocks and hiding your hands“.
This sort of pushback against the voices of people of colour, those of us most and consistently effected by HIV, is quite common. We are seen as a strong client base for HIV organizations, meaning that our infections with HIV create a stable source of revenue, but our access to positions of influence is always denied. These corporations are not practicing what they preach by way of representation but go one step further by silencing our voices from the outside as well.
We read Mr. Johnson’s article, entitled The Down Side of U=U, published by Thebody.com and enjoyed it. It highlights many of the same issues we have but in a lighter 1400 word essay. We also have been monorting his Twitter feed, just to see if he has received any apologizes for the unmitigated hate. Of course he has not, but there has been a solid amount of praise for his work.
Any movement that can not withstand critique by those who benefit from its success or suffer from its failures is nothing short of illegitimate.
how should U=U be shared
This may surprise most Americans, but the concept of HIV organizations is very foreign and odd to most living in Western Europe. Because the response to the original AIDS epidemic was not met with the same exacerbating governmental resistance, there was no need for their creation. In most countries, it is the government, medical community and providers that are responsible for gay male healthcare.
Yes, doctors are actually trained to treat patients who happen to be gay, male and possibly living with HIV. To this end, the outcome has been drastically different. The UK is not an anomaly is being able to achieve the UNAIDS 90/90/90 goals. Most Western EU countries have achieved or surpassed at least one, but usually two or more of these goals. The USA is not even close to hitting one of the targets.
Reaching out to the medical community and ensuring that every person tested for HIV, if negative or positive, receives the full package of facts about treatment effects is the first step. This includes a longer and healthier life, low and most times no side effects, one or two pill daily regiments, less doctors visits and of course, those who are undetectable cannot pass the virus on via sexual activity.
All of this information needs to be shared. One is not more important than the other. But, this science needs to become common knowledge. Media outlets need to report it, schools need to teach it, internet influencers need to share it. We all have a responsibility in this matter. In the hands of one white created and led organization and a few gatekeepers, U=U isn’t a blessing for all, but a weapon used against many.
we are more than our vial load counts
In the bad ole days of AIDS, many of us began to live our lives around our T-cell count levels. Some were so ill that they needed visits with their providers once a month, others every three (3) months. But the outcome was the same. A visit with blood work test results told us how long we literally had to live.
Conversations began with ‘How are you doing” and the inevitable response was “my T-cell count is….”
We weren’t doing this on purpose. We didn’t want to live this way, because it wasn’t living, it was terror and torture by blood tests. We did it, because it was what we were taught to do by our doctors, providers but most of all by HIV/AIDS organizations that made our T-cell counts into a movement.
The U=U movement is dangerously close to doing the same thing. Some would argue that it already has. For those of us living with this virus, blood test results are hard enough, but linking them to our value as men, our ability to be loved, is cruel. Especially when you consider the large amount of guys that are not undetectable and those who never will be.
Just like T-cell counts, a viral load count is just one of the many measurements of positive health. Our mental and emotional state are also important to this equation because it can reduce our overall health. We are already stressed when giving blood, but our focus needs to be on greater issues than one test value every three (3), six (6) or twelve (12) months.
we want more than to have sex with neg guys
If you look at the core value of U=U it is about sex. It seems like a movement for privileged guys who couldn’t get laid on Grindr because no one wanted to have sex with their poz asses.
For the rest of us who have been living with HIV for decades, we have much bigger fish to fry. But even when it comes to sex, we have learned to date and have sex with other HIV positive guys and those negative guys who are educated enough, or want to be, to begin a dialogue and then be with us for who we are, not our HIV status. This has helped not only our sex lives but our self-esteem.
When you were diagnosed before modern HIV treatments, you lived through a time when people didn’t even want to touch you, swim in the same pool, eat from utensils you ate from or even breath the same air. We are not so fragile that a negative guy not wanting to have sex with us is life shattering. We know it is his loss, because we are amazing.
Even with this being said, this movement gives off stereotypical homophobic vibes. Those views based on all gay men care about is getting laid. So, if you are living with HIV and negative guys reject you, now all you have to do is say “Hey asshole, haven’t you heard of U=U” and tighty whities drop all over the internet.
We need to teach and support those living with HIV that their value isn’t dependant on who wants to have sex with them. We deserve to be seen as more than objects for others’ pleasure.
Yes, we all want to, at some point have meaningful relationships, but if they rise and fall based on our blood work, they were not real to begin with.