The 27th of January saw a giant leap forward in real talk about HIV, sex, and Undetectable risk. In an interview with HIV activist and blogger Josh Robbins, Anthony Fauci, M.D., Director of the National Institute of Allergy and Infectious Disease (NIAID) for the National Institute of Health (NIH), made history by stating:

“Biologists and scientists are always reticent to say zero risk. In other words, nothing is 100% effective, and nothing is 100% risk-free. But if you stop there, then you get confusion.”

“See, it’s impossible to live in a world with zero risk, but from a practical standpoint with how you conduct yourself at work, how you do this, how you go to work, how you travel, how you have sex -what’s the risk? From a practical standpoint, the risk is zero, so don’t worry about it.”

This news was quickly followed up by words from the founder of the #uequalsu movement, Bruce Richman, executive director of the Prevention Access Campaign. “This is the kind of clarity about messaging that we’ve needed. The fact that Dr. Fauci clearly and intentionally confirmed “in practical terms, no risk” needs to be shouted from the rooftops. We’re still fighting [HIV] organizations that won’t let go of that barrier of fear between us and HIV-negative people. Layers of stigma and serophobia run deep in this field.”

The Facts:

Life, particularly gay male life, can be complicated and stressful sometimes. Our decisions about what we can and should do will sometimes vary significantly from those of our straight brothers. What we wear, where we go, and even who we tell that we are gay can be the literal difference between life and death. Even our sex lives are filled with hard choices that can have long-term and permanent negative consequences. The AGE of AIDS did not make any of these issues easier. Fear and uncertainty were fueled by inconsistent and unreliable information from our doctors, government, and even the HIV/AIDS organizations set up to assist us. “Risk” became a buzzword for all of our sexual choices. “How risky is anal sex?” “Will condoms reduce my risk of contracting HIV?” “Does undetectable equal zero risk of infection?” We were trained and advised to seek an impossible standard for living.

But we cannot have this conversation without taking responsibility for our actions and words. The desire to have a risk-free life is one of basic human self-preservation but an impossible standard for anyone to achieve. It is not wrong to want to limit the amount of risk in our lives, but it is unrealistic to attempt to forge a totally risk-free one. Life involves risk, and this means with our sex lives as well. The only certainties in life are death and taxes; everything else consists of some level of uncertain risk. But to make proper decisions about what levels of risk we find acceptable, we rely upon those in the medical field to give us clear and concise answers, which we never get. Hell, we’re still waiting for someone to tell us the honest truth about how much risk is actually involved in receiving oral sex!

Undetectable is more than just a word; its a movement:

Once scientists could find and isolate the virus that causes AIDS, treating and controlling HIV has been the number one priority in stopping the spread of this illness. Various medication “cocktails” have been tailored to an almost extraordinary level. Now, HIV is a treatable, once-a-day pill, health concern for most, without the adverse side effects of the past or specific one-year death sentence. Undetectable is the goal of all HIV treatment.

This is mainly due to the Viral Load Test, which measures the amount of HIV in the blood. The American Centers for Disease Control, CDC, defines an Undetectable viral load as “when the amount of HIV in the blood is so low that it can’t be measured.” This does not mean someone is HIV-negative or will remain undetectable without medication. How long before someone’s viral load remains undetectable and suppressed without proper medication depends upon the individual, their CD4 count, and overall health. NO ONE CAN SAY EXACTLY WHEN THAT CAN HAPPEN. Missing one or a few doses will not automatically increase someone’s viral load, and resuming medication treatment usually results in a quick rebound to undetectable levels.

For a growing segment of gay males living with HIV, undetectable has meant a level of freedom and choice in their lives. They no longer have to fear infecting sexual partners with this illness, and their health has either remained constant or improved significantly. With this in mind, they have chosen to disclose their HIV status as UNDETECTABLE rather than HIV POSITIVE. This move has also been seen on various dating websites as an option for status disclosure. This word has become a rallying cry against HIV stigma, as those who are undetectable are no longer a high risk to any sexual partner, with or without condom usage. But the fear, shame, and stigma remain, as scientists and those in the medical community refused to embrace #UequalsU or give a definitive answer about the risk involved in sexual activity with a guy who is HIV positive but undetectable until recently. To be clear, the CDC still has not stated these words.

We still have a long way to go in getting the message out about being undetectable. This includes guys who are undetectable themselves but, for whatever reasons, refuse to accept the science. There are many reasons why this population could feel this way, but it is essential to understand that #hivhaschanged, and we all must work to get the facts out and to believe them ourselves.

Words matter:

The male human body is a marvel of invention whose secrets are still unfolding before us. The same can be said about HIV. In just four (4) decades, this illness went from an unknown “gay cancer,” devastating the body of any infected, to a manageable and treatable virus. Along the way, we have hit many bumps in the road and false starts as to treatment and control, but we are currently further along than we have ever been to halt it in its tracks. Unfortunately, due to homophobia, racism, and religion, both the gay male body, sex, and HIV are under-researched and understood. The United States government and healthcare community are known to research HIV heavily for the straight population while neglecting the majority affected/affected by this disease; gay males. This has led many within our community to spread fear and stigma inside the void left by a lack of scientific study and facts.

The medical community introduced the idea of risk into our minds about sex. Still, it never gave a proper or complete definition of what it can and should mean regarding our sexual choices and partners. What does “high/low risk” actually mean? These words say nothing and mean even less. But they make sense within the confines of a society against male homosexual sex and refuse to fund research into it. So, we were left to define these terms ourselves, with mixed results. This is how we went from a community that loved and supported our HIV-positive brothers to one so fearful that the HIV stigma within us is more significant than what most Poz guys receive from straights.

Medical professionals and scientists dislike using words like zero or 100% regarding anything. Still, at some point, we need these institutions to make factual statements about their research so that gay males can make decisions about our behavior. This cannot be done in a climate of fear of lawsuits or being dismissed by peers who disagree with the results. In 2008, The so-called Swiss Study was the first to detail those undetectable as being unable to transmit the HIV virus and were very quickly refuted and ignored by the general medical community. Yet, here we are an entire decade later, saying the exact same words to a community that still does not want to believe in the science.

HIV testing/infection in gay males: 

The United States and the United Kingdom have done research into how often gay males actually are tested for HIV within a year and general STATS on HIV infection. These surveys from willing participants cannot hold the whole story about our entire community, but they paint a chilling picture.

  • Data from the Gay Men’s Sex Survey 2014, a cross-sectional survey of MSM aged 16 years or older living in the UK. Only men who did not have diagnosed HIV and were living in England were included in this analysis. Younger men, older men, and not gay-identified men were least likely to have tested for HIV.
  • Pink News Reported: only 77% of UK gay and bisexual guys have ever been tested for HIV, and one in four has never ever had an HIV test. About 36% are unaware of their current HIV status.
  • Cary James, the Head of Health Promotion at Terrence Higgins Trust, said: We’re concerned that a third of UK gay men are not definite about their HIV status – particularly as we know that one in seven men who have sex with men are undiagnosed.
  • Of 1419 American MSM with HIV testing data (89% of total), 1106 (78%) reported prior HIV testing, of whom 105 (9%) had tested positive. Among HIV-negative/unknown ever testers, 51% reported currently testing on a regular schedule, of whom 1% reported testing monthly, 33% quarterly, 38% every 6 months, 22% annually, 3% every 2 years, and 3% on another schedule.
  • 1 in 6 American gay and bisexual men living with HIV is unaware they have it.
  • Gay and bisexual men accounted for 82% (26,376) of new HIV diagnoses among all males aged 13 and older and 67% of the total new diagnoses in the United States.
  • Gay and bisexual men aged 13 to 24 accounted for 92% of new HIV diagnoses among all men in their age group and 27% of new diagnoses among all gay and bisexual men.
  • Gay and bisexual men accounted for 55% (10,047) of people who received an AIDS diagnosis. Of those men, 39% were African American, 31% were white, and 24% were Hispanic/Latino.
  • It is predicted that 50% of Gay/Bi Black American men will contract HIV within their lifetimes. As the New York Times reported. “Last year, the Centers for Disease Control and Prevention, using the first comprehensive national estimates of lifetime risk of HIV for several key populations, predicted that if current rates continue, one in two African-American gay and bisexual men will be infected with the virus. That compares with a lifetime risk of one in 99 for all Americans and one in 11 for white gay and bisexual men. To offer more perspective: Swaziland, a tiny African nation, has the world’s highest rate of HIV, at 28.8 percent of the population. If gay and bisexual African-American men made up a country, its rate would surpass that of this impoverished African nation — and all other nations.”
  • Southern states today account for an estimated 44 percent of all people living with an HIV diagnosis in the US, despite having only about one-third (37%) of the overall US population. Diagnosis rates for people in the South are higher than for Americans overall. Eight of the 10 states with the highest rates of new HIV diagnoses are in the South, as are the 10 metropolitan statistical areas (MSAs) with the highest rates.
  • Black gay, bisexual, and other men who have sex with men (MSM) face an especially heavy burden, accounting for 59 percent of all HIV diagnoses among African Americans in the South. In fact, of all black MSM diagnosed with HIV nationally in 2014, more than 60 percent were living in the South.

Making regular HIV testing a part of every sexually active gay male’s life is an important step in not only helping his overall health and longevity but also that of our community. The stigma around HIV is still so high that too many guys are afraid to take the damn test! This is the portion of our community most in need of hearing that #uequalsu because they are the ones actually infecting guys.

But the news is not all bad. Actually, it looks pretty good. Once those infected with HIV are placed on proper medication, they usually reach undetectable levels within one (1) to three (3) months, making them unable to pass on the virus. UNAIDS has created the 90-90-90 Programme, which is “now building towards a new narrative on HIV treatment and a new, final, ambitious, but achievable target”: (you can check out your country’s full stats by clicking the link)

  • By 2020, 90% of all people living with HIV will know their HIV status.
  • By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

Europe is very close to reaching this goal. Eleven European Union countries were included in the study (Austria, Belgium, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, and the UK). Estimates were for late 2013. In all eleven countries, at least 81% of ART-treated people were virally suppressed, with Denmark and Sweden already achieving the 90% goal. Estimates for the UK were 81% of HIV-positive people diagnosed, 82% of diagnosed people on ART, and 82% of treated people with viral suppression.

A fantastic example is The Netherlands’ Capital city of Amsterdam, which is among the first cities to reach and exceed the 90–90–90 targets. Home to over one-quarter of all people living with HIV in the Netherlands, Amsterdam has used a reliable and accessible public health system to full effect. A wide range of flexible entry points is available for HIV testing and sexual health promotion, especially for gay men and other men who have sex with men. This has reduced the number of people living with HIV who are unaware of their HIV status. Harm reduction services also have been integrated into the city’s HIV strategy and have reached high coverage among people who inject drugs. Once people are diagnosed with HIV, they are efficiently linked to a network of experienced clinical centers that provide universal access to expert HIV treatment and care.

The United States, on the other hand, is not doing as well.

The United States of America has reported that 15% [14–16%] of an estimated 1.1 million people living with HIV in the country in 2014 were undiagnosed. Also, The USA appears to face more significant challenges to reaching the second 90 than countries in western Europe. According to the latest national report, an estimated 71% of people living with HIV received medical care in 2014. Still, only 57% of people living with HIV met the national criteria for continuous HIV medical care. Viral load was suppressed in 77% of persons who received care in 2013 and 81% of persons with a viral load test during 2013, which is equivalent to 55% of the total number of people who had been diagnosed with HIV diagnosis by the end of 2012 and were still alive in 2013.

But the nation can take a page from one of the homes of the Gay Rights movement, New York City, which has made significant progress in its AIDS response and is now close to achieving the 90–90–90 targets. Among the approximately 90,000 people living with HIV in the city in 2015, 94% were aware of their serostatus, 87% of those who knew their status were accessing antiretroviral therapy, and 91% of people on treatment were virally suppressed. The 2493 new HIV diagnoses reported in 2015 were the lowest in decades, and for the first time ever, there were no HIV infections through mother-to-child transmission.

Ten facts about HIV suppression, but the one comment we think is most important:

The American National Institute of Health states:

People living with HIV who take antiretroviral medications daily as prescribed and who achieve and then maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner. 

Three sizeable multinational research studies involving couples in which one partner was living with HIV and the other was not—HPTN 052PARTNER, and Opposites Attract—observed no HIV transmission to the HIV-negative partner. In contrast, the partner with HIV had a durably undetectable viral load. These studies followed approximately 3,000 male-female and male-male couples over many years while not using condoms. Throughout the PARTNER and Opposites Attract studies, couples reported engaging in more than 74,000 condomless episodes of vaginal or anal intercourse.

HIV Criminalization Laws:

According to the CDC website, these laws are outdated and lacking in modern scientific evidence and research.

“During the early years of the HIV epidemic, many states implemented HIV-specific criminal exposure laws. These laws impose criminal penalties on people living with HIV who know their HIV status and potentially expose others to HIV. In 1990, the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, which provides states with funds for AIDS treatment and care, required every state to certify that its criminal laws were adequate to prosecute any HIV-infected individual who knowingly exposed another person to HIV.”

“An analysis by CDC and Department of Justice researchers found that, by 2011, a total of 67 laws explicitly focused on persons living with HIV had been enacted in 33 states.3 These laws vary as to what behaviors are criminalized or result in additional penalties. In 24 states, laws require persons who are aware that they have HIV to disclose their status to sexual partners and 14 states require disclosure to needle-sharing partners. Twenty-five states criminalize one or more behaviors that pose a low or negligible risk for HIV transmission.”

“The majority of laws identified for the analysis were passed before studies showed that antiretroviral therapy (ART) reduces HIV transmission risk, and most do not account for HIV prevention measures that reduce transmission risk, such as condom use, ART, or pre-exposure prophylaxis (PrEP). The analysis encouraged states with HIV-specific criminal laws to use its findings to re-examine state laws, assess the laws’ alignment with current evidence regarding HIV transmission risk, and consider whether the laws are the best vehicle by which to achieve their intended purposes.”

Saying ZERO in the face of these laws not only protects defendants and gives them the power to properly submit evidence regarding their lack of ability to expose and thus infect another individual, but it also has the power to increase HIV testing as the only common defense is a “lack of knowledge of HIV infection.”

Ending Stigma: 

One small word, ZERO, can literally change the course of this disease and how gay males see themselves and their sexual partners. It can also go a very long way in increasing HIV testing, disclosure, treatment, and ending stigma. Simply telling the truth about HIV transmission from an undetectable guy will go a long way in changing our world. No matter what anyone or any organization wants to say, this is our illness in most of the world. We claimed it. We fought it. We are beating it. We lost lovers, brothers, and friends, but many of us are still here! We created the Red Ribbon and AIDS Memorial. We marched, and too many of us died. This stigma must end with our generation. HIV infection should not be a scarlet letter around any of our brothers’ necks. A positive diagnosis makes you no less a person, man, or human being. And it should not make you less desirable as a sexual partner, boyfriend, lover, or husband. You have ZERO chance of becoming infected by an undetectable partner, even if you choose not to use condoms. Period!

Saying ZERO means ZERO, backed by the facts and science we know to be accurate, will stop the haters in their tracks and get us back onto external battles like full Civil Rights, Marriage Equality for all, and Equal protection under the law.

Now, if we can get someone to talk honestly about PrEP.

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