That awkward negotiation before imminent encounter with a sexual partner met on mobile apps, online or at a bar often includes a brief health information exchange about HIV. Health educators recommend discussing HIV status before sexual encounters. Disclosure could lead to safer sex, more relaxed rendezvous and enhanced intimacy.
While in recent years having this conversation has gotten progressively easier for all parties involved, in many cases the exchange ends up being a useless formality made of insensitive questions ("Are you clean?"), superficial acronyms ("DDF?"), and uninformative answers ("I'm good", "Yeah, clean", "Neg", "Poz", etc.).
To have a meaningful conversation about HIV status, people should corner intentions and sexual partners in the realm of actuality, by keeping it to-the-point and asking the following questions: "When did you last test for HIV? What was the test result?" Equally important is to open minds to reality by remembering that the time of binary HIV statuses is pretty much over.
I can count five HIV statuses, plus a new one. They entail different responsibilities, possibilities and risks.
Let's review them on a continuum from the safest to the problematic ones.
"I'm HIV positive, undetectable."
People in this group clearly know their status. They take HIV medications every day and see a medical provider regularly. The amount of HIV virus in their blood is suppressed below the threshold detectable by available tests. An undetectable viral load greatly reduces the likelihood of HIV transmission. News coming from the Conference on Retroviruses and Opportunistic Infections in Boston highlighted the encouraging results of a recent study: HIV positive patients on anti-retroviral treatment who are virally suppressed did not transmit HIV to their negative partners.
"I'm HIV negative. I test regularly. I always use condoms."
Folks in this group use HIV testing and counseling as a form of prevention. They test for HIV on a regular basis (for gay and bisexual men the recommendation is once every 3-6 months). They use condoms consistently and correctly. While condoms don't provide absolute protection against any sexually transmitted infection, it has been repeatedly demonstrated by laboratory and epidemiology studies that their use is highly effective in lowering the likelihood of transmission.
"I'm HIV-positive. I don't know what my viral load is."
Not only an undetectable viral load reduces the risk of HIV transmission to negative partners, but viral suppression improves health outcomes in positive patients. Unfortunately only 25 percent of HIV positive people living in the United States are virally suppressed. The remaining 75 percent are not linked to medical care, were not retained in care, are not on medications or don't adhere to their treatment as prescribed. As a result, they are more likely to infect their sexual partners. There's a silver lining in this group: people who are HIV positive and not in treatment at least know their status. Knowledge gives them the chance to protect sexual partners and possibly come to terms with the barriers that keep them from accessing treatment.
"I don't know my status."
Among the 1.1 million people in the U.S. who are HIV positive, approximately 20 percent do not know their status to begin with for all sorts of reasons: fear, stigma, they honestly believe they are not at risk, et cetera. The truth is that all sexually active men and women are at risk for HIV. CDC recommends HIV testing for everyone between the ages of 13 and 64 at least once as part of a routine medical visit. Some of these folks are well aware they should get tested for HIV and hopefully they will test soon.
"I'm HIV negative." (Or at least he thinks he is).
Some of the "neg" guys out there belong to this troublesome group. At some point they tested negative for HIV. Months or even years later they believe their status hasn't changed. They proudly assert it left and right. They may even have condomless sex with other self-proclaimed "neg" men (a harm reduction technique called sero-sorting). Sexually active people who uses condoms inconsistently and don't test for HIV regularly cannot call themselves HIV negative. Many may be uninfected indeed, yet among them there are those who belong to the 20 percent of folks unaware of there their HIV positive status. The lack of knowledge laying on a faulty sense of awareness is an aggravating issue for this group.
Lastly, there's a sixth HIV status. It's recent, exciting and increasingly more visible. It belongs to the top of the continuum we reviewed.
"I'm HIV Negative on PrEP."
People on PrEP take a daily dose of the HIV medication Truvada to reduce their risk of becoming infected. In addition to the high level of protection provided by the treatment, these men and women see a medical provider regularly, just like people in the first group. According to guidelines, they routinely test for HIV and may use condoms for added protection, just like people in group two.
It doesn't get safer than this for sexually active people.
What's the conclusion? The same one that public health advocates reached and preached for decades: know your HIV status. If you are negative, avoid infection by using all available protections. If you are positive, seek treatment.
By knowing your status and act accordingly, you contribute to the ultimate goal of controlling the epidemic.
Asking "Are you clean?" doesn't help anyone.