Pandoras Box

Tom, a 38-year-old New Yorker, could hardly believe what he was reading. Splashed across newspapers, websites like MSNBC.com, and online bulletin boards in January were shocking headlines like "Unprotected Sex OK for Some With HIV," trumpeting an announcement by the Swiss AIDS Commission, which after reviewing data from several studies had concluded that HIVers who are stable on their treatment regimens could safely have unprotected sex with seronegative partners. "I could not have been happier when I read that," says Tom, who is normally reluctant to become sexually involved with HIV-negative partners. "I feel like an entire pool of potential mates may have been opened up for me."

He isn't alone. The publication of the Swiss declaration opened a virtual Pandora's box in the HIV community, with many HIVers like Tom saying they may now be more likely to have sexual relationships with seronegative partners, while others, because they believe they're not infectious, are questioning whether to continue serosorting, disclosing their status, or practicing safer sex.

On the other side of the issue are HIVers who call the announcement "dangerous" and "immoral," and who have denounced the commission's conclusions as well as the validity of the research they examined.

And for those falling somewhere between these opposing positions, the Swiss announcement merely highlighted an ongoing sexual anxiety that many regularly grapple with: What can I do with my partners without infecting them?

"There's an enormous amount of confusion when it comes to sex," says 53-year-old Daniel Carmin of Los Angeles. "I've asked my friends, 'If we have undetectable levels of virus, what do we have to transmit?' And we just looked at each other, puzzled."

Anecdotal evidence would seem to support the notion that an undetectable viral load diminishes transmission risks, say some long-term HIVers and those who've tracked HIV's epidemiology.

"This is something we've seen here in San Francisco for a while," notes 48-year-old Lee Jewell, who was diagnosed with HIV in 1986. "I've had barrier-free sex with a couple of negative guys, including my partner at the time I tested positive, and they haven't been infected. I personally have not heard of others transmitting their virus to their uninfected partners through unprotected sex."

Though unscientific, the informal evidence is so persuasive that some physicians have privately told their patients that they believe them to be noninfectious.

"My HIV doctor once told someone I was dating that I would probably never transmit the virus to him," says John Mitrushi, a 49-year-old from Pleasantville, N.J. "He said, 'I would bet my life on it.' And that was four years ago."

But it's statements like that -- and announcements like those from the Swiss AIDS Commission -- that has American AIDS experts like Monique Howard, executive director of the New Jersey Women and AIDS Network, fearing that more and more HIVers will now be more willing to engage in risky sex. "I think a lot of people may say 'I'm undetectable and take my meds; therefore, I don't have to use condoms,' " she says. "I am very fearful people will use that research as their justification to throw caution to the wind."

Thomas Hardy, a 47-year-old Philadelphia attorney, says he expects some HIV-positive gay men to use the study to justify not disclosing their serostatus, particularly to casual or anonymous sex partners. "There are guys who prefer not to disclose because there's still a lot of stigma, prejudice, and discrimination out there," says Hardy, who believes HIVers like himself have an obligation to disclose their serostatus. "They might wonder why they should take a chance on being rejected by disclosing something that doesn't pose a risk to anyone anyway. If you're looking for an excuse not to disclose, here it is."

That same vein of logic could easily be used to undermine a community-level intervention that AIDS experts say has played a vital role in reducing HIV transmission rates, particularly among gay and bisexual men -- "serosorting," the practice of choosing sex partners of the same HIV serostatus so that there's no risk of new infection through unprotected sex.

But backed by the Swiss agency's conclusion that they might no longer be infectious, many HIVers who practiced serosorting could question why they should continue to limit their sex partners. That's exactly what's happening with men like New Yorker Tom, who'd recently avoided dating an HIV-negative man he met online because of transmission fears. But now, believing himself to be noninfectious, he's had a marked change of heart: "I'm definitely going to meet him now."

Hardy, however, isn't convinced that he should abandon tried-and-true prevention methods, including serosorting and using condoms, especially given that U.S. AIDS organizations quickly denounced the Swiss statement and reiterated their calls for HIVers to continue to practice protected sex. "You don't change behavior based on just one study," he says.

Sherri Lewis agrees. During her 23-year fight against HIV, the 54-year-old Lewis has heard far too many wondrous predictions that ultimately were proved wrong.

"Remember how people thought that when they achieved undetectable viral loads taking protease inhibitors they could stop taking their medications -- or safely go on drug holidays? That didn't turn out to be true," says Los Angeles resident Lewis, who as Sherri Beachfront hosts the weekly HIV-themed podcast Straight Girl in a Queer World. "Who knows what they'll discover years from now that debunks this conclusion?"

Mitrushi also worries that some HIVers will fail to note that the Swiss announcement came with some very important caveats. In order for infection risk to be eliminated, the HIV-positive partner must have no other sexually transmitted diseases -- and must have maintained an undetectable viral load for at least six months. Additionally, the negative partner must also be free of sexually transmitted diseases.

"Who really knows for sure that their partners have no STDs?" he asks. "How many of us know for sure that we don't?"

Similarly, it's not possible to be certain that one's viral load is undetectable at the moment of sexual contact, warns John Newmeyer, Ph.D., an epidemiologist at San Francisco's Haight Ashbury Free Clinic. "You can still have a viral spike from time to time," he says. "There's no way of knowing if your viral load test from three weeks ago is still relevant today."

There's also no way of knowing from a blood test whether you have detectable virus in your genital fluids. "My HIV specialist says it's possible to have high viral loads in genital secretions at the same time you have undetectable virus in your blood," warns Lewis, who believes she was infected with HIV through unprotected sex. "If you're having sex without condoms, it's those fluids that pose the transmission risks."

And just because you may not be exposing your partner to HIV doesn't mean condomless sex is risk-free, adds Santa Clarita, Calif., HIVer Jayson Stonne: HIV-positive men and women could be putting themselves at risk for a host of other STDs or even superinfection from a different HIV strain.

In light of the many unanswered questions raised by the Swiss commission's announcement and the many variables that affect HIV transmission risks, it would be dangerous to advocate unprotected sex, concludes Howard. "We at the New Jersey Women and AIDS Network will continue to stress using a barrier during sex to prevent transmitting or acquiring HIV," she says. "It's far too early, and there's far more research that still needs to be done to do otherwise."