A few days ago, a guest post by HaifischGeweint appear on the Crommunist blog over at the Freethought Blogs network. It is about the stigma attached to individuals with HIV/AIDS and focuses on laws requiring individuals that are HIV positive to let their sexual parters know before engaging in sex. HaifischGeweint appears to label these laws “institutionalized HIV/AIDS discrimination”.
Just so there are no misunderstandings
Just to make sure that we are reducing the risk of misunderstandings, let us get some things clear. HaifischGeweint clearly states that he or she “very strongly disagree with engaging in unprotected sex without first having an honest conversation about STIs and safer sex (no matter what your status)”. HaifischGeweint is also careful to point out that he or she “cannot stand by someone who lies about their status when asked about it or who (regardless of their status) deliberately avoids getting tested and/or practising [sic] safer sex. Full stop.”
Second, people with HIV/AIDS experience a lot of stigma. A lot of people just assume that HIV+ individuals have been sexually promiscuous without using protection, even if the HIV infection was the result of rape, having sex with a long-term partner that cheated on you or getting contaminated blood during surgery. We should do everything within reason to work together against irrational stigma against people with HIV/AIDS. But no matter how noble the goal is, we should not promote scientific falsehoods in order to achieve it (see below).
HIV, sex and informed consent
I am not going to spend a whole lot of text on the main issue here, because there are other serious problems with the blog post (see below), but I think it is clear that informed consent is important when it comes to sex (and most other serious human activities). In a perfect world, everyone would get tested, ask their partner about sexually transmitted infections and tell them if they have any as well as use protection. Unfortunately, this is a fantasy. It does not exist, and it does not appear to be reachable within the foreseeable future. So how should society protect people from being at uninformed risk of being infected by HIV? One avenue is via the legal system, where a person with HIV/AIDS is punished when he or she has sex with another person who has been denied informed consent. Should the punishment be 25 years in prison if there was no intention? That seems a bit excessive, but then again, I am not a legal scholar.
I find it quite ironic that HaifischGeweint seems to put a lot of responsibility onto the other person to ask about HIV status compared with the responsibility of the person with HIV telling about his or her status. In reality, how much different, in terms of emotional difficulty, is it to say that one has HIV compared with answering “Do you have HIV?”? Although I do not know for sure what the difference is in terms of emotional impact, I think it is safe to say that both are emotionally difficult. But let’s flip the situation over. Imagine having HIV and that your partner has another sexually transmitted infection that will substantially decrease your health and quality of life as well as the capacity of your immune system. Surely, you would want him or her to tell you? So the value of informed consent really goes both ways. This would lead me to conclude that both the person with HIV/AIDS and the other person both have a moral responsibility to have an open and honest conversation about sexually transmitted infections before having sex.
So what is the main problem? I think it has to do with the concept of intention in the legal system. Clearly, having HIV and having sex with someone with the intention of giving them HIV is very different from the same process but without that intention. From what I can tell, it is fairly uncontroversial that former group should be brought to justice. So the conversation seems to be about whether or not it is possible to unintentionally deny informed consent to one’s sexual partner (the other perspective being the rejection of informed consent when it comes to sex, which I think few people hold) and if so, how hard should the punishment be. I have no definite answers to these questions at this time.
As a final comment, I must object to the “but he/she was not infected!” argument. This is because whether or not you are infected is a probability game. Whether or not the partner got infected or not, the same actions was performed by the person with HIV/AIDS (i.e. denying informed consent by not telling). In that sense, it is difficult for me to count it as a mitigating factor. I find it very unsafe to base the bulk of legal decisions on the results of a probabilistic processes, although I do realize that it has, and should have, some influence.
Instead, let us move on to the meat of this article, namely a harsh criticism of some scientific errors in the post written by HaifischGeweint. As it turns out, HaifischGeweint contributes to the spread of misinformation over HIV/AIDS. This is particularly sad and harmful considering that HaifischGeweint is an HIV/AIDS activists, that presumably should know better.
Infection is a legitimate scientific concept
HaifischGeweint writes that:
Most people who are poz [HIV+ positive – Emil’s note] aren’t walking around with such an active and excessively contagious infectious process coursing through their circulatory system that it is in any way appropriate to refer to them as “infected”. And in fact, even for those who are so unfortunate to be dealing with a hyperbolic bloom of the virus in their system, this is usually a temporary state, often associated with the earliest phases in conversion (which can easily go unnoticed for many newly converted) or the final stages of AIDS (in which case, they are unlikely to just be out for a casual stroll like anyone else).
The point is that words like “infected” and “infection”, when talking about people who are poz, carries a connotation of uncleanliness, filth, and/or viral transmission […]
I do appreciate the argument that the term “infected” can have negative connotations. That means that we should be careful in our usage of the term and show thoughtfulness and respect towards people with HIV/AIDS. The term “infection” should ideally not produce any more negative connotations when associated with HIV/AIDS than with the common cold.
However, the term infection is scientifically legitimate in this context. Having an infection simply means that a pathogen has entered a host, is replicating and is interacting with the host in various ways. While it is true that HIV hides inside cells, there is still viral replication going on (both when the cell divides and when free virus particles go through their infectious cycle). Disallowing the term “infection” would, strictly speaking, make it wrong to say that HIV is a sexually transmitted infection. This would, of course, be absurd.
So to sum up, we should be careful about the connotations of the words we are using, but we should not arbitrarily delegitimize valid scientific concepts just because we think they have bad connotations. There has to also be a scientific argument. I will examine one such argument in the next section, but from a different perspective.
“Undetectable viral load” does not mean “non-transmissible”
HaifischGeweint continues:
The point is that words like “infected” and “infection”, when talking about people who are poz, carries a connotation of uncleanliness, filth, and/or viral transmission — again, medical intervention has actually advanced to the point that many poz people are no-transmissible or even un-detectable (I’ve seen it with my own eyes while working for a doctor whose only poz patient had been non-transmissible for 13 years and started testing un-detectable). You don’t personally have to agree with this argument, but I do, so I will be referring to people as becoming converted (or at risk thereof) unless I’m quoting a source that uses different language, such as the Supreme Court of Canada.
It appears that HaifischGeweint is suggesting that individuals with an undetectable viral load cannot transmit HIV. It is not explicitly stated, but it is a possible interpretation from the text.
While having an undetectable viral load decreases the risk of spreading HIV, I have found three arguments for why “undetectable viral load” does not imply “non-transmissible”:
(1) The viral load in e. g. semen might be higher from blood: Politch (2012) published in AIDS showed that 25% of the men who have sex with men in their study who had an undetectable viral load in their blood had HIV in their semen, up to a copy number of over 2500. So having an undetectable viral load is not a guarantee that you cannot spread HIV.
(2) Risk factors for HIV infection: the partner may have another sexually transmitted infection that makes it more likely to be infected with HIV, such as genital herpes.
(3) Change in viral load: the viral load might have changed since last measurement do to a variety of factors, perhaps such as non-compliance.
The claim that having an undetectable viral load means that you cannot transmit HIV is an incredibly dangerous myth.
HIV can be transmitted via oral sex
HaifischGeweint makes the following astounding claim:
For instance, if you aren’t having penile sex, how do you protect yourself (obviously condoms are out) and what is your risk of inheriting or transmitting something like HIV or chlamydia from the different activities you are engaging in? (Hint: enzymes in human saliva eliminate the HIV virus but not chlamydia; some infectious processes such as heat blisters from herpes or aphthous ulcerations from bad oral hygiene or smoking can compromise either your lips or gingiva, increasing your risk of inheriting even infections that your saliva would normally eliminate.)
Does HaifischGeweint really believe that HIV cannot be transmitted through oral sex unless there are blisters or ulcerations? This is perhaps one of the most destructive myths that HaifischGeweint has promoted.
Hladik (2008) notes that it is estimated that approximately 1.5 million people have been infected by HIV via oral sex. The oral portions of he pharynx and the esophagus has a squamous epithelium and the stomach and small intestine has only a single layer of columnar epithelial cells. These are sites of mucosal invasion by HIV and can occur without there having to be blisters or ulcerations. These makes it easier to become HIV infected, but it is wrong to state that HIV cannot be transmitted via oral sex if you do not have them. While the probability per exposure event is low, improbably things happen every day.
This is another dangerous myth spread by HaifischGeweint.
Conclusions:
HIV/AIDS activists have a special moral and intellectual responsibility. They surely know that there are a lot of harmful and destructive myths around about HIV/AIDS. Therefore, it is so much worse when someone like HaifischGeweint decides to spread some of these around. Clearly, as an HIV/AIDS activist, HaifischGeweint should know better.
We should do everything within reason to remove the stigma attached to being HIV+ positive, but we should not delegitimize valid scientific concepts and we should certainly not spread dangerous myths about the transmission of HIV.
Having an undetectable viral load does not mean that you cannot transmit HIV as the viral load in semen is higher, the partner may have other sexually transmitted infections that makes it more likely for HIV transmission to occur and the viral load might be different than when it was measured.
HIV can be transmitted through oral sex, even without wounds or blisters.
References and further reading:
Hladik, Florian, & McElrath, M. Juliana. (2008). Setting the stage: host invasion by HIV. Nat Rev Immunol, 8(6), 447-457.
Politch JA, Mayer KH, Welles SL, O’Brien WX, Xu C, Bowman FP, Anderson DJ. (2012). Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men.
AIDS. 26(12):1535-43.