The Big Disconnect Around HIV Prevention

HIV stigma and the logical dissonance between "it's not a death sentence" and "if you have sex without a condom, you will die".

BY Josh Kruger

December 27 2013 5:00 AM ET

I’ll  admit it: Untreated HIV is, in fact, a death sentence. But because American society and in particular the LGBT community built industries, both for- and not-for-profit, surrounding HIV and AIDS treatment and prevention, HIV-positive individuals now have access to the same longevity and quality of life as their HIV-negative counterparts. Still, AIDS service organizations and government groups continue to trumpet the party line that tells young people, especially, that if you have sex without a condom, you will die.
 
In fact, the familiar refrain that HIV is not the same as a passive, years-long form of capital punishment is mealy-mouthed or, in its more stigmatic sense, completely devoid of any attempt at true understanding. After all, physicians, researchers, sensible outreach workers, and HIV-positive individuals themselves now adopt, thankfully, forward-thinking approaches toward HIV, including treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) as well as early use of antiretrovirals. These approaches and medicines now take early death and poor quality of life completely off the table for most HIV-positive folks. 
 
Despite the scientifically proven efficacy of these models and the complete practical dearth of side effects from medications like Complera or Truvada, the drumbeat telling us “HIV equals death” continues like internalized stigma masquerading as spooky gimmickry.
 
In particular, the naysayers and the sex-negative organizations and activists in the HIV and AIDS treatment and prevention industry have a serious unease with PrEP, TasP, and almost anything that doesn’t involve condoms. Indeed, the AIDS Healthcare Foundation leads the charge in its shrill obsession with everything not latex-based and, most dangerously, internalizes stigma by acting like bareback sex is the same thing as Russian roulette. It is not. 
 
Curiously, these same activists and organizations are willing to “empathetically” hold hands during diagnosis, force the image of an unwilling victim down the throats of the newly HIV-positive, and take personal responsibility and adult decision-making completely off the table. For example, the hackneyed spirit of “it’s not a death sentence” logically supposes that HIV is a dangerous, spooky thing that somehow just happens by someone’s life. And while the notion itself is quaint, it creates logical and cognitive dissonance. 
 
More specifically, condom-based campaigns using sex-negative imagery (remember the man in a diaper on a billboard or the scorpion raping a woman, all campaigns trumpeted by outdated condom-obsessed AIDS organizations) imply that HIV and, subsequently, its treatment will both give you explosive diarrhea (nowadays this does not occur, thankfully) and the same moral cover as a poisonous arachnid. Logically, then, society must feel that HIV and by extension the HIV-positive are deserving of sanitation, neutralization, and eradication. 
 
If this were not true, then we would not be willing to scare the hell out of every young thing walking around with a mucous membrane. Yet because this is in fact the approach of a widespread HIV infrastructure more identifiable as something from the age of Clinton instead of Obama, we must confront the problematic nature of some approaches in HIV prevention.
 
Now, thankfully, such a thing as treatment as prevention exists. That is, because I take one pill, once a day, with no side effects whatsoever personally, and I maintain an undetectable viral load (less than 20 copies of HIV RNA in every milliliter of my blood), I am statistically and practically prevented from transmitting HIV even to men with whom I have bareback sex. In addition to this, my body now enjoys the trauma of only cigarettes and too much caffeine rather than the inevitable tragedies of Kaposi’s sarcoma, bird flu, shingles, and every other malady common in those at AIDS levels or those who, for whatever reason, do not treat their HIV. 
 
Basically, HIV has had a more profound social and cultural effect on me than it has in the biological sense because I adhere to my medication precisely as described. Obviously, then, even the whisper of a death sentence is ridiculous and unnecessary. Yet this “it’s not a death sentence” is the exact refrain newly diagnosed folks hear from their compassionate friends and, in the worst cases, misguided so-called HIV experts, typically now-reformed former partiers who are nothing but envious of those HIV-positive folks still living and having a good time. This is patently obvious in the sneering concern-trolling these alleged professionals maintain whenever their colleagues mention the efficacy of the TasP model, which, at least according to The New England Journal of Medicine, has the same efficacy surrounding HIV prevention as condom use. Curiously, I rarely if ever hear mention of peer-reviewed scientific academic articles in the arguments against PrEP and TasP. 
 
Instead, I hear (or see) nothing more than incessant personal anecdotes, moralism, and finger-wagging. 
 
The fact of the matter is that we cannot prevent HIV by implying it is a spooky, scary, fatal, abstract thing and then, out of the other side of our mouth, pat the hands of the newly HIV-positive by telling them “it’s not a death sentence.” No wonder the newly diagnosed are terrified, after years of hearing it is. 
 
We can, however, apply a multipronged, sex-positive, personal decision–based model of TasP, PrEP, condoms for those who wish to use them, and health services targeting the whole well-being of individuals living with or statistically likely to seroconvert to HIV. More to the point, the finger-wagging going on right now in the HIV treatment and prevention industry toward TasP and PrEP should be directed, rather, at the more dated and sex-negative one- trick-pony approach that simultaneously and paradoxically couples “it’s not a death sentence” with “if you have sex without a condom, you will die.”
 
Until we scrap both of these pernicious approaches and phrases, we’re going to sustain a cycle of fear and inevitable self-harm; and until we embrace the totality and naturalness of human behavior—even drug and sex behaviors—we will see HIV infections stubbornly rise across key demographics.
 
Josh Kruger is a writer and editor in Philadelphia. His regular column, The Uncomfortable Whole, explores what, if anything, is normal today in America and runs in Philadelphia Weekly, that city’s largest alternative weekly newspaper.
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