In the movie Outbreak, there is a touching scene. Rene Russo is in a hospital bed, ill with a deadly virus that is highly contagious through casual contact. Dustin Hoffman, in love with Russo, is covered in virus-proof rubber and plastic gear. His head is enshrouded in something that looks like it's out of Star Trek. Russo, desperate for human touch, runs her hand along the protective plastic of Hoffman's helmet. Hoffman, with tears in his eyes, removes his helmet to allow her to touch his face and, consequently, exposes himself to the deadly virus.
This poignant scene from the movie -- an emotional act of love, of faith in the soon-to-be-released vaccine and the recognition of the need for human contact -- is a metaphor for a real-life drama played out every day in the real world, in a world with AIDS: Two people, risking exposure to a dangerous virus in order to have physical contact. But what is romantic and beautiful in the movie is demonized in real life. When a positive person has "unsafe sex" with another, according to ever-changing and ever-challenged definitions of what is safe and what is not, it is called murderous. No consideration is given to the complexities of the circumstances.
I do not advocate unsafe sex. But any successful prevention effort must recognize the realities of intimacy, desire and risk in a practical way for all people -- positive and negative. And not just in the movies. We can start with the truth.
Truth #1: The hottest part of safer sex is the posters promoting it. People do not adhere, for long periods of time, to absolutist safer sex guidelines. Sex -- and varying levels of unprotected sex -- is here to stay.
Truth #2: Oral sex poses a fraction of the risk inherent in receptive anal intercourse. That's why no one -- and I mean virtually no one -- uses condoms for oral sex. Most people find the risk of transmission by way of oral sex, regardless of the conflicting data, to be acceptable.
Truth #3: The risk of transmission between two partners of the same serostatus is different than between two partners of differing serostatus. Potential reinfection, even with different strains of the virus, is an acceptable risk for many positive people. Many negative people believe they can trust their partners to be truthful or monogamous.
Prevention efforts that do not acknowledge the truths above and the realities of human need are doomed to failure. Absolutist standards perpetuate self-defeatism and, ultimately, riskier behavior. Have we stopped transmission by intravenous drug users by telling them to stop using drugs? Of course not. Yet to this day, needle exchange programs have not increased drug use but have been incredibly successful in slowing transmission.
We know what makes people buy Coca-Cola, we know why people watch MTV, but we don't know what makes otherwise intelligent people engage in highly risky sex. Until we figure that out, we need to focus on programs that accommodate relative risk. Relative risk prevention guidelines are not an endorsement of unsafe sex but are, similar to needle exchange programs, an effective method of slowing HIV transmission. They give informed guidance to the many who are not going to adopt the absolutist safer sex standards.
In the perfect world, such as in the movie Outbreak, a cure is just around the corner, surfacing in time for the final roll of credits. In the real world, it isn't close and, for some of us, the final roll of credits is getting closer by the day.
Let's deal with the truth, get real and slow transmission.