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April / May 2010
Prevention for Positives
by Bill Strubbe
Is it sensible (and sensitive) to hold HIV-positive people solely responsible for stemming new infections?
Jonathan Klein resents the assumption that positive people like him are exclusively responsible for exacerbating the HIV epidemic. And he questions whether HIV-positive people should be the focus of prevention efforts such as the Centers for Disease Control and Prevention’s 6-year-old program Prevention for Positives (P4P).
“It’s pretty clear [to me] that most new transmissions are coming from people who assume they’re negative,” says Klein, who runs the gay travel agency Now Voyager in San Francisco. “The vast majority of people who [know] they’re positive take steps to eliminate or at least greatly reduce the chance they’ll transmit the virus.” (Research backs this up.)
Richard Wolitski, PhD, deputy director at the CDC’s Behavioral and Social Sciences Division of HIV/AIDS Prevention (and himself living with HIV), says P4P is not intended to be a slap in the collective face of positive people. “We recognize that the majority of people with HIV perceive themselves as having a responsibility for preventing HIV transmission,” Wolitski says. “Prevention for Positives is one part of a comprehensive strategy, and both HIV-positive and negative people play an important role.”
Many positive people have never heard of P4P but practice their own versions, including using condoms, practicing serosorting (having sex only with people of the same HIV status), keeping viral loads undetectable—and disclosing their status. “If I meet someone and it looks like we’re going to have sex, I say something,” says Blaine Stanford, also of San Francisco. “I meet most people online, and all my profiles say ‘poz,’ so I rarely [have to] talk about it.” But Dave Mahon, another positive San Franciscan, says, “There’s probably a judgment call each time. I guess we all make up our own rules as to how much risk is involved for yourself and the other person.”
Wolitski thinks positive people could use some backup in making these choices. “When I was first diagnosed,” he says, “issues such as how to disclose and how not to transmit HIV to anyone were big for me. And our research shows that these are important issues to the vast majority of people living with HIV.” So the CDC funds four P4P programs—practiced by AIDS service and community-based organizations—to help people develop strategies for disclosing their status to family, friends and partners.
One program, Healthy Relationships, involves five 120-minute sessions. Working in tandem, someone living with HIV and a mental health professional lead workshops, teaching participants problem-solving and decision-making skills to help them navigate safer sex and disclosure. Another program is Willow (Women Involved in Life Learning from Other Women), co-facilitated by women with HIV. Partnership for Health trains health care providers to integrate prevention messages into every clinical visit, and Together Learning Choices (TLC) puts 13- to 24-year-olds in small, interactive group settings where they hone their abilities to set goals, solve problems, communicate assertively and negotiate safe sex.
Before HIV combo therapy became available in the mid-’90s, the CDC focused on medical treatment of positive people, paying little attention to their sexual relationships and struggles with preventing transmission. In 2001, with positive people living longer and being more sexually active, the CDC turned to prevention strategies. Wolitski says P4P evolved from community programs around the country—weekend retreats in Atlanta, support groups in San Francisco and others—that were helping newly diagnosed people in precisely the ways P4P is doing now.
Forty-eight-year-old Tony Mills, MD, remembers when HIV prevention was directed mostly at negative people. Posters touting safe sex were plastered on nightclub walls and condoms placed in toilet stalls—and HIV-negative people were the ones urged to use them. “Then,” he says, “the CDC [developed] the perspective that maybe we should be targeting people who are positive, getting them to take responsibility and have safe sex.”
Mills, who is HIV positive and served on the board of the American Academy of HIV Medicine, helped produce a variety of P4P tools, including a video to teach health care providers how to talk to their HIV-positive clients about safe sex and disclosure.
Mills discounts the notion that P4P encourages doctors to pry into their patients’ sex lives and wag fingers at them. When he sees new HIV patients, Mills says, “I take cues from them, playing off what they tell me about themselves, and parlay that into a discussion rather than a lecture. I focus on trying to get my patients to be as healthy as possible, not [on pressuring them] about protecting society, which could certainly raise people’s hackles.”
Mahon says his doctor has never asked him about safer-sex practices, but he would view such a discussion simply as part of the doctor’s job in helping keep him healthy. Stanford agrees that it is “what a good doctor should do, but I don’t think they should nag or bang someone over the head.”
But Klein, who has been positive for at least 20 years, feels different. “My doctor has never given me that kind of lecture, and it’s a good thing, because I’d jump down his throa t. It might be part of a doctor’s job to disseminate information about HIV transmission, but they shouldn’t be telling patients what degree of risk is acceptable. That’s something each person needs to decide for him or herself.”
Mills hasn’t received a negative response to his safe-sex discussions—perhaps partly because he is openly gay and HIV positive. “I try to create an environment where people can be open. Sometimes on the first visit they tell me things that they have never talked about before—sometimes more than I want to hear,” Mills laughs. “But that’s fine because if they’re ever in a crisis—whether it’s unsafe sexual practices, drug use, the possibility of reinfection or superinfection—they know I won’t judge them.”
And yet, Klein stresses, focusing too much effort on positive people could misdirect our limited prevention efforts and funding. After all, in which scenario is a negative person more at risk for HIV: having safe sex with a positive person, or having unsafe sex with someone who says he’s negative but hasn’t actually been tested?
Search: infections, Prevention 4 Positives, P4P, mental health, prevention
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comments 1 - 11 (of 11 total)
Charles, Minneapolis, 2010-05-19 06:08:16
Lets stop talking about this dumb opinion and focus on a cure for HIV/AIDS not a dumb vaccine; thats your answer to the problem. Gay culture itself is sex-based in my opinion, how are you suppose to stop infection; when gay culture dont have meaning anymore. When you see a changed in Gay media such as magazines, books, tv shows than you will see a change in HIV rates in the gay community.
Olympic60, Short Hills, 2010-05-09 07:07:19
The premise that hiv+ people are "soley" responsible for the spread of the virus presumes personal responsibility is only a requirement for positive people. Of course we should be educated on transmission and practice prevention diligently, but prophylatics are made for the rest of population too. This blame assertion is another example of the discrimination that + people must confront everyday. At least this one is easy to dispel.
Bradley, Canton, 2010-05-06 23:58:45
Recently, I released How To Share Your HIV Diagnosis with Family, Friends and Sexual Partners, which can be obtained at positivelightforpositivelivingbooks.blogspot.com
I wrote this book to empower, relate, educate and build confidence in people with HIV. For some, being positive isn't as challenging, but for others it is. And for those that find it so, they need effective tools to give them the self empowerment to fight, not just fear but the stigma that comes from being HIV positive.
PozInMaine, Maine, 2010-04-27 09:32:17
My doctors job is to tend to my health. My sex life is none of his business. Discussing it with him only fuels scapegoating and stigma. I have changed doctors over this intrusive questioning.
Frederickgnp, Tampa, 2010-04-27 09:04:45
I agree about all talking about sex to include Parents, Aunts, Gran Parents, Friends , Teachers, Preachers and yes, Doctors and
Nurses for lets all be honest about who we our and to include Sex/HIV conversations at the dinner table. Open and Transparent conversations about romance, love, committment and good old fashion SEX. It would be great if the conversation was to include, Condoms, HIV Rapid Screening KITS, Pre Exposure Treatment Options, and yes , just plain, NO to sex, if one chooses.
Cala, , 2010-04-25 03:12:58
Yes, I thinks should ask...every Doctors appointment, when the nurses ask is you are having sex, what type of protection do you use..and even ask if there are any questions....
FREDERICK WRIGHT, TAMPA, 2010-04-23 23:03:23
I Think "out of touch" is right on track. Some say "HIV Cases in total are in the 14 millions for 2009. The super-infection or re-infection is a fear message from the out of touch HIV policy machines for every person is different and creates a unique HIV strain for their DNA, so using fear to not deal with sex and this illness is an old message. Hence, it is clear why a HIV Rapid Screening Kit are not available for sale over the counter, for the policy makers do not want people to know the truth.
Jack, San Francisco, 2010-04-22 12:40:42
No it is not sensible or sensitive to hold HIV positive people solely responsible for stemming new infections. Unless you also make us solely responsible for the budgets, programs, and services for all organizations and laws. I did not invent AIDS and I do not pass it along. I wish "POZ™©®" magazine was an advocate and not just a vehicle for these sort of mindless machinations. And why is it even necessary to include reinfection and superinfection in this discussion? Ugh.
grace, usa, 2010-04-22 11:08:09
The CDC is out of touch with reality, still asking # of sexual partners, rather then # unprotected. It just takes 1. Ask all the married women with HIV. I resent the assumption that people who know their status are responsible for spreading the virus. New guidelines to 'hit them hard and early' with meds is based on this assumption, and not on looking at the health of the consumer, and the long term implications of going on meds early, which we still don't know the toxicity impact of.
Frederick Wright, Tampa, 2010-04-21 11:35:47
This gentalman has some good points. However the estimate of the CDC thinks 250 thousand people or double those numbers in America do not know they are HIV positive. This makes me wonder who is Holding up HIV Rapid Screening kits over the counter for sale to the public? Rapid HIV screening kits are now 12 years old and still no OVER The Counter HIV KITs avaiable to the public. I ask all of you, who's head is stuck in the sand? Is it the HIV community, CDC or the Leaders in HIV's NON-PROFITS.
Mark S. King, Ft. Lauderdale, 2010-04-21 08:23:55
comments 1 - 11 (of 11 total)
I couldn't agree more with this approach. Those of us with HIV MUST bear a higher responsibility to prevent transmission (life ain't fair, sorry). For that matter, sexually active HIV negative folks should be "lifted up" more for staying that way. Too often, becoming infected is seen as a booby prize filled with perks and attention. Anyone staying negative deserves a freaking medal.