Paul Curtis Bellman, MD, is a physician whose private practice in Greenwich Village, New York, has specialized in caring for HIV-positive patients since 1986. Dr. Bellman is a board certified internist and currently an associate attending in the Department of Medicine at St. Vincent’s Manhattan and a senior lecturer in the Department of Immunology at Weill Cornell Medical College in New York. He is a 1982 graduate of the New York University School of Medicine and has been involved in the clinical care of HIV-positive people since the epidemic began. Bellman actively participates in clinical research as well as the clinical practice of HIV medicine.

Note: The contents of this essay should not be construed as specific medical advice regarding the treatment or prevention of HIV. If questions arise regarding treatment or prevention based on this essay, please consult your physician. This essay is also not intended to suggest that carefully considered current safe-sex guidelines regarding HIV prevention such as those available from the Centers for Disease Control and Prevention (CDC) website should be ignored or changed as a result of some of the research on HIV transmission reported on here. Please follow current safe-sex guidelines carefully until, and if, revisions to those guidelines are made.

In his victory speech on election night, President-elect Barack Obama said, “If there is anyone who doubts that America is a place where all things are possible, who still wonders if the dream of our founders is alive in our time, who still questions the power of democracy, tonight is your answer. It’s the answer…told by the many…who believed this time must be different because their voices could be that difference. It’s the answer spoken by young and old, rich and poor, black, white, Hispanic, Asian, Native American, gay, straight, disabled and not disabled.”

As a doctor who has treated people living with HIV/AIDS since the early ’80s, it is my hope that when Barack Obama is inaugurated, he will add to the above list: “and HIV-positive and HIV-negative people.” Because the time has come for HIV/AIDS to be a nationally recognized epidemic, and it is my great hope that the new administration, led by Barack Obama, will bring a new day of reckoning to our fight against HIV/AIDS in America.

In his speech, Obama claimed that the very act of electing the first African-American president was itself an indicator of change. He said, “It’s the answer that led those who’ve been told for so long by so many to be cynical and fearful and doubtful about what we can achieve to put our hands on the arc of history and bend it once more toward the hope of a better day.… It’s been a long time coming but because of tonight, because of what we did on this day, change has come to America.”

Certainly on the occasion of this 20th World AIDS Day, we need a world of change. As the number of people living with HIV globally tops 30 million and as we discovered this year that the HIV infection rate in the United States is 40 percent higher than previously estimated, it is clear that our approaches to preventing HIV are not working optimally. It is my belief that the key to stopping AIDS lies in the destigmatization of people living with HIV—and a key to that lies in illuminating the fact that people on treatment are less infectious than is generally understood.

As a physician who has worked on the front lines of the HIV/AIDS epidemic in New York City since the earliest days, I’ve got some very good news to share. There has been new progress in medical treatment for HIV-positive people. The goals shared by doctors and people living with HIV—for HIV-positive people to have a normal life span and a great quality of life—are increasingly possible.

Recently FDA-approved medications are proving to be highly effective in treating what were previously very difficult to treat drug resistant HIV-positive patients. This development is one of the most important and helpful in HIV treatment since antiretroviral (ARV) therapy was first introduced 20 years ago. It means physicians can now treat almost every HIV-positive person who needs medical care.

In 1996, we experienced the first major breakthrough in treatment: a development known as highly active antiretroviral therapy (or HAART). Using a combination of certain medications (or “cocktails”), we saw dramatic improvement in patients whose lives previously could not have been saved.  

However, over the years since, a significant number of patients developed drug resistance to their initial HAART cocktails or certain combinations of medications. To address this, new ARV medications were developed. However these new meds were often reformulations within existing classes of drugs and they were too few and too ineffective against drug-resistant virus to help some patients.

As a result, we have needed either more potent drugs with different mechanisms of interference with viral replication or drugs that remain effective even when some degree of drug resistance has been developed to other drugs in that class.

Fortunately, today, both types of new drugs are available and the results are extraordinary. Even the most difficult-to-treat, multi-drug-resistant patients in my practice are responding to drug cocktails utilizing these new medications. The way some of my sickest patients are rebounding to health reminds me of the days when the lifesaving powers of HAART first became available.

In addition to our improved ability to save the lives of most people living with HIV is the impact that being able to lower people’s viral load can have on our ability to stop the spread of the disease Attaining an undetectable viral load is an important goal of HIV therapy. This result doesn’t only mean that an HIV-positive person is more effectively treated; it also means he or she is theoretically less contagious. It appears that effective treatment that reduces the viral load of HIV positive patients to undetectable levels for more than six months (and if no other sexually transmitted infections are present) severely limits the chance that HIV might be transmitted through sex from an HIV-positive person to an HIV-negative one.  

If this finding is correct, then its proper incorporation into HIV prevention strategies could have an enormous impact in reducing the incidence of new HIV infections. This finding could potentially transform the landscape of the HIV/AIDS epidemic globally in as positive a way as effective treatment has.

The discovery of the strong link between a person’s viral load and his or her level of infectiousness was made by a Swiss governmental commission comprising a team of highly regarded HIV experts led by Bernard Hirschel, MD. He led an investigation about new HIV infections and the conditions under which they occur. Dr. Hirschel found that no new infections were observed in the HIV-negative partners of HIV-positive people when the HIV-positive partner was on effective treatment as measured by an undetectable viral load. It didn’t matter whether the sero-discordant couples practiced safe sex. According to Hirschel, effective treatment of HIV-positive people—and not whether or not they practiced safe sex—was the most reliable means of stopping HIV transmission.

Hirschel advised that his finding applies only to monogamous, sero-discordant couples in which the positive partner has been on fully effective treatment for six months as defined by an undetectable viral load. Furthermore he/she must be fully adherent with his or her treatment. Hirschel urges that strict safe-sex precautions be followed in all other situations. He also acknowledges that his assertion is based exclusively on studies of heterosexual couples and that further study is required to determine whether the same outcomes would be seen in gay couples.

Hirschel’s findings have raised questions about whether effective treatment for HIV could serve as a form of prevention. Prevention strategies based on the notion of effectively treating HIV-positive people to the point that they are noninfectious (or at least minimally infectious) would, of course, have to stress compliance and monogamy. And regardless of whether a “treatment-as-prevention” approach were employed, safe-sex education would remain a cornerstone of HIV prevention efforts as the majority of HIV-positive and negative people do not find themselves in monogamous relationships with someone whose viral load has been immeasurable for six months or more and who has no other sexually transmitted diseases and who is perfectly compliant with his or her treatment regimen.

Still, while perhaps the majority of people might not meet the criteria necessary for being able to forgo safe sex in a serodiscordant heterosexual relationship, I believe it would help people understand the necessity for strict safe-sex precautions in the many situations in which the conditions for non-infectiousness or extremely low infectiousness can not be met. And I believe most people would more cheerfully and consciously be more adherent to their medications if they understood the potential for treatment to bring about a state of sexual non-infectiousness.

Implementing a comprehensive prevention strategy based on Hirschel’s findings would require improved access to testing and effective treatment. People would need to know their HIV status and be comfortable communicating it to potential sexual partners before having sex. And those who are HIV positive would need to be able to access and afford treatment for HIV.

It also requires that public health authorities further evaluate and if appropriate endorse changes in current safe-sex recommendations and then carefully educate the HIV-positive and HIV-negative public about those changes. Current guidelines regarding how to practice safe sex can be found on the Centers for Disease Control and Prevention (CDC) website. These guidelines should be strictly followed.

For all of these things to happen—for people to be willing to get tested, get treated and disclose—HIV/AIDS needs to be destigmatized so that people are not afraid to face the disease and ask for support and care if they have it.

Many HIV-positive and negative people, subconsciously fear the transmission of HIV. The very possibility that HIV-positive people may not be infectious (sexually or otherwise) could itself be the foundation to remove the enormous burden of shame, guilt and stigma that HIV-positive people suffer daily.

Destigmatizing HIV/AIDS must be an essential piece of any prevention strategy. A comprehensive public health education campaign should be launched to destigmatize HIV-positive people—and the disease itself. Historically, HIV prevention efforts have been based on safe-sex or abstinence-only messages. This approach has led at best to a stabilization of the HIV infection rate—but it has not succeeded in reducing the number of new infections even though HIV is preventable.

Interestingly, the rate of new HIV infection is climbing most dramatically in communities in which stigma, prejudice and marginalization are particularly intense. It is well known that fear and loathing around HIV in America are barriers that interfere with HIV testing and appropriate medical care and, as a result, drive new infections. Stigma also increases the likelihood that proper HIV care will be delayed until serious medical complications force people into care—sometimes tragically too late.

Imagine the impact on HIV prevention efforts if almost every single HIV-positive person were treated properly for HIV and, as a result, became noninfectious? Imagine if more people at risk for HIV were comfortable getting tested and had access to testing centers and follow-up care? The majority of new cases of HIV are the result of the virus being transmitted from one person to another with neither partner knowing that one partner is HIV positive. Imagine how encouraging it would be for the countless number of people too frightened to be tested or treated to learn how effective HIV treatment has become—and, most important, that the treatment not only saves lives but also dramatically reduces the risk of HIV transmission.

Imagine for a moment the way the HIV community could be healed if it were widely known by everyone—positive or negative—that having the virus does not intrinsically mean that one can sexually transmit HIV.

To date, the CDC has taken a cautionary view of Hirschel’s assertion. The CDC issued a statement that said, “There are no scientific data that the risk of transmission is zero. The CDC underscores its recommendations that all sexually active people with HIV use condoms consistently and correctly with all sex partners.” While this is reasonable, I hope the CDC recognizes the potential significance of rendering the HIV community non-infectious and makes a commitment to further research whether Hirschel is correct and, if so, then quickly integrate his findings into prevention approaches.

Renowned HIV public health experts such as Ronald Stahl, PhD, MPH, and Julio Montaner, MD, FRCPC, FCCP, are talking about prevention strategies based on reducing the community viral load by identifying and treating effectively the greatest portion of HIV-positive people possible (keeping in mind that HIV treatment is not necessarily indicated for every HIV-positive person).
They believe that the more HIV-positive people who are effectively treated within a community, the less likely it is for new HIV transmissions to occur. This is a viable and important approach that does not depend on Hirschel’s assertion being 100 percent true in every instance. There is ample evidence that HIV-positive people with low or undetectable viral loads are at the least much less infectious, if not entirely so, therefore reducing the odds that they will spread the virus, even if they don’t disclose or practice safe sex.

The concept of reducing a community’s viral load in order to reduce transmission is an intriguing concept that already has some scientific support from a study of HIV-positive and negative people in British Columbia. Its more generalized success in other communities and other countries depends upon effectively treating the greatest proportion of HIV-positive people possible.

The World Health Organization (WHO) just published an analysis that suggests that in countries such as South Africa, where the virus is rampant, widespread HIV screening—coupled with immediate treatment for those who test positive—could “rapidly reduce transmission to the point where elimination might be feasible.” A paper recently published in the British Medical Journal The Lancet reported that most HIV-positive South Africans are unaware of their status and that fewer than half of those who should be getting treatment under current guidelines are receiving it. The report claims: “If annual, voluntary HIV testing for everyone 15 [years of age] and older were started immediately and drug treatment initiated for those who tested positive, transmission [rate] would plummet to less than one new case per 1,000 people in less than a decade. Currently, 15 people per 1,000 are newly infected with HIV every year in South Africa.” Implicit in this WHO analysis is the assumption that effectively treated HIV positive people are at least minimally sexually infectious or sexually noninfectious.

There is an important caveat to the approach of “treatment as prevention.” Currently, it is not medically advised that every single HIV-positive person be placed on treatment. Many patients with high CD4 cell counts remain healthy for years—sometimes even for decades—without treatment. It needs to be shown that the communal benefit of earlier treatment in many patients who wouldn’t currently be advised to start treatment under current treatment guidelines outweighs the toxicity of the medications in individual patients.

I believe as we continue to learn more about drug toxicity and how to prevent it and manage it when it occurs, our insight will allow us to explore earlier treatment for more HIV-positive people. That will have the secondary benefit of reducing the community’s viral load and the incidence of people who newly acquire HIV. Some of the new drugs that are helping overcome the problem of drug resistance appear in clinical practice to be less toxic and better tolerated than older drugs.

Drug toxicity is not the only factor that can reduce the number of people on treatment. Poverty, discrimination, lack of resources and inefficient use of health care resources can and do limit our ability to best treat our patients. In addition, as I mentioned before, so does an atmosphere of blame, shame and fear.

I strongly believe that we will see a change in the way people view those living with HIV once the general public understands that HIV-positive people are not intrinsically infectious and that almost every HIV-positive person can be treated effectively and thus be noninfectious or at least minimally infectious. The notion of HIV-positive people being “clean and safe”—in other words, “noninfectious”—can be used as a powerful tool to destigmatize the disease and HIV-positive people once and for all.

Historically, HIV-positive men and women have been marginalized, stigmatized and even actively discriminated against in society. This impedes the ability of HIV-positive women and men to achieve the “dream of our founding fathers” as President-elect Barack Obama so eloquently put it. People living with HIV have experienced misery, social isolation, fear, blame and shame. Although progress has been made in educating the public about HIV/AIDS, ignorant and hurtful ideas persist. I believe that by reviewing and understanding how such outdated and wrong ideas arose historically we can help put them where they belong—in the past.

The first term used to describe HIV/AIDS when it first was recognized in 1980–81 was GRID for Gay-Related Immune Deficiency. At that time it was not yet known how GRID was transmitted, but it was indelibly imprinted in the minds of the American public that it was “gay related.”
Although it seemed early on to be most clearly linked to gay sex, some people were afraid that even coming into casual contact with a gay person might put them at risk. In addition, the link to gay sex itself would prove to be highly prejudicial coming at a time when the American public, due to gay liberation in the late ’60s through the late ’70s, was just awakening to the awareness of our diversity including our many gay, lesbian, bisexual and transgendered members.

Unfortunately, the appearance of GRID in the early ’80s would reinforce negative stereotypes about gay men and gay sex, including but not limited to the idea that sex between men was some how immoral or even that it intrinsically caused GRID.

It was just a short step from that view to the idea that gay men were to blame for the disease itself. In addition, even when the specific cause of GRID was identified and the modes of transmission better understood, the fears of the American public were constantly stoked, leading many to worry that homosexual men would ignite an epidemic of heterosexual AIDS.

Around that time it was realized that GRID did not only occur in gay men.  In fact, it was next given a new name or at least a new acronym in the medical profession. It was called “the 4 Hs” or derisively “the 4 H club.” Each of the four Hs stood for a risk group: homosexuals, heroin addicts, Haitians and hemophiliacs. The scarlet letter was an H.

The general public was afraid of people who could be identified as belonging to one of these H groups who were marginalized and discriminated against even before the AIDS epidemic. Simply put “regular” people were terrified they could themselves contract AIDS by associating with these people in the at-risk groups.

In 1984 the HIV virus was identified and the means of transmission was more clearly defined as being sexually transmitted or transmitted by blood contact by a transfusion or a shared needle. A blood test known as an HIV antibody test could tell who had been exposed to the HIV virus. It was widely assumed that exposure to HIV meant that AIDS, if not already present, would soon develop. Regular people were relieved somewhat but were still terrified of associating with HIV-positive people or even people who could be identified as a member of one of the at risk H groups.

Today in America an increasing number of new HIV infections are occurring in another at risk group: women, particularly minority women who lack access to health care and for whom an HIV-positive status is highly stigmatizing. In fact a recent Harris survey (sponsored by the Foundation for AIDS Research, amfAR) of the attitudes of Americans toward HIV-positive women shows a shocking level of ignorance including the idea that HIV-positive women somehow did bad things to become HIV positive. Indeed the ignorant attitudes regarding HIV-positive women today are quite similar to the attitudes towards gay men in the early ’80s.
It is time to correct broadly held misconceptions. For example, the Harris survey also revealed that the majority (86 percent) of the American public believes that HIV-positive women should not have children. More Americans believed that women with schizophrenia or the congenital condition Down’s syndrome were more fit to be mothers than HIV-positive women. In fact HIV-positive women who receive medical care are quite capable of giving birth to healthy children, and they can expect to be capable and healthy mothers who can expect to live to be grandmothers.

It’s time to leave behind these stigmas, prejudices and taboos associated with HIV and replace them with a clear understanding of what it means to be an HIV-positive person in 2008. 

With proper medical therapy, HIV-positive people can almost always be prevented from developing AIDS. It is crucial that the public understand that when someone is “HIV-positive” it does not mean he or she has AIDS. AIDS signifies a severe level of immune deficiency that usually only develops today in HIV-positive people who do not get timely and/or proper medical care. The public must understand that AIDS itself can often be effectively treated and that AIDS patients with treatment can usually become healthier HIV-positive people who no longer have AIDS. The public must also understand, however, that some HIV-positive people do have AIDS and that they require ongoing public support and services.

The significant advances we are seeing for people living with HIV should and must continue to translate into better understanding about what it means to be HIV-positive and into better lives for HIV-positive people. Progress in treatment for HIV should inform the way we approach prevention and change the general public’s view about people living with the virus for the better. Progress should also enable HIV-positive men and women to more participate as fully empowered and respected participants in society—in the workplace, in their families and in their love lives. Progress for HIV-positive people is good news for HIV-negative people in our society as well.

Using the term “HIV infected” to describe an HIV-positive person has become be embedded in our language in a way that fosters prejudice and shapes how people think and feel. “Infected” as in “HIV infected” conjures the word “infectious” and that associates to a threat to others and for others a danger to them. Some people in society are still afraid of HIV-positive people, and it is no wonder that when HIV-positive people sense that fear they suffer devastating emotional and life consequences.

Humans are very sensitive to how we are perceived by others and sometimes shut down all together when we sense moral judgment, criticism and fear. We are also sensitive to other’s feelings and often need to protect others from our own truths. As an example, I have observed that some of my HIV-positive patients are afraid to tell family members about their HIV status to protect their loved ones from what they fear will be emotional suffering as a consequence of that disclosure. The result of this sensitivity when it blocks communication is that it, ironically, can increase everyone’s suffering.

People have both a conscious and an unconscious mind. At times, we may seem to be consciously managing to be okay, but inside we may be hurting. It requires a lot of loving support at an individual as well as on community and cultural levels to heal this kind of hurt.

From my vantage point as a physician who is privileged to care for and get to know many HIV-positive men and women, I have observed that a diagnosis of HIV is, for almost every one of my patients, a trauma to their individual psyches and a shock to their souls. It is a shock than can have after shocks, and the trauma caused by hearing you are HIV-positive can compound challenges and traumas that pre-date an HIV diagnosis. Obviously the impact of this trauma differs from person to person.

I have found that the time at which a person was first diagnosed as HIV positive is connected to the impact of that news. HIV-positive people diagnosed before 1996 when HAART first became available are likely to be more impacted by the fear of illness and death than a person diagnosed more recently. Greater knowledge about current advances in HIV treatment also helps considerably. But even well-informed, newly diagnosed HIV-positive people with a prognosis for excellent health can be greatly impacted by the fear of getting sick—perhaps to a greater degree than they might be consciously aware of.

Before HAART, an HIV diagnosis was traumatizing because of its very real and potential devastating consequences of illness and death. When a lack of treatment options meant than a diagnosis of HIV often led to a premature death, even belonging to a high risk group for HIV—even in the absence of a test result—was equally terrifying and traumatizing.

Reducing the trauma of an HIV diagnosis is another key component in our being able to successfully stop AIDS.

Trauma is when it’s so bad that one can’t be present in the experience of it. Coping mechanism such as shutting down emotionally, chronic anxiety and alcohol and drug abuse arise in an attempt to escape its impact. It is highly traumatizing to believe as a consequence of being HIV positive one is at some level a threat to others and for others a danger to them. It’s why social support, individual help and education at an individual and societal level about HIV are so important to heal that wound.

In fact HIV-positive people only place negative people at risk for HIV as a result of specific unsafe sexual practices or a sharing of drug paraphernalia.  This most often occurs today as it did 20 years ago due to psychological distress and poor choices made in an atmosphere of fear, stigma and marginalization that inhibits the discussion and disclosure necessary for risk reduction.
I believe what is most of all necessary to prevent new HIV infections is an atmosphere of concern, respect and inclusion that facilitates discussion, disclosure and importantly HIV testing that includes real education and fully informed consent. Many HIV-positive who transmit HIV do not even know that they are HIV positive and/or do not seek the appropriate medical treatment.

Recently a well-known writer on HIV and gay-related issues told me that one of my colleagues, a well-regarded and excellent HIV doctor, told him that when he sees new HIV positive gay patients today he chastises them for not being more careful. If so, I disagree with his approach to the clinical counseling of a newly diagnosed HIV-positive person. My approach would be to be supportive and understanding. Ironically, I have observed that recently infected HIV-positive patients already feel somehow to blame for their HIV diagnosis. My goal is to help them move past the self-blame and shame that can often lead to depression and/or chronic anxiety in newly diagnosed people. But the experience of my patients resonates with the general sentiment in our society as reported by the Harris survey cited earlier.

Our current public health authorities can do more to identify and address stigma as a driving factor in the incidence of new infections and in reducing the quality of life of HIV-positive people. The stigmatization of HIV-positive people comes from the combination of all these wrong ideas—that HIV-positive people did bad things to get infected, are somehow to blame for being HIV positive and threaten to infect other currently HIV negative people.
In this mix of ignorance and fear are misconceptions and prejudices about gay sexuality and sexuality in general. They are part of the American cultural landscape and thus part of the psychological reality conscious and unconscious of HIV-positive and HIV-negative people.

Public health authorities can advantageously use the news that significant progress has been made in HIV treatment and that HIV-positive people on effective treatment may be sexually noninfectious or at the least much less infectious. This could serve as an unprecedented opportunity to educate and re-educate the general public in America and globally about the reality of HIV.

Of note is the fact that 27 years into the global HIV epidemic and 12 years after effective treatment was first available for many HIV positive people neither the CDC nor NIH has completed a study to see whether it is true that HIV-positive people on effective treatment are sexually non infectious.

The NIH has just begun a study designed to determine how immediate treatment for HIV patients with HIV-negative partners affects both the risk of transmission and the health of the HIV-positive partner. The study is scheduled to run through 2014. According to the doctor leading the study, it may provide the clearest answer to the question at the center of debate: Can we treat our way out of the epidemic?

I am glad the NIH is finally conducting this well designed study—something it should have done long ago. But five years seems a long time to answer a question that I believe we should have learned a long time ago. It seems likely that the answer to the question of whether or not we tcan treat our way out of the epidemic? is almost certainly yes. The better and more difficult to answer questions are: Will we treat our way out of the epidemic. And if not, why not? I hope another five years are not wasted until the studies results are available to more aggressively implement a more comprehensive strategy.

Recent research has suggested that some HIV-positive men who consistently have undetectable viral loads in their blood may have detectable virus in their semen. Detectable virus in the semen may indicate that these men are potentially sexually infectious. This would mean that some men who might be considered sexually noninfectious on a blood test may indeed be sexually infectious.

One study reported that 5 percent of men who had undetectable viral loads had detectable virus in their semen at least on one of several occasions measured. Another fascinating study reported that some HIV drugs poorly cross the blood testis barrier and some drugs cross it well. So it may be necessary to be on certain HIV drugs or drug cocktails to eliminate HIV from the semen. It seems to me in any case that while the bar may have to be raised to include an undetectable virus in the semen to declare someone sexually noninfectious the concept remains sound. Similar studies of course need to be performed in women to assess sexual infectiousness.

In my own clinical practice in Greenwich Village, I have seen in the past several years a number of gay men as new patients who had recently tested positive despite attempting to adhere consistently to current safe-sex recommendations. In fact, the only risk factor for a number these individuals, some of whom had never engaged in protected or unprotected anal sex, was unprotected oral sex. Oral sex is categorized as safer sex. It is advised that condoms be used for oral sex, but in practice that safe-sex recommendation is rarely adhered to.

What I found interesting and potentially relevant to the task of preventing new HIV infections is that these individuals who recently tested HIV positive engaging in oral sex rarely if ever inquired about their prospective partner’s HIV status or, if positive, their therapy status. Although it has not been conclusively demonstrated, it is likely that oral sex between an HIV-positive man on fully suppressive ARV therapy indeed carries with it a negligible risk of HIV transmission. It is likely that an HIV-negative man faces a much greater risk with an HIV-positive man either not on treatment at all or not on a fully effective treatment. An HIV-negative man also faces a much greater risk with a man who may self report as HIV negative but who may not have been tested recently enough to know conclusively that he is HIV negative.

There seems to be a “don’t ask, don’t tell” ethos among men who have sex with men (MSM) in New York in which each person is responsible to fend for himself according to his situation and comfort level—which is essentially what current safe-sex recommendations instruct. I believe some of the difficulty that MSM experience in having more frank talk about their health situations and concerns stems from the fears and stigmas that date from the epidemic’s beginning and persist today. A number of my patients have told me this indeed is their own experience.
I believe that if today’s atmosphere encouraged a more frank “do ask, do tell” discussion of HIV in terms of testing and treatment, it would prevent new infections. If for example my patient learned that a prospective partner was HIV positive and not on treatment or not on fully effective treatment or if not tested recently enough to be sure of his or her status then the patient might have avoided unprotected oral sex with that partner and consequently not become HIV positive.
Many public health authorities have suggested that people will misunderstand the idea that HIV people on effective treatment are sexually noninfectious and will relax safe-sex precautions, leading to new infections.  I strongly disagree with this approach. It cynically maintains the current atmosphere of misinformation and mistrust even at a scientific public health level in order to “protect” the public from the consequences of the truth. Why not give people real prevention tools that depend on real knowledge of how HIV is transmitted rather than take those tools away from them?

In summary, destigmatizing HIV-positive people is crucial to the tasks of reducing the number of new people becoming HIV positive as well as properly diagnosing and more effectively treating HIV-positive people. Meeting this challenge will help both HIV-positive people and HIV-negative people get better access to treatment and prevention.

Imagine a public health leadership that undertook to truly educate the public about HIV-positive people, including the HIV-positive members of the public. Imagine the benefit for HIV-positive people and the public at large if HIV were destigmatized. Imagine the consequences for the developing world if we could export a true public health understanding about HIV to developing countries along with lifesaving medications! 

Let’s develop a public health campaign involving a joint effort of the medical profession, public health officials, government, industry, media, foundations, clergy and, most of all, the community of HIV-positive people to destigmatize HIV in our society and empower HIV-positive people once and for all.

The opinions expressed in this essay are those of Dr. Paul Bellman and do not necessarily reflect the views of POZ and Smart + Strong.