Holes in the Swiss statement?
GAY AS OTTAWA
Nicholas Little / Ottawa / Wednesday, August 27, 2008
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Last January, a team of Swiss scientists released a statement about HIV transmission that has become one of the most-talked about prevention developments this year.

The Swiss statement makes a surprising assertion. The likelihood, it says, of an HIV positive person infecting their HIV negative partner during hetero sex is less than 1 in 100,000 if all of the following conditions are met:

1. They take their medications faithfully without ever missing a dose, and

2. They are seeing their HIV doctor regularly and having their viral load monitored closely, and

3. Their viral load is consistently undetectable (no more than 40 viral copies per mL of blood) for at least six months, and

4. They are certain they have no other STIs (sexually transmitted infections) at any time.

I've negotiated open relationships less complicated than that! So if you're a gay dude in Ottawa feeling a little confused about what the Swiss statement does (or doesn't) mean for your sex life, I doubt you're alone.

I'm simplifying, but there have basically been two types of reactions to the Swiss statement:

On one side we have mostly big institutions that have tried to keep their cool but are essentially pissed at the Swiss scientists. They worry that mere mortals cannot process a prevention message this complex and, as such, HIV infection rates will rise when people fuck up one or more of the conditions.

There are some big players in this camp: Public Health Agency of Canada, World Health Organization and UNAIDS, American Centers for Disease Control and Prevention, Canadian AIDS Treatment Information Exchange and some community AIDS service organizations like the AIDS Committee of Toronto.

This first camp's cautions about the Swiss statement are not unfounded and are worth reflecting on. Here are some of them:

The statement is based on hetero, vaginal sex — not anal sex. But it is gay guys who bear the heaviest HIV burden in countries like Canada and anal sex is higher risk for HIV than vaginal sex — even if the Swiss conditions are met. Will gay guys realize the Swiss statement is not about them?

The statement isn't based on sufficiently robust scientific data. While it points to a preliminary finding worthy of more research, is the data on which the statement is based solid enough to make such a bold statement at this time?

Who the hell knows if they have an STI or not when so many STIs can produce unnoticeable symptoms (or none at all!) while still increasing poz people's infectiousness and HIV negative folks' vulnerability. Do both HIV positive and HIV negative people understand how important it is to get regularly tested for STIs?

Furthermore, HIV positive gay men in particular tend to have higher rates of STIs, making it even less likely they would meet the Swiss conditions.

And on top of that, measuring viral load is tricky. Firstly, we test for viral load in the blood, which does not necessarily correspond to viral load in cum or vaginal fluid. Moreover, many people experience "blips" in their viral loads. And what about the time between taking a viral load test and getting the results, perhaps a couple weeks later?

Some also worry that people will use viral load strategies in place of condoms, instead of using them as complementary harm reduction tools. Will the possible benefits of the Swiss statement be nullified if people use condoms less often as a result?

The response of the second camp tends to be taken less seriously than the first because they lack hefty UN initials preceding their names or the all-knowing MD initials following. This camp tends to be comprised of people living with HIV, harm reduction activists and a handful of community organizations (usually the ones run by the community itself).

This second camp feels vindicated (sometimes smugly so) that scientific data is now beginning to confirm what they have observed anecdotally in their own lives for years. They agree with the first camp that condoms are the absolute best tool we have to reduce HIV transmission, but they also enthusiastically embrace additional harm reduction tools irrefutably proven to reduce HIV transmission.

Epidemiologist and prevention pundit Elizabeth Pisani writes: "Most people process complex information about risks and rewards every day of their lives. The life partners of people who take antiretorvirals are among the best placed in the world to understand the consequences of perhaps becoming infected with HIV. Public health professionals don't need to treat them like idiots. Rather, we should lay out the risks as accurately as we know how, and let people decide for themselves."

Pisani acknowledges that gay men have less to gain from the Swiss statement than straight folks, but she refuses to throw the bareback baby out with the blood-borne bathwater: "If you are a man with an infected wife, a 215 in 10,000 chance over 10 years may seem worth the risk. If you are a woman with an infected husband, we're talking a 425 in 10,000 chance over 10, still worth a [gamble] to many people. If you're a gay guy, the odds crash to 3,524 in 10,000, and you may want to hang on to the condoms. But isn't it for you to decide?"

Well, is it?


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Reader Comments


 
Of course you decide
Of course it is for you to decide. But as Pisani says, people should be given all the accurate info about what their decision will mean for their own health and HIV transmission throughout a population. That way, people will know full well what the consequences of their decisions may be. Also, I'm curious to see which harm reduction techniques are "irrefutably proven" to reduce HIV transmission during barebacking, which is what I assume you are talking about at that point.
chris d, toronto on
08/27/08 2:32 AM EST
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Irrefutably proven harm reduction techniques...
Hi Chris, thanks for kicking off what I hope might be some good conversation about the Swiss statement. I find it a pretty fascinating topic because it touches so many hotly debated issues. For a list of harm reduction techniques for guys who choose not to use condoms for anal sex, see this column: http://tinyurl.com/barebackcolumn Of course, you've seen that column before because you also posted comments there. My aim in this article was 1) to explain the Swiss statement for folks who aren't sure exactly what the Swiss scientists said and 2) to summarize the 2 different types of responses that tend to be made about the Swiss statement. What really interests me is to hear what other gay guys think about it all and whether or not they expect their sex practices to change in reaction to the Swiss statement.
Nicholas Little, Ottawa ON
08/27/08 8:59 AM EST
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Update: Aug 27 developments
An Aug 27 AIDSmap story discusses yet more studies related to the Swiss statement, which have only created more debate and discussion: http://tinyurl.com/SwissAug27
Nicholas Little, Ottawa ON
08/27/08 9:19 AM EST
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There are no harm reduc. techs. for barebacking
The Swiss group does not claim their findings have anything to do with male male sex, so I don't see how the Swiss paper has any relevance to that issue. Secondly, there are no proven harm reduction techniques for barebacking, except for using a condom.
chris d, to on
08/27/08 9:38 AM EST
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Chris D, where's the evidence?
My article states: “The statement is based on hetero, vaginal sex — not anal sex. …Will gay guys realize the Swiss statement is not about them?” I think that sufficiently responds to your first point. Your second point is flat out incorrect and in 2008 (with no decline in new HIV transmissions among Ottawa gay guys!) it is unethical to pretend that condoms are the only option available to sexually active people interested in reducing risks during sex. YES, CONDOMS ARE UNQUESTIONABLY THE BEST PREVENTION TOOL WE HAVE. Absolutely no one is debating that fact and my article says as much. However, I challenge you to post a link to scientific, peer-reviewed studies that say there is no connection between viral load and infectiousness of HIV+ people. To the contrary, what you will find is many, many studies confirming that “Infected individuals with low viral loads, controlling for other factors, were very unlikely to transmit to their partners.” (http://www.medscape.com/viewarticle/420640) I’m not saying what we should *do* with that information, I am simply saying that that finding has been proven in study after study. It is a scientifically sound statement. SO: If a low viral load makes an HIV+ individual less infectious and a high viral load makes an HIV+ individual more infectious, then if a sero-divergent couple chose to have sex without condoms ONLY when the HIV+ partner had an undetectable viral load (and to use condoms when the viral load was detectable), are you honestly suggesting the risk would be no different than if they chose not to use condoms at any time? I appreciate your eagerness to debate, Chris D, but the arguments need to be backed up with peer-reviewed evidence. Otherwise, they are arguments based in ideology – adequate for personal opinion, but hardly sufficient for evidence-based public health policy. If you can provide links to scientific studies showing, for example, that condom-less sex WITHOUT an STI is just as safe as condom-l
Nicholas Little, Ottawa ON
08/27/08 1:26 PM EST
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(...con'd)...
(...con'd).... If you can provide links to scientific studies showing, for example, that condom-less sex WITHOUT an STI is just as safe as condom-less sex WITH an STI, please do share them.
Nicholas Little, Ottawa ON
08/27/08 1:27 PM EST
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kjkjlkjlkj
You didn't address any of the "irrefutable harm techniques" in your past article that you linked to above. Those are the techniques I am talking about and none have been shown effective. If you are going to make an assertion that "behaviour x lowers risk" then it is up to you to prove that claim. If you do not show evidence and I say "that statement is not true" it's not up to me to prove your statement is not true. Intelligent design proponents similarly think they score a point when they say "scientists can't show proof the world wasn't designed" even though it is up to IDers to prove that the world was designed in the first place. Secondly, I'm not sure what your viral load spiel is about. I do not debate that people with a lower viral load may have a lower chance of transmitting a STI. But since a person who barebacks cannot determine the viral load of themselves or their newfound partner prior to sex I don't get where you are going with that idea. I do agree that an effective harm reduction technique would be if people who just met nd are about to bareback immediately got tested by professionals at a lab/clinic, somehow rapidly determined their viral loads, and if negative, then barebacked. But even the study you link to above showed evidence that people with very low detectable viral loads may have transmitted STIs to each other, although that is contested. Of course the risk is yours.
chris d, to on
08/27/08 3:56 PM EST
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dgfw
And lastly, as you say, the Swiss statement has nothing to do with gay men. So I still don't know why you wrote this article but as an excuse to bring up your views on barebacking and harm reduction among gay males which is completely unrelated to the swiss statement.
chris, to on
08/27/08 3:59 PM EST
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Why I wrote this article
Thanks for inquiring about my motivation to write this article, Chris. As I stated in post#2 above, "My aim in this article was 1) to explain the Swiss statement for folks who aren't sure exactly what the Swiss scientists said and 2) to summarize the 2 different types of responses that tend to be made about the Swiss statement." I also wrote: "What really interests me is to hear what other gay guys think about it all and whether or not they expect their sex practices to change in reaction to the Swiss statement." Your posts have given me a clear idea of what you think about the Swiss statement. Thanks for that. I hope other guys will share their take on it all too. Hell, I may even share my own personal opinion about it! Thanks again.
Nicholas Little, Ottawa ON
08/28/08 2:20 AM EST
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