The Resonance Project

What we heard from gay men and their service providers about: Undetectable Viral Load 

What we heard from gay men and their service providers about:

The HIV-positive participants generally viewed undetectable viral load in positive terms. For many, it reduced anxiety about transmission and could reduce stigma. For some, undetectability was even the basis of a new identity, which they distinguished from being just HIV-positive. It could also contribute to a feeling of sexual liberation and to better sex.

However, some HIV-positive participants and many HIV-negative participants expressed considerable caution about relying solely on undetectable viral load as a means of reducing HIV transmission risk.

Among service providers, we noted a lack of consensus about the role of undetectable viral load as part of risk reduction strategies.

Undetectable viral load awareness and concerns

While we did not measure gay men’s level of awareness about undetectable viral load (UVL) or their level of confidence in its ability to reduce the risk of HIV transmission, these levels of awareness and confidence seemed to vary greatly. Those gay men in the focus groups who were living with HIV, knowingly interacted with positive men, or were connected to HIV organizations seemed to have greater knowledge and confidence levels in the concept of undetectability as a risk reduction strategy. These knowledge and confidence levels also seemed to vary according to geographic location. The most commonly cited caveats regarding undetectability and its impact of the risk of transmission included: frequency of viral load tests; re-infection with different strains; the impact of other infections; viral blips; adherence to treatment; and, the applicability of research focused on heterosexuals to gay men.

In the Village everyone knows what it means to be undetectable. In outlying regions when I say that I’m poz undetectable, I get three question marks. Pos, <35, MTL1

Until I moved here I was still operating on the data from 20 years ago when raw was forbidden, period. I had to go do a lot of research before I could convince myself that it was an OK thing to do...I went to the web and looked up everything I could and spoke to some health professionals...They all said the same thing; having sex with somebody that is known to have low viral load is safer than having sex with a stranger with a condom. I couldn’t believe that they were all saying the same thing. Wow! So I started having unprotected sex with him [poz partner]. I’m always the top. that’s the stipulation.  Neg, 35-49, VAN2

Undetectable viral load and risk calculation

In general, HIV-positive participants expressed more confidence in the idea that an UVL sufficiently lowers the risk of transmission than HIV-negative participants. However, a few participants had opposing views to that of their peers. Having an HIV-positive partner had been particularly instructive for some negative men around risk management. Many gay men emphasized that while it might lower the risk, some risk remains. For some gay men—both positive and negative—UVL provided sufficient reassurance to have condomless sex, while for others it did not. Gay men were divided: Are undetectable men safer sexual partners than others? Some gay men wondered: Can I trust that a sexual partner is really undetectable?

You also can’t lose sight of the fact that it’s a crapshoot. you might get away with it once. you might get away with it twice but then one day you might wake up and get that phone call. Neg, 50+, TO1

I don’t know. If you’ve been with somebody for 5 years and you’ve barebacked the whole time, and they’re still negative, that raises a lot of questions. Pos, <35, TO1

A lot of negative guys are seeking out undetectable positive partners… Saying undetectable is the same as negative, I think it’s actually better, because a negative person’s status is only as good as their last test. Pos, 50+, VAN1

Undetectable, a lot of people think ‘oh I’m never going to get infected’ or ‘I’m never going to infect anybody else.’ So therefore, get rid of the condoms now... But there’s still that less than 0.05% that you can. Pos, 50+, TO3

Undetectable as identity: “The new negative”

Many HIV-positive men espoused the idea of undetectability as an identity (as opposed to ‘poz’ or ‘positive’) as a way to signify that they were healthy and posed a lower risk of transmission. They felt this helped reduce stigma. However, some positive and negative participants questioned the impact of identifying as undetectable in a context where the concept was not well understood in the community.

I wear my undetectability like a badge of honour. I’m very proud to be undetectable. Pos, 50+, VAN3

It takes the emphasis off the illness and puts it on my health. HIV-positive has such baggage attached to it and undetectable doesn’t really have that baggage. Pos, 35-49, VAN3

Just to say undetectable, most people who are positive they know what that means and they know that they are in a healthy phase, in a healthier phase. Pos, 35-49, TO1

Concerns about over-confidence in undetectability

Some service providers described how some gay men used the term as a “magic phrase” to convince their sexual partners to have condomless sex. They expressed scepticism about gay men’s ability to understand undetectable viral load accurately or appropriately. Some service providers described gay men as being overly confident in undetectability, and as engaging in “risky” or “unprotected” sex when they chose to have condomless sex on the basis of undetectability as the sole risk reduction method.

They just take it as a license sometimes to just go with it, to proceed either in risky behaviour or unprotected sex. Do they have a complete understanding? Not always. So basically it’s just a two-second conversation ‘oh he said he had undetectable viral load, we don’t need to use a condom.’ They’re not looking at what does an undetectable viral load mean, at what time and how do STIs and other things impact the spikes in viral loads. SP, 50+, PH, TO

The focus of HIV/AIDS prevention is bringing us back to a point where we can have condomless sex without conversations, without concerns, without consequences. It’s just mindboggling. We have had guys who have come in who have serosorted based on a partner who’s undetectable. SP, 35-49, PH, TO

Positive men as educators

Service providers had the impression that negative gay men were learning about undetectability from positive men. Gay men living with HIV confirmed this; they felt that they often had to educate their sexual partners about the meaning and implications of undetectability.

Positive guys, usually they’re more knowledgeable about those things. Negative guys, it’s not even on their radar. The only bridging of that is the negative guy who knows positive guys or has friends who are positive or is having sex with positive guys. That’s where that knowledge transfer is happening. SP, <35, GMHO, VAN

I don’t always want to explain what PrEP is and Truvada and HIV and undetectable to some guy I just want to suck my dick [group laughter]. Straight up. Pos, 35-49, TO1

Impact on stigma reduction

Some service providers described undetectability as reducing levels of stigma and self-stigma related to HIV and infectivity. They also described how some gay men saw sexual partners with UVL as more desirable and safer than partners who claimed to be negative. They discussed the tension between messages that destigmatized positive men and messages that accurately reflected the state of evidence around undetectability and transmissibility. This tension was often described as being emotional versus rational.

The undetectable thing is a bit of a hope for them that they aren’t that huge risk. They’re not this source of HIV, they can have a relationship and their partner doesn’t have to be positive. I think that’s really liberating for positive guys, this idea that I don’t have to feel like this viral source. SP, 35-49, PH, VAN

It’s this delicate dance because you do want to talk about what undetectable and what treatment does for people and how it affects peoples’ health. But you also don’t want to increase stigma against people who aren’t on treatment. it’s this  delicate dance of trying to reduce stigma while also explaining likelihoods of transmission. SP, 35-49, CBO, TO

Divide among service providers

Service providers demonstrated their own varying levels of confidence in the efficacy of undetectability, and a few admitted that their own levels of knowledge on this topic were not as complete as they would like. Some service providers erred on the side of caution by advising gay men of all the uncertainties of UVL, while others described such messages as overly conservative. Some service providers acknowledged a divide among their colleagues, characterizing some who touted the risk reduction possibilities of UVL as being irresponsible.

It frustrates me to no end. I do believe that some doctors are being irresponsible when they’re advising people who are undetectable that they don’t need to use condoms. Most patients don’t have the capacity or medical knowledge or are in a psychological position to take that information in a way that is accurate. Doctors giving that advice so freely doesn’t take into account all the complexities. SP, 35-49, CBO, TO

There’s a huge flame war on my Facebook…it’s a big division and it’s where logic just disappears down an emotional void. People are attached to condoms, they’re attached to safe sex or they’re attached to HIV status or they want to de-stigmatize. Most attachments are very powerful and they really divide the education messages. SP, 50+, PSYC, VAN

Patten S, LeBlanc MA, Jackson E, Adam B (2016). The Resonance Project Community Report: Emerging biomedical discourses on HIV among gay men and their service providers.

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