Living with HIV can be expensive — you never know when you may need to dash to the pharmacy for some damn thing. Or renew your subscription to Vanity Fair. So I was happy to get on a list for a marketing company that would pay me to be interviewed about various subjects. 

If there’s anything I like discussing, it’s my opinion.

Recently they called and asked if I drank scotch. Of course, I responded. Love the stuff. Okay, it doesn’t precisely jive with the fact I’m a recovering addict and alcoholic, but it was the right answer. I was invited to join a focus group on one of the vilest alcoholic beverages known to man. No actual drinking would be involved. And they paid cash.

A few days later I was escorted into the focus group room with seven other men. I looked closely at the group and it dawned on me — the Wrangler jeans, the scuffed work boots, the indifference to hair products — that I was dealing with decidedly straight men who lived outside my safe haven of Atlanta. As the saying goes, the only thing wrong with Atlanta is that it’s surrounded by Georgia.

The facilitator began by asking us to describe the sensations of drinking scotch. “It’s got a smooth feel to it, yep,” one man offered. I agreed. “Smooth” would become my default answer for most of the evening. What followed was a litany of the pleasures of drinking a dozen different brands.

“That J&B has a peaty taste,” said one, to several heads nodding in agreement. “Yup,” said another, “but ‘course, your single malts usually have that. I prefer the bite of Dewars, m’self.”

What the hell were these men talking about? Was “peaty” actually a word?

“And you, Mark?” asked the facilitator. “What about the Famous Grouse?”

I couldn’t remember if Famous Grouse was a bird or a Dr. Seuss character. I was sinking fast.

“It’s smooth,” I replied a little nervously. Thankfully, a head or two nodded, and they returned to their debate over double malts and peatiosity.

The facilitator then produced magazines and asked us to cut out pictures that reminded us of scotch. Well, you can just imagine my relief. I had no idea there was a talent portion to the evening. I snatched up Rolling Stone, pulled myself away from the movie reviews, and artistically cut out pictures of pouting women and buff men. Whereas the others in the group carelessly ripped out whole pages with no sense of composition whatsoever, I requested glue and produced a dramatic collage entitled “Shake Me, Stir Me: My Scotch Experience.”

When asked at what times we enjoyed the drink, I listened to accounts of fly-fishing trips with the boys, drinking scotch fireside, and imbibing with “the little lady” after a grilled sirloin. I might as well have unearthed some lost army of terra cotta rednecks in the Georgia mountains.

Uncomfortable emotions began to stir inside me. I resented the authenticity they took for granted – and the effortless masculinity I had always viewed as a threat to my own. But truth be told, they were simply sharing stories of their friends and their wives, while I had offered nothing real about myself.

They were guilty only of being themselves, and my selfish defenses were ridiculing them for it. But I was too threatened to see it at the time. My bombast remained securely hidden.

“I enjoy it best when I lick it off my gay lover’s balls,” I wanted to say. How could I march in a gay pride parade with “No One Knows I’m HIV positive” emblazoned on my t-shirt, I begrudgingly wondered, but I couldn’t come out in a room of eight men?

“Let’s say a bottle of scotch came to life as a man,” the facilitator queried — a bit too conceptually for the room, in my opinion. “What would he be like?”

“Oh, he’d be a friendly, boisterous man!” one said. “Yeah,” said another, “with mud on his boots. A real outdoors man. Definitely not a dandy man.” It was hard to know if you were being insulted when they used good ‘ol boy euphemisms.

“Interesting,” said the facilitator. “What’s a ‘dandy man?’”

“Well,” he replied, “he definitely wouldn’t kiss boys, if ya know what I mean!” This piece of striking wit was greeted with guffaws all around. Pot bellies and hair pieces wiggled with laughter.

I now have a moral obligation to start yelling, I thought. I must climb on top of this table, begin stomping my Cole Haans, and scream “You know what I like about scotch? It keeps my AIDS in check!” I wanted to rip my shirt wide open and wiggle my nipple rings at them. If only I had a tattoo the size of a Cutty Sark bottle that read “FISTING DADDY.”

“And what would this scotch man, come to life, look like to you, Mark?” the facilitator asked. All eyes turned to me. The time was now.

“Well…” I began. “He’d be, ah… smooth.” Everyone nodded with approval.

I left after the two hour interview with sixty dollars in cash and a nagging sense of an opportunity missed.

My God, what would Larry Kramer think?

Mark

***

When I initially wrote this more than ten years ago, I was comfortable with my stereotyping of straight men — and Georgians in particular — for comic effect. There was zero self-awareness in the essay. Re-reading it this week, I realized it had a mean spiritedness that bothered me. I revised it in an attempt to reflect my own insecurities during the focus group, which clearly colored my attitude toward the other men in the room. Alas, the piece may be beyond repair.

And what an artifact this is, considering that anyone watching the redneck television vehicle Here Comes Honey Boo Boo knows that her “Uncle Poodle” (Lee Thompson) has come out publicly as a gay man. What’s more, Lee also disclosed recently he is HIV positive. You should definitely check out Sean Strub’s article about this, because Thompson claims to have pressed charges against his former partner for not disclosing his status, and that the partner is now serving a five year jail sentence. HIV criminalization meets trash TV!

This article originally appeared on Mark's own blog My Fabulous Disease which you can read here.

There has been a flurry of articles recently with headlines like “Undetectable Viral Load? Not Necessarily in Semen” like this one in POZ.  Discovery of this connection isn’t the least bit new, of course, but what’s drawn attention is new research from Boston which furthers our understanding of the associated risk a little more. More on what that research says in a moment.

The headlines may sound alarming for those who thought, because they’d reached undetectable, they were much less infectious because of low levels of virus in their blood. But if there is in fact virus in the semen, are we back to square one, the walking time bombs we’ve always been? Certainly the headlines seem to imply that. And certainly the headlines seem to reinforce the message for poz guys everywhere “wear a condom, whatever your viral load”.  But do the headlines reveal the full picture?

It’s clear we’ve made good progress towards quantifying what IS the risk of virus in the semen, and in the associated risk of HIV transmission. Today I want to look at what we’ve learned and what are the implications for people living with HIV.

Semen – the traditional view

The virus in the blood vs. virus in the semen debate is a complicated and technical one. As a result, there has been a tendency for prevention experts to try and make things simple for us. Here’s how CATIE, for example, answers the question “If my viral load is undetectable, can I still pass HIV to others?”  

“Yes. While HIV may not be detectable in the blood, there might still be enough to infect someone. Also, there may be higher levels of HIV in semen or vaginal secretions. So, even if you have an undetectable viral load, you might still infect someone if you share needles or have unprotected sex.”

There is nothing here that isn’t absolutely correct.  But the answer doesn’t help quantify the risk for us – and quantifying risk, or trying to, is exactly what informed decisions are built on. In this particular case, we need to know what science tells us about three key questions:

• What is the likelihood of virus appearing in the semen if it can’t be detected in the blood?
• Where virus is detected in semen, what are the likely concentrations?
• Are those concentrations likely to cause HIV transmission?

All three questions are answerable, albeit with provisos, from research. That research suggests, in a nutshell, that while a quarter of ‘undetectable’ gay men have HIV in semen, the risk of transmission is likely quite low.

The research on “undetectable” gay men’s semen.

The Boston research has helped quantify the likelihood of both virus being present in the semen in "undetectable" men and the likelihood of it causing transmission. This study involved 101 gay/bi men. This AIDSmeds article summarizes the results. Eighty-three of the 101 men had undetectable levels of HIV in their blood samples. Though most also had undetectable HIV in their semen samples, 25% of those had detectable seminal viral loads. This is in the range that previous studies have confirmed.

What’s interesting is that the men who had an STI were 29 times more likely to have viral discordancy. The implication is that without an STI, undetectable in the blood means, way more often than not, undetectable in the semen.

Now let’s look at those 25% of undetectable men where virus was detected in their semen, because it’s important to understand how much virus was present.  The median level in the semen was 200 - in other words, unlikely to infect anyone.  A viral load below 1,000 has in fact, rarely been associated with HIV transmission.

So let’s summarize what we’ve learned from Boston: if you have an undetectable viral load there is a one-in-four chance of virus being measurable in your semen, considerably smaller if no STIs are present. And if that virus in your semen reflects median levels found in the study, the chances of transmission are tiny.

The problem is that median levels are just that – some men will in fact have higher levels of seminal virus, thus increasing the risk of transmission.  So, while the median range for measurable semen may have been 200, the actual range was 80 to 2,560 copies. We need to look at other research to find out whether those higher levels of seminal virus are likely to cause transmission.

It’s not as clear cut as one would like, but AIDSmap reports a small 2008 study from San Francisco found that the median seminal viral load in men transmitting HIV to partners was 4,300 and the lowest was 110. A larger (1,199 gay men) 2009 study from the UK found that two out of 41 transmissions of HIV (5%) were from men with an apparently undetectable viral load, as measured in their blood.

BUT as AIDSmap  qualifies “studies of the link between viral load and transmission suffer from it being difficult to pin down transmitters in a cohort of gay men with multiple partners and where viral load may be measured months after the transmission.”  In other words, it is wrong to conclude the men had undetectable virus (in the blood) at the time of transmission.

What does all this mean? It’s hard not to suggest that in “undetectable” men, virus in semen at levels likely to result in HIV transmission represents anything other than a small but nevertheless potential risk.

How we process risk.

It’s notoriously difficult to turn research data like this in to helpful risk guidelines, a topic which was explored in some depth in my recent interview with CATIE’s James Wilton here. 

What is clear is that the risk associated with semen in otherwise undetectable men is low, but cannot be expressed as zero.

But what risk CAN be expressed as zero? Certainly not with  condoms, the cornerstone of our HIV prevention programs.  A recent literature review reported in CATIE concluded condoms can be highly unreliable. CATIE summarizes “The review found that there is a variety of ways in which condoms are being used incorrectly and the prevalence of incorrect condom use is surprisingly high.”  That and breakages, even when condoms are used properly, present an alarming  picture.  Breakage and slippage or complete failure of the condom to afford protection was reported in 25-45% of those studied, with an event rate of up to 8%.  (“Fit or feel” issues, by the way, were reported in 7-30% of those  studied and in up to 45%  of events, with erection difficulties reported by 19-20%  and up to 20% of events.)

How do condoms stack up to undetectable viral load as a means of affording protection?  Some prominent advocates have suggested that the use of condoms in people living with HIV affords LESS protection than having an undetectable viral load.  Respected POZ magazine founder Sean Strub said that here. Even Canada’s most prominent AIDS researcher, BC’s Dr Julio Montaner said in a PositiveLite.com interview “I’m very comfortable that HAART is at least as protective – or more – than condoms.”

Overall though, we’ve been slow to acknowledge the risk from unprotected sex amongst sero-discordant partners has changed radically since the advent of undetectable viral load.  But here’s a recent exception. The ever-progressive Heath Initiative for Men (HiM) said just this month ”Most of the time, guys with undetectable blood viral loads who are taking treatment as prescribed, and get tested regularly for STIs (and treated if need be), also have undetectable viral loads in cum and rectal secretions.”

They go on, very significantly, that “for some gay men, if their partner is on treatment as prescribed by his doctor, has an undetectable blood viral load that is monitored regularly and is getting tested (and treated if need be) for STIs regularly, their risk of picking up HIV is greatly reduced, even without condoms. This may be something you want to talk about with your partner, together with his doctor.”

Conclusion

Given the evidence, even with its gaps, it’s not unreasonable to suggest that  the risk of transmission associated with semen when your blood viral load is undetectable has been over emphasized and overstated.  Why? It’s hard not to think it’s connected with our desire to see condom use maintained.

Not that this desire isn’t well founded. Condoms may not be 100% effective, or even close, but they are the best prevention technology we have right now.  So let’s be clear; it’s inappropriate for people living with HIV to stop using condoms, whatever their viral load, without carefully reviewing the risk to themselves and their partners.  That, as HiM suggests, may involve discussion with your partner and your doctor, hopefully an informed one.

But ultimately it depends, as does life in general, on what risk you consider reasonable. You make similar informed decisions every time you cross the road.

PositivelIte.com writer Michael Bouldin said “It’s not that we don’t know what constitutes risky behavior; it’s that it’s simply not possible to always avoid it, or in a given moment even desirable. Walking a red light can get you killed; it can also get you to a job interview on time.”

How we process risk is fluid too.  It depends on the context – the time, the place, the partner – and to what extent we are informed.  And to be frank, there are problems here. Canadian Treatment Action Council (CTAC) chair  Alex McLelland recently said on PositiveLite.com “As a community, we have not developed or even responded with relevant guidelines on how to incorporate the new reality that people living with HIV who are on treatment and have viral suppression do not always need to use condoms.”   

So risk is a very fluid concept for us consumers, isn’t it? It’s less so for HIV educators, who need to ensure that anything less than zero risk constitutes a warning shot across our bows.

Warning shots are fine and we need them. But we need to interpret them, try to qualify the degree of risk that might apply to us, just as we hover on the curb before crossing the road. In the case of the danger of virus in semen in those of us who are undetectable, the warning shot doesn’t pack a lot of punch for me, if you peel its skin away and look at the underlying research. But your experience may vary. In the context of informed decision making, you really need to make up your own mind.

Bob Leahy: James, you gave a presentation at the Gay Men’s Sexual Health Summit in Toronto last week on Understanding and Communicating Risk: Viral Load and HIV Transmission. That’s a topic that fascinates us here, and one we’ve been following on PositiveLite.com for some time. Clearly it’s important for people living with HIV to have the best possible understanding of this too.  With this in mind, thank you for agreeing to talk to PositiveLite.com and helping us understand more.

I guess we should start with the basics.  Tell us what an undetectable viral load means in plain language.

James: Undetectable basically means that the amount of virus (also known as the viral load) in a body fluid is below the limit that our viral load tests can detect. Viral load is regularly measured in the blood to monitor how well treatment is working for someone living with HIV. Generally, successful antiretroviral treatment can reduce the blood viral load to undetectable levels within a few months of starting. In Canada, an undetectable blood viral load normally means that there are less than 40 copies of the virus per ml of blood. Tests to detect the amount of virus in other body fluids such as semen, vaginal fluid, and rectal fluid, are not available to people living with HIV but have been developed for research purposes.

Bob: So a person with a lower viral load is likely less infectious than one whose viral load isn’t under control?

James: A lot of research shows that a lower viral load in the blood is generally associated with a lower risk of sexual HIV transmission. Although blood isn’t a fluid that’s often involved in the sexual transmission of HIV, the viral load in the blood is generally correlated with the viral load in the fluids that are, such as semen, vaginal fluid, and rectal fluid. In other words, if the viral load is controlled in the blood, it’s also generally controlled in those other body fluids. However, this isn’t always the case and some people living with HIV can have detectable amounts of virus in the genital and rectal fluids even though the viral load is undetectable in the blood. This is more common if someone has a sexually transmitted infection (STI) but can also happen when there isn’t an STI.

It’s important to note that pretty much ALL the research that has been done to date around viral load and HIV transmission has been among heterosexual couples.

Bob: I guess the big question is HOW MUCH less infectious and how we communicate that risk so that people can make decisions appropriate to their own situation? There is research from last year that made international headlines - HPTN 052 – with its conclusions that in the right circumstances, the chance of transmission in sero-discordant (heterosexual) couples was reduced by 96%.   Can you comment on how important was that study in trying to understand our own risk?

James: There are two different pieces of information people living with HIV normally want to know with regards to antiretroviral treatment, viral load, and the risk of HIV transmission. The first is HOW MUCH treatment can reduce their risk of transmission, also known as the relative-risk reduction. The second is HOW LOW that risk is reduced to when they are on treatment, also known as the absolute risk of transmission. People living with HIV are often most interested in the latter; their absolute risk of transmitting HIV when they are on treatment and have an undetectable viral load.

Unfortunately, biomedical HIV prevention trials such as the HPTN 052 study are not designed to provide information on an individual’s absolute risk of HIV transmission. These trials tell us about the change in risk of HIV transmission in a population using an intervention relative to a “control” population not using the intervention, in other words the relative risk-reduction. The relative risk-reduction is important to know because it tells us how effective a strategy is at reducing the risk of HIV transmission and can be used to compare the effectiveness of one strategy to another. The 96% relative risk-reduction calculated in the HPTN052 study tells us that antiretroviral treatment is highly effective at reducing the risk of HIV transmission among heterosexual couples who are mostly having vaginal sex.

However, the relative risk-reduction is not something that an individual can use to easily assess their absolute risk of HIV transmission. It’s really difficult to quantify someone’s absolute risk of HIV transmission while on treatment because it depends on a number of different factors unique to an individual such as how often they are having sex, how often they are using condoms, how well they are adhering to treatment, if they have any STIs, and the type of sex they are having. Therefore someone’s absolute risk of HIV transmission while on treatment may be higher or lower than another individual on treatment. We really need studies that try to calculate the absolute risk of HIV transmission from a single exposure to HIV through different types of sex (when the viral load is undetectable).

In the absence of additional information on absolute risk and in the face of these uncertainties, there are still messages that we can give to individuals so they can make informed choices and keep their risk of HIV transmission as low as possible while using “treatment as prevention.” This includes using condoms correctly and as often as possible, adhering to meds, regular viral load testing and regular STI testing and treatment for STIs.

Bob: Of course that leaves gay men a little in the dark doesn’t it, because that HPTN 052 data doesn’t necessarily reflect the realities of the risk associated with anal sex, for instance?

James: There is a much larger research gap when it comes to gay men.

We really don’t know if the relative risk-reduction while on treatment will be the same for gay men as for heterosexual couples. However, researchers think that it could be similar.

Even if the relative risk-reduction is the same for gay men, the absolute risk of HIV transmission while on treatment may be higher for gay men (who are having anal sex) than for heterosexual couples (who are mostly having vaginal sex). We know that bottoming without a condom (unprotective receptive anal sex) is up to 20 times more likely to lead to HIV transmission than unprotected receptive vaginal sex. Therefore, the higher initial risk associated with anal sex may mean that the absolute risk of HIV transmission when undetectable is much higher for anal sex than for vaginal sex.

The 96% relative-risk reduction from being on treatment is equivalent to approximately a 20-times reduced risk of HIV transmission. Furthermore, when not on treatment, we know that the risk of HIV transmission through bottoming is up to 20-times higher than vaginal sex. Therefore, if being on treatment reduces the risk of HIV transmission through bottoming by 20-times, the absolute risk of HIV transmission after this reduction in risk may still be in the same range as vaginal sex when not on treatment. 

This is all hypothetical and really emphasizes the need for more research

Bob: So the message here is that we need more research in to the impact of undetectable viral load on MSM, right?  Is anything going on?

James: Yes, we need more research. I know of some that’s going on in Australia and the Netherlands, hopefully we will see some results at the next International AIDS Conference in Washington this summer.

Bob: Let’s talk about risk guidelines for a moment.  Tell us how risk factors – percentages like 96% - are ultimately translated in to low-high risk language. What degree of certainty needs to be in place before they are formulated in this way?

James: There is no guide for translating risk-reduction percentages (relative risk reduction) into low-high risk language (absolute risks). The CAS Transmission Guidelines do not use risk-reduction percentages to determine which activities or behaviors should be placed into “high” or “low” risk categories. The CAS Transmission Guidelines were developed when our knowledge of HIV was much more limited. At the time the guidelines were developed, we knew that unprotected vaginal/anal sex was significantly more risky than oral sex and that condoms could significantly reduce that risk. It was this knowledge that formed the basis of these guidelines.

In the past decade there has been a significant amount of research emerging around the biology of HIV transmission and new HIV prevention technologies. It’s only recently that we have had to deal with these relative risk-reduction percentages and we really haven’t figured out the best way to incorporate all this information into our discussion of risk. It’s difficult because the use of “treatment as prevention” and other new prevention options have a number of caveats and uncertainties and there are still large gaps in the research.

Bob: So in the case of risk guidelines which include reference to undetectable viral load, we don’t yet have that degree of certainty? What about for heterosexual couples?  Isn’t the data strong enough there for risk guidelines to be in place, based on HPTN 052, do you think?

James: There is strong evidence that being on treatment and having an undetectable viral load significantly reduces the risk of HIV transmission for heterosexual couples. However, simply saying that the risk is “low” doesn’t reflect some of the caveats and uncertainties of this approach or the research gaps that exist, particularly among gay men.

We definitely need the latest science to be incorporated into guidelines so people are getting accurate information on “treatment as prevention” and this information is accompanied by the appropriate messages to keep this risk as low as possible. This information is already starting to show up in different guidelines, including treatment guidelines which are suggesting that physicians discuss the role of treatment as prevention with patients. Mostly people are considering undetectable viral load as an additional strategy for HIV prevention, along with regular condom use. However, the HPTN 052 study was only released last year and there is still a lot we don’t know. We are still trying to figure out how to communicate this information and incorporate it into different guidelines.

Bob: You’re probably aware that all this is a bit frustrating for some poz folks. Community leader and POZ magazine founder Sean Strub, for instance questions  (Five Things  about HIV They’re not Telling You)  the risk associated with undetectable viral load and what we are being told.  Strub says “We have neglected to recognize the extent to which a person who is on treatment and undetectable is rendered non-infectious.”  How fair a statement do you think is that?

James: Well first of all we need to avoid using the term non-infectious. There is a general consensus that the risk of HIV transmission is not eliminated when the viral load is undetectable.

Among people who are well versed with the research, I think most agree that being on antiretroviral treatment and having an undetectable viral load significantly reduces the risk of HIV transmission for heterosexual couples.

I don’t think that information is being withheld, we just don’t have a consensus yet on what we should be saying. For most people, the research that we have only provides partial answers to the key questions and this information is difficult to communicate accurately because of the caveats and uncertainties. There are no simple messages yet that applies to everyone. There is the potential for a lot of misunderstanding to occur which could have negative consequences. A major concern is that people may switch from the correct and consistent use of condoms to a strategy that is less protective.

However, I do think we need to acknowledge that not everyone consistently uses condoms (for a variety of reasons) and these individuals need accurate messages on other ways to reduce their risk of HIV transmission, including “treatment as prevention.”

Bob: Strub also talks about the relative risk associated with undetectable viral load and the use of condoms, saying that undetectable may afford the greater protection of the two. When I interviewed Dr Julio Montaner he said much the same thing “I think you should be fully comfortable with advising fully suppressed individuals on HAART that they are as well protected as when using condoms, if not better protected” is what he said to me.   What do you think of these comparisons?

James: I think we need to be careful when we make comparisons to condoms because these are two very different strategies and both have their own caveats.

We also have to make sure we aren’t always pitting condoms against “treatment as prevention” and creating an either/or situation. Both can fail to prevent transmission in their own ways and using both in combination may add an extra “backup” layer of protection.

We know that if a condom is used consistently and correctly (and the condom doesn’t break, slip or leak), then the risk of HIV transmission is pretty close to zero because no exposure to HIV can take place. HIV cannot pass through the material that is used to make condoms. Of course, condoms are not without their own caveats. Condoms aren’t always used consistently and there are lots of ways in which condoms can be used incorrectly. Also, we know that a condom can break even if it’s used correctly.

The use of “treatment as prevention” is different and there are more uncertainties. Unlike condoms which prevent an exposure occurring in the first place, “treatment as prevention” aims to reduce the risk that an exposure leads to infection. Since an exposure is occurring, other factors that influence the risk of HIV transmission from an exposure also come into play and may decrease the effectiveness of this strategy. For example, we know that tearing and inflammation, anal sex, and other STIs can increase the risk of HIV transmission from an exposure and therefore may increase the risk of transmission when the viral load is undetectable.

Also, with “treatment as prevention” you are relying on the viral load in the body fluids to be undetectable. However, it’s difficult to know what the viral load in the blood is at any given time and it’s even more difficult to know what the viral load is in the genital and rectal fluids. In addition, undetectable doesn’t mean that there is no virus, so there is still HIV present that could lead to transmission. All these uncertainties make it very difficult to know if, and how well, this strategy will work.

So which is more effective: Condoms or “treatment as prevention”? It really depends on the individual, their risk factors and how well they are able to use the prevention strategy. We know that both are highly effective in reducing the risk of HIV transmission through vaginal sex if used consistently and correctly. In this case, some people may find the consistent and correct use of one option easier than the other and therefore that option may be more effective for them.

However, if used consistently and correctly, condoms are the still most reliable and effective strategy available because they prevent an exposure from occurring in the first place and there are fewer uncertainties and caveats associated with condoms compared to the use of “treatment as prevention.” Also, condoms can lower the risk of HIV transmission to the same level for anal and vaginal sex while the risk of HIV transmission may be higher for anal sex than for vaginal sex while using “treatment as prevention.”

In the end, HIV prevention needs to help individuals adopt strategies to reduce their risk of transmission that are appropriate to their individual circumstances and the acceptable level of risk they and their partners are willing to take. We definitely need guidelines for people who want to use “treatment as prevention” and are willing to accept the risk that comes along with its uncertainties. These guidelines need to include important messages that can help a person keep the risk of HIV transmission as low as possible while using “treatment as prevention”.

Bob: I want to turn to what we know about semen. Almost every prevention message you see discussing undetectable warns that undetectable viral load in the blood doesn’t necessarily translate to undetectable viral load in the semen. But isn’t it true that in more cases than not there is that correlation?

James: Many people who have an undetectable viral load in the blood also have an undetectable viral load in the semen and other bodily fluids. However, studies suggest that this isn’t always true. The percent of people in these studies who have an undetectable viral load in the blood, but a detectable viral load in the semen, ranges widely, from 3% to 48%. Similar studies suggest that the same also applies to vaginal and rectal fluid.

We really need more research to gain a better understanding of how common this is, and why it happens, among people living with HIV who are undetectable in the blood.

Bob: How about the amount of viral load in the semen?  Isn’t it true that where it IS detectable in the semen but not in the blood, the viral load in the semen isn’t typically very high, the research seems to indicate, and thus not very infectious?

James: Most research has looked at the association between the risk of HIV transmission and the viral load in the blood, not the viral load in other fluids. This means we don’t really know what a “high” viral load in semen (or other bodily fluids) is in terms of infectiousness.

We do know that, in some cases, the amount of virus in the semen (among people who are undetectable in the blood) can be quite a lot higher than undetectable, over 5000 copies/ml. This difference may be quite significant in terms of HIV transmission but we don’t really know and need more research in this area.

Bob: Do you think we are moving towards a place in time when we will see risk guidelines which take in to account the impact of undetectable viral load?  Any guesses when that might be?

James: I definitely think we need to move in that direction. I know of a lot of organizations in Canada that are reviewing the evidence and discussing what their key messages need to be around viral load and risk of HIV transmission. In terms of guidelines from Public Health, I am not sure when those will come. It’s difficult because there are lots of research gaps and the research is still emerging quickly.

Bob: In the meantime it’s being argued before the Supreme Court that a person with undetectable viral load translates to extremely low risk of transmission.  Do you think that has the potential to confuse people living with HIV?  If so what can be done to end that confusion?

James:  The Supreme Court is considering what constitutes a “significant risk” of HIV transmission under criminal law. We need to keep in mind that criminal negligence is a serious charge and the burden of proof is different than it is for public health messages.

We know that the evidence shows that the risk of heterosexual HIV transmission is significantly lowered when someone is on antiretroviral treatment and has an undetectable viral load. Whether this risk is lowered to below what the law defines as a “significant risk” to be considered criminally negligent is up to the Supreme Court.

The court’s decision shouldn’t change the prevention messages we give to people living with HIV who want to use “treatment as prevention.” Regardless of the court’s decision, we still need to inform individuals that treatment does not eliminate risk, there are a number of caveats associated with this approach, and there are certain things an individual can do to keep this risk as low as possible. We will also, of course, need to inform people living with HIV who want to use this as a prevention strategy about the law and any changes that happen with the Supreme Court decision.

Bob: James, thank you so much for talking to us.

James is the coordinator of the Biomedical Science of HIV Prevention Project at the Canadian AIDS Treatment Information Exchange (CATIE) where his work focuses on the biology of HIV transmission and new HIV prevention technologies.

This article by Edwin J Bernard first appeared in issue 210 of NAM’s HIV Treatment Update, Winter 2012. For more information on NAM and HTU, or to subscribe to HTU, go to www.aidsmap.com

“Nothing short of barbaric.” This was the comment of a BBC presenter, confronted with the number and sheer arbitrary injustice of criminal convictions of people accused of transmitting HIV or exposing other people to it. In some cases, people have been jailed for failing to disclose HIV in situations where they couldn’t possibly have transmitted it.

And yet, says Edwin J Bernard, there have been some encouraging international policy developments in the fight against the unjust persecution of people with HIV.

Worldwide, arrests, prosecutions and their associated media reports continue to have a devastating impact on the people accused of exposing or transmitting HIV, as well as adding further to the stigma of living with HIV.

Yet since HTU last covered the issue of HIV and the criminal law (HTU 199, September 2010), there have been some remarkably encouraging national and international policy developments.

"Nothing short of barbaric"

For the past 18 months, the Global Commission on HIV and the Law, led by the United Nations Development Programme (UNDP) on behalf of the Joint United Nations Programme on HIV/AIDS (UNAIDS), has been gathering evidence from all over the world about the impact of the law on HIV. The Commission has been examining issues much broader than the criminalisation of HIV non-disclosure, exposure and transmission. These include the criminalisation of sex between men, sex work and drug use; the impact of the law on women and children; and the impact of intellectual property law and trade agreements on the availability of generic antiretrovirals.

However, some of the world's leading experts on the criminalisation of HIV non-disclosure, exposure and transmission are part of the Commission's Technical Advisory Group, including the UK's Professor Matthew Weait. And the Commission's report (due soon) is expected to censure countries that continue to treat people with HIV as potential – and actual – criminals and where HIV-related stigma is trumping evidence-informed laws and policies.1

At the Commissions' High Income Countries Dialogue held in Oakland, California, in September 2011, the issue of criminal prosecutions for HIV non-disclosure, exposure or transmission was very much at the heart of the meeting. The often emotional testimony was skilfully moderated by BBC presenter Nisha Pillai, herself moved to tears by the end of the meeting, overwhelmed by the stories of legal injustices perpetrated against people with HIV.

"The Western world’s treatment of many people with HIV is nothing short of barbaric," Pillai wrote in a blog entry a few days later. "The distressing testimony I witnessed from people living in the world’s richest countries – the US, Canada, the UK, Denmark, Germany, and elsewhere in Europe – left me profoundly shocked… The reason is simple – criminalisation... In some states of America you can kill someone in a car accident and get a lighter sentence than if you fail to pass on HIV to a sexual partner. Passing on herpes or hepatitis C isn’t prosecuted, but not passing on HIV is. The injustice is staggering. Seldom in my many years as a BBC journalist, and now as an international moderator, have I felt so outraged."2

The meeting was hosted by the sole US member of the Commission, Oakland Congresswoman Barbara Lee. Congresswoman Lee recently unveiled the Repeal HIV Discrimination Act which creates financial incentives and support for states to review and reform HIV-specific laws that are not consistent with good public health or HIV science.3

The Western world's treatment of many people with HIV is nothing short of barbaric. The distressing testimony I witnessed...left me profoundly shocked. Nisha Pillai, international moderator“Laws that place an additional burden on HIV-positive individuals because of their HIV status lag far behind the medical advances and scientific discoveries in the fight against the epidemic,” said Congresswoman Lee. “Instead of progress against the disease and protection for people living with HIV/AIDS, criminalisation laws breed fear, discrimination, distrust, and hatred. Although our country has made notable advances in the global fight against HIV/AIDS, we have a long way to go. The decriminalisation of HIV/AIDS is one way we can reduce stigma in our communities, while fighting the epidemic in a rational, holistic, and truly rights-based fashion."4

Although it is unknown whether the bill will pass when introduced to the US House of Representatives, at the very least it will create awareness and debate amongst US lawmakers about the issue.

Since 2008, when they produced their policy brief on the issue,5 UNAIDS and UNDP have been actively trying to persuade governments and policymakers to repeal HIV-specific criminal laws and to limit the application of general criminal law to actual cases of intentional transmission, where a person:

• knows his or her HIV-positive status;
• acts with the intention to transmit HIV;
• and does in fact transmit it.

At the heart of this position is the need to establish a threshold for criminal liability that would serve justice in truly blameworthy cases – where the intention to harm can be clearly established – while avoiding overly broad application of the criminal law which risks jeopardising public health and human rights.

Basing legal decisions on good science

Three years before the 'Swiss statement'6 on the impact of antiretroviral therapy on infectiousness, the Netherlands' highest court decided that one act of insertive unprotected anal sex when the accused was on treatment was not significant enough to be considered a risk of serious harm. The result is that, consistent with UNAIDS' recommendations, only maliciously intentional exposure or transmission remains a criminal offence.7 The impact of the Swiss statement was not only felt in Geneva, where HIV exposure charges were dropped because the risks were considered to be purely "hypothetical",8 but also in Austria,9 Canada10 and the US military.11

In August 2011, UNAIDS convened an expert meeting in Geneva on the scientific, medical, legal and human rights aspects of the criminalisation of HIV non-disclosure, exposure and transmission. This was the first part a project funded by the Government of Norway to expand on its 2008 policy brief in order to provide more detailed guidance and inform law and policy internationally.12

Criminalisation laws breed fear, discrimination, distrust and hatred. Congresswoman Barbara LeeThe meeting presented a unique opportunity to explore the latest developments in HIV science – such as the impact of treatment on transmission risk and life expectancy. It was also a chance to provide the UNAIDS Secretariat and other stakeholders with recommendations that would promote an application of criminal law to HIV non-disclosure, exposure and transmission, if any, that serves justice, without jeopardising public health objectives and fundamental human rights. The meeting reached expert consensus on issues such as HIV-related risk and harm; clarifying criminal intent and acceptable defences; and highlighting limitations of scientific evidence in proving transmission.13

The second part of the project – a high level policy consultation – will take place in February 2012 in Oslo. It is hoped that the Oslo meeting will lead to a greater understanding of the current issues around HIV non-disclosure, exposure and transmission and assist countries to reform their HIV-related criminal laws, policies and practices.

The problem with HIV-specific laws

However, for every sign of progress – such as the February 2011 suspension of Denmark's HIV-specific criminal law14 or Guyana's rejection of a new HIV-specific criminal law in September 201115 – there have been at least as many problematic developments, such as Romania's new HIV-specific criminal statute, implemented in October 2011,16 or South Africa's opposition leader Helen Zille's recent speech calling for men who don't use condoms to be prosecuted for attempted murder.17

In addition, many jurisdictions, notably high-income countries in Australasia, western Europe and North America, continue to prosecute people living with HIV inappropriately for non-disclosure, alleged exposure and non-intentional transmission.18 Last year also saw prosecutions in Belgium19 and in the Congo20 for the first time, both using anti-poisoning laws. The vast majority do not meet criteria for “deliberate” transmission, despite the frequent use of this word in the media.

HIV-specific laws are found all over the world - notably in Africa, central Asia, eastern Europe and Latin America.21 At least 32 states of the United States also have such laws, and in the US there are arrests on an almost daily basis.22

Rather than criminalising HIV transmission, most US laws criminalise behaviour that may or may not (and in some cases definitely does not) risk HIV transmission. Some outlaw practices that are not significantly risky or harmful (for example, sharing sex toys, spitting, performing oral sex); and others criminalise non-disclosure of known HIV-positive status, regardless of whether or not a condom or other risk-reduction methods is relied upon.23 Consequently, states with HIV-specific laws that make disclosure compulsory, that do not require proof of intent and/or that do not require proof of significant harm or transmission have generally had much higher prosecution rates than those without.24

For example, Louisiana's HIV-specific criminal law, first enacted in 1987 and revised in 1993,25 specifies that it is "unlawful for any person to intentionally expose another to HIV through sexual contact or through any means or contact (including spitting, biting, stabbing with an HIV contaminated object, or throwing of blood or other bodily substances) without the knowing and lawful consent of the victim." The maximum prison sentence is ten years. A 1993 appeal26 found that the statute was neither too vague nor too broad and it has not been challenged since.

In recent years, several people with HIV in Louisiana have been arrested for behaviour that carries a very low risk of HIV transmission, including a man for having oral sex with his wife;27 a male sex worker for suggesting to an undercover policeman, but not actually having, unprotected sex;28 and an injured man receiving medical attention for throwing a "blood-covered identification card into the face" of, and "trying to spit" on, a healthcare worker.29 The outcome of these cases is unknown.

Criminalisation confusion

In the rest of the world, most prosecutions are taking place under general criminal laws, such as physical or sexual assault statutes. Their relevance to HIV non-disclosure, exposure or transmission is often based on legal precedents informed by one or more cases taken to appeal early in the HIV epidemic that were commonly informed by HIV-related stigma and/or incomplete understanding of HIV science. In an attempt to fit non-disclosure, exposure or transmission into a wide variety of legal definitions, many jurisdictions appear to have inappropriately characterised the risks and/or harms of these acts. When the law is unclear – as it often is when it evolves based on case law – this also creates uncertainty over what behaviour is criminal and what is not, leading to conflicting standards of HIV-related risk and the conflation of non-disclosure with a malicious intent to deceive or harm.

This is the case in Canada, the country with the second highest number of prosecutions – at least 130 – after the United States. That’s about one prosecution for every 550 people with HIV – considerably higher per capita than in the US where there have been well over 300 prosecutions but whose larger HIV-positive population means that about one person per 3300 has been prosecuted. Prosecutions intensified following a 1998 Supreme Court ruling which established that a person who knows they are living with HIV has a duty to disclose their HIV status before engaging in conduct that poses a “significant risk” of exposing another person to the virus. Non-disclosure (regardless of whether it is active deceit or as a result of not discussing HIV risk) is treated as fraud that invalidates consent to sex and which results in this sexual contact being classified as an assault.

The problem is that "significant risk” has not been clearly or consistently defined and prosecutions for non-disclosure prior to oral sex31 and sex with condoms32 have taken place. As a result, substantial confusion amongst people living with HIV, healthcare workers and legal practitioners exists regarding when the duty to disclose arises.33

This week, in a case that will have far-reaching implications for people living with HIV in Canada, its Supreme Court will revisit two cases, allowing a re-examining of the 1998 ruling in the light of inconsistent lower court decisions. In particular, it will examine what constitutes a "significant risk" of HIV transmission in the context of recent scientific developments. Although both sides agree that the "significant risk" test is unfair and should be reassessed, the representatives of the Crown are arguing that the only way to make the law work fairly is to obligate disclosure (and, therefore, criminalise non-disclosure) before any kind of sexual activity, regardless of the risk involved. Advocates working to assist the defence are hoping that the Court will recognise advances in HIV science and rule that when a person with HIV uses a condom and/or has an undetectable viral load due to effective antiretroviral therapy the criminal law will not apply.34

When disclosure is no defence

Although the current situation in Canada seems harsh, some countries in Europe have an even more draconian approach. In Austria, Finland, Norway, Switzerland and Sweden, people with HIV can be prosecuted for having consensual unprotected sex even when there was prior disclosure of HIV-positive status and agreement of the risk by the HIV-negative partner.35

Fortunately, most of these countries are in the process of examining such laws and policies. Norway has set up a special committee to examine whether its current law should be rewritten or abolished: its recommendations are due in May.36 Switzerland is currently revising its Law on Epidemics, to be enacted later this year, and the latest version appears to be mostly consistent with UNAIDS' recommendations.37 And a recent conference attended by police, prosecutors and politicians that highlighted the many human rights concerns over its current laws and policies, may result in a review of the Swedish Communicable Diseases Act, as well as a change in the application of legislation and regulations for people with HIV in Sweden by the end of the year.38

England and Wales: a 'best practice' example...

The expert meeting heard how a partnership between the HIV sector and the criminal justice system in England and Wales led to the creation of prosecutorial39 and police guidelines,40 which have helped to clarify the circumstances regarding when prosecutions might be warranted and reduced the flow of cases reaching court. Attempts to replicate this pragmatic response are now going on in Scotland,41 the Canadian provinces of Ontario and Quebec, on a federal level in Canada42 and in the Australian state of Victoria.43

The Crown Prosecution Service prosecutorial guidelines were recently updated to highlight how tests for recent infection are unreliable for legal purposes,44 and to clarify that the reduced transmission risks of having an undetectable viral load on treatment could be seen as an "appropriate safeguard" alongside condoms and thus be used as an affirmative defence in 'reckless' transmission cases.45

...but guidelines aren't always followed

However, there continue to be inappropriate investigations, arrests and prosecutions with remarkably different outcomes often solely depending on whether the accused obtained timely access to good legal advice. "What's weighing on my mind," Lisa Power, policy director at Terrence Higgins Trust (THT) tells HTU, "probably because of these latest cases, is how often the police are still not following their own guidelines and what a huge difference it makes if someone gets a decent, experienced lawyer early on. It's important to remember that so far not one person has been found guilty in England and Wales [who] pleaded not guilty from the start and got decent representation."

Not one person has been found guilty in England and Wales [who] pleaded not guilty from the start and got decent representation. Lisa Power, policy director, Terrence Higgins TrustThis suggests that not only should anyone living with HIV contact THT Direct for referral to a lawyer and/or other support the moment they are involved in a criminal case – as a defendant or a complainant – but also that any healthcare worker should do the same, mindful, of course, of patient confidentiality issues. The benefit of the latter is that THT is then aware of an ongoing case and the healthcare worker may receive some good advice about how to best support the prospective complainant or defendant.

"I think a healthcare worker should ring THT Direct if they have doubts as to their own practice," Yusef Azad, NAT's director of policy and campaigns tells HTU, "and also, when it is published, look to the [updated] BHIVA/BASHH guidance [on the management of the sexual and reproductive health of people living with HIV] - but they, of course, should not disclose any identifiers of a patient without that patient's consent."

For more information

For NAM’s book on HIV and the criminal law and the latest news on the subject, visit: www.aidsmap.com/law

For information if you are personally affected, see: www.myhiv.org.uk/Telling-people/Law. If you are being investigated, or you think that someone may make a complaint against you, it’s important you get good advice from an HIV organisation and find an experienced lawyer prior to making any statement. THT Direct, can help you find both these; you can speak to them in confidence on 0808 802 1221. You may also want to speak to THT Direct if you are thinking of making a complaint. You can find HIV organisations near where you are using NAM’s online e-atlas at www.aidsmap.com/e-atlas.

Edwin’s own blog, which gathers together news and developments on the subject from around the world, is here and you can follow him on Twitter @edwinjbernard.

POZ magazine founder Sean Strub has made a trailer for what he hopes will be a full-length documentary featuring people unjustly criminalised for HIV non-disclosure, exposure or non-intentional transmission. See www.youtube.com/watch?v=iB-6blJjbjc.

References

1.The report will be available at the Global Commission on HIV and the Law's website, www.hivlawcommission.org

2.Pillai N A scandal: HIV in the western world. Nisha Pillai blog, 26 September 2011, at www.nishapillai.com/blog.

3.Available at: www.hivlawandpolicy.org/resources/download/650

4.Barbara Lee press release. Lee Introduces Bill to Fight Discrimination Against People Living with HIV. 23 September 2011.

5.UNAIDS/UNDP Policy Brief: Criminalisation of HIV Transmission. Geneva, 2008.

6.See www.aidsmap.com/page/1322904

7.See http://aidsmap.com/law-country/Western-Europe/page/1444983/ - item1444987

8.Bernard EJ Swiss court accepts that criminal HIV exposure is only 'hypothetical' on successful treatment, quashes conviction. aidsmap.com, 25 February 2009.

9.International AIDS Society Statement on Austrian Laws Impacting People Living with HIV/AIDS (PLHIV) from AIDS 2010, GNP+ and ICW. 12 July 2010.

10.Positive Living BC Top court to review HIV sex law. 25 August 2011.

11.Bernard EJ US: Military court discusses viral load and HIV exposure. Criminal HIV Transmission, 20 May 2008.

12.UNAIDS Expert meeting reviews scientific, medical, legal and human rights issues related to the criminalisation of HIV exposure and transmission. 7 September 2011.

13.Comprehensive background papers and the meeting report will be available soon at www.unaids.org.

14.Bernard EJ Denmark: Justice Minister suspends HIV-specific criminal law, sets up working group. Criminal HIV Transmission, 17 February 2011.

15.Isles K Guyana hailed for not criminalising HIV transmission. Demarara Waves, 8 September 2011.

16.Sens Pozitiv Knowingly transmitting HIV is a criminal offence in Romania. 17 June 2011.

17.Fokazi S Zille targets men who don’t use condoms. Cape Argus,9 November 2011.

18.Global Network of People Living with HIV (GNP+) 'The Global Criminalisation Scan Report', Amsterdam, 2010. For more up-to-date information, see the author's blog, criminalhivtransmission.blogspot.com.

19.Bernard EJ Belgium: First criminal conviction under poisoning law, advocates caught unawares. Criminal HIV Transmission, 13 June 2011.

20.Bernard EJ Congo: First ever criminal prosecution nets 15 years for husband under poisoning law. Criminal HIV Transmission, 11 March 2011.

21.GNP+ Op. cit. 

22.Center for HIV Law and PolicyEnding and Defending Against HIV Criminalisation, Vol 1:  State and Federal Laws and Prosecutions, Fall 2010;  Positive Justice Project Prosecutions for HIV Exposure in the United States 2008-2011

23.Galletly CL, Pinkerton SD Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV. AIDS Behav. 10(5):451-61, 2006.

24.Bernard EJ Kafkaesque: a critical analysis of US HIV non-disclosure, exposure and transmission cases, 2007-2009. 18th International AIDS Conference, Vienna, abstract THPE1016, 2010.

25.La. Rev. Stat. Ann. § 14:43.5

26.State of Louisiana v. Salvadore Andrew Gamberella Nos. 93 KA 0829, 93 KA 0830 Court of Appeal of Louisiana, First Circuit 633 So. 2d 595 29 December 1993.

27.Husband held on rape, HIV charges. The Times-Picayune, 12 February 2008.

28.Pleasant M Houma man accused of attempted HIV exposure. The Daily Comet, 21 June 2009.

29.Associated Press Louisiana Man Arrested After Allegedly Trying to Expose Hospital Staff to AIDS Virus. Fox News, 29 December 2009.

30.Elliott R Is Canada fuelling HIV stigma? The Mark, 15 August 2011.

31.See R v. Aziga, (4 April 2009), Hamilton CR-08-1735 (convicting on aggravated sexual assault charge based on unprotected oral sex).

32.See, for example, R. v. Mabior, 2008 MBQB 201 (Can. Man.) (requiring disclosure of HIV status even with condom use if viral load is detectable), reversed by R. v. Mabior, 2010 MBCA 93 (Can. Man. C.A.).

33.Mykhalovskiy E. The problem of "significant risk": Exploring the public health impact of criminalising HIV non-disclosure. Social Science & Medicine 73(5):668-75, 2011.

34.Bernard EJ. Canada: Urgent - support the call for prosecutorial guidelines in Ontario. Criminal HIV Transmission, 23 November 2011.

35.GNP+ Op. cit.

36.UNAIDS. Countries questioning laws that criminalise HIV transmission and exposure. 26 April 2011.

37.Unpublished personal communication with the author.

38.IPPF press release World AIDS Day 2011 - Sweden in the spotlight! 1 December 2011.  See also: www.hivandthelaw.com/campaign/what-can-you-do/success-stories/sweden-0

39.Crown Prosecution Service Intentional or Reckless Sexual Transmission of Infection: Legal Guidance. Updated July 2011.

40.See: www.nat.org.uk/Our-thinking/Law-stigma-and-discrimination/Criminal-prosecutions.aspx

41.Unpublished personal communication with the author.

42.See: www.ontarioaidsnetwork.on.ca/clhe/

43.Push for HIV law clarity. Star Observer, 22 September 2011.

44.UNAIDS New report explores implications of tests to estimate timing of HIV infection for criminal prosecutions. 4 August 2011.

45.See: www.cps.gov.uk/legal/h_to_k/intentional_or_reckless_sexual_transmission_of_infection_guidance/ - Safe

Even in darkness, in the bitter cold of northern Pennsylvania on a January night, the town of Milford can’t help displaying its charm. I’m walking through Main Street and the shops splash warm light in my path as strolling shoppers offer smiles and salutations.

This isn’t a night for shopping, however. It’s Bingo Night, and I am making my way down a side street for the local church. I follow the sounds of a boisterous crowd that lead me to the fellowship hall.

The tables in the small hall are stuffed with people and the elevated sounds of good cheer reverberates throughout. Many in the crowd turn to me, the bundled up stranger, and they call out welcomes, whoever I am. Tables are littered with bowls of chili and chips and salsa.

I give a woman in an apron my ten dollars, which affords me chili, all the brownies I can eat, and a bingo card.

A chorus of cheers suddenly rings out, and there in the doorway is my host Sean Strub. But the crowd isn’t celebrating the AIDS activist of queer history, but rather the civic pioneer who has done so much for the restoration of Milford in the fifteen years he has lived here. The cheers give way to a round of friendly applause, and Sean makes his way to me as chili and brownies and soda are enthusiastically offered him from every direction.

If these townspeople are living a Frank Capra fantasy, then Sean is their George Bailey, popular and humble, a friend to all. I keep waiting for someone to raise a toast “to the richest person I know.”

It’s impressive and sincere. The entire scene is imbued with the kind of openheartedness that a jaded gay man like myself hardly recognizes anymore. I’m a bit dumbstruck.

“Really, Sean?” I ask him as he finally arrives at my table. “I mean, really. Applause?”

Sean blushes and beams in equal measure, both convincingly. He steps to the head of the room to take his position calling the numbers, naturally.

For a week I’ve been in Milford, Sean‘s idyllic town a short drive from New York City, to stay with him and work on the issue of HIV criminalization. There has been a startling rash of new prosecutions of people with HIV who did not disclose their status to sex partners. It is a topic Sean has been passionate about for years now, but only recently have people like myself paid much attention. It’s an uphill battle, not simply convincing lawmakers that these prosecutions are bad for public health because they discourage HIV testing, but, surprisingly, because a majority of people, even gay men, support the laws.

As HIV as an issue has aged, stigma has risen. Younger gay men who find themselves infected are judged far more than were men of my generation. The shame of becoming infected “when you should know better” and the certain rejection they will face from their peers (“I’m drug and disease free, you be too”) make them more likely to want to hold someone else responsible for their infection.

It’s a sad blame game, fueled by vengeance and humiliation. With lawyers and jail sentences involved.

A ten year old girl, all curls and colorful hair clips, cries “bingo!” and the crowd responds enthusiastically. She approaches the prize table to select her reward with the careful discernment of a grocer choosing the most perfectly ripened fruit.

Beside me, a gay couple, one of many who split their time between careers in New York and a home in Milford, are bringing me up to speed on gay life in the bucolic town.

“There’s gay dances about once a month in a hotel basement up the street,” one is saying. “We even had a drag show last year.” I’m skeptical of the local drag talent pool, but the couple assures me that corporate attorneys and physicians aren’t the only highly skilled professionals that make weekend escapes to the serenity of Milford. “It was an all-star lineup,” he continues. “Matter of fact, there’s a birthday party tonight at a lounge on main street for one of the drag queens. Should be lots of fun. You should check it out! It‘s probably already started.”

The incongruity of church bingo and a drag queen birthday is too much to resist. I surrender my bingo card to one of the kids and give a wave to Sean.

The lounge resides in the parlor of one of the town’s handsome, renovated hotels, but the crowd isn’t what I had hoped. A pair of men are playing pool, dividing their attentions between the table and college football skirmishes on the overhead monitors. They are clearly unaware of any drag festivities afoot, and I wasn’t about to be the one to inform them.

And then, sitting at the bar with his hands folded neatly in his lap, I find evidence of another party attendee. He is a gay man of a certain age, with frosted hair and a small, sparkling package on the bar before him. It is bejeweled from the efforts of a hot glue gun and a dozen or so rhinestones.

He is sitting patiently with his offering, and I wonder of his relationship with the drag queen in question, deciding that he is a devoted fan ready to pay his respects. He appears unfazed by the nonexistent party turnout and sips from his white wine glass without care.

The gay couple from the bingo game appear, and their apologies are written across their faces. “It’s okay, it’s probably too early for a party anyway,” I say. I’m sure the drag queen will eventually make an entrance, but something about an outrageous wig, sequins and enormous eyelashes on the scene feels as if it will spoil the natural environment. It’s time to head out. I don’t want to break the spell of Milford.

That spell is one of belonging, of community, of home. After a couple of months living a nomadic existence, visiting family and now Sean after the breakup of my relationship and exit from Ft Lauderdale, my spirits have been lifted just as my longing for my own sense of community has heightened. I see the settled, peaceful faces of the residents here and want that for myself. I know that my work with the criminalization issue is valuable, and yet I wonder if Sean knew that he was also giving me safe haven and a chance to be valued beyond our project, all in the warmth of new friends and domestic tranquility after a few difficult months.

The more my spirits are raised, the more I know I must move on, to Atlanta, where friends and an anxious realtor await me, where my belongings are boxed and stored and ready to find their place.

I want to know that place, too. It’s time to find home again.

You can read Mark S. King’s regular blog, My Fabulous Disease, here.