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Dec 18, 2010

Hello Dr. Frascino,

I have a friend who is HIV+. He tells me since he has become positive, he always uses protection. The other night we were talking and I asked him about his sex life since becoming positive. He told me he still gets some. But when I inquired further, I found out that although he uses protection always, he does not tell his partners he is positive. He tells me since he is using condoms, there is no reason for him to tell them. Is his conclusion or approach correct? What do you think?

Response from Dr. Frascino


I strongly recommend disclosing HIV status well before doing the dance with no pants. HIV disclosure is never easy and there can be complications. I have written several blogs on this topic (see below) and we have an entire chapter in the archives of this forum dedicated to the topic. Have a look and suggest that your friend do the same.

Be well. Stay well. Noel.

Dr. Bob

A Telling Tale of Trick or Treat: Remember to Spit, Don't Swallow! By Bob Frascino, M.D. October 20, 2010

Earlier today I noticed a preponderance of pumpkins, Costco-sized bags chock-full of small boxes of Milk Duds and other dental cavity inducers, and munchkin-sized costumes fit for either a mini Lady Gaga or a Tea Party Rally for Christine "I am not a witch" O'Donnell! With my keen sense for the obvious, I realized Halloween (or a GOP takeover of Congress) was fast approaching. Both are scary propositions.

I also quickly realized it was time to shed my full-tilt-boogie procrastination and generate another blog entry. While I fired up my trusty lap-Mac to tippy tap something out and take advantage of my current caffeine-induced craze, a myriad of potential blog topics raced to mind -- Life? Love? Sex? Coffee? . . . Coffee? How did that crop up into the list? Hmm. Well true, I was finishing my third large nonfat vanilla cappuccino of the morning; could it be I have a monkey on my back and his name is Juan Valdez?

A friend just stopped by dribbling his icy frappuccino on my keyboard (thank you very much) and mentioned I seemed "full of PEP" today. Rather than disclose it was my third cappuccino, I made up some nonsense about having added an extra dose of Vitametavegamin to my morning protein shake. As you can probably tell, I was stalling for time to come up with just the right topic for today's missive.

I wiped the sticky icky frap remains from my keyboard as x$%r6&* appeared on the screen. I then reread my last few coherent sentences and noted the words "pep" and "disclose." Hmm. Perhaps I should write about post-exposure prophylaxis (PEP) or maybe HIV-disclosure issues. It is interesting I chose to make a lame joke about my peppy deportment rather than to "disclose" that excessive consumption of caffeine was the true cause of my zippy-dippy demeanor.

Disclosure of any secret is seldom easy and HIV status disclosure can be incredibly difficult, especially when dealing with a potential new trick -- or treat! So let's discuss when and exactly how should positively charged individuals disclose their HIV status to their partners?

This issue is complex, because when, where, how and with whom we decide to do the dance with no pants is so wildly variable. There are those who believe disclosure isn't really necessary, as long as you stick to safer sex guidelines before sticking it in. They very reasonably argue that all sexually active consenting adults know (or should know) the risks involved and consequently should be taking all necessary precautions to protect themselves and prevent any chance of HIV transmission, regardless of what their partners say -- or don't say -- about their HIV status.

There are also situations of anonymous "cum-and-go" sex in back rooms, dark alley ways, sex clubs or saunas where the wham-bam-thank-you-sam occurs before a "how do you do." A detailed exchange of medical information isn't really a viable or realistic option for a gaggle of horned-up hotties in a jacuzzi. Hopefully those participating in these casual sex-a-thons realize the increased level of risk and take appropriate precautions against STDs, including HIV.

Disclosure becomes more of an issue when an HIVer is starting a new relationship. Some virally enhanced folks choose to serosort (date only other HIV-positive partners). Sure, this may simplify things somewhat; however, it sure can decrease your chances of a great date on a lonely Saturday night. Besides, serosorting just isn't a feasible option for everyone.

So why is disclosure such a bugaboo anyhoo? First of all, revealing one's positively charged status is often an immediate deal breaker for impending nookie. And, let's face it, none of us enjoys rejection or being looked at as if one's touch was toxic. Also, there are plenty of cases where this sensitive private information has been leaked or shared by a loose-lipped or malicious "ex."

Consequently, many poz folks, even those with the best intentions, may choose to delay disclosure until mutual trust and affection are established. This tactic, however, can be a double-edged sword because the longer one waits to disclose, the more likely it is the new partner will feel betrayed, particularly if the relationship has progressed to the horizontal mattress mambo stage.

It's important to realize that being virally enhanced doesn't mean you can't or shouldn't have mind-blowing fusion sex, but it does complicate the logistics, as we need to be continually cognizant of protecting our partners and we need to deal with the potential negative consequences of having our HIV status revealed.

One last note, about rejection: If someone dumps you because you are HIV positive, he is rejecting the virus, not you! Buddha was once asked how to brave his critics' insults and anger. Buddha replied, "If someone offers you a gift and you decline to accept it, to whom does the gift belong?" Buddha was one wise and insightful dude! To rephrase his advice in a less contemplative fashion: If someone blows a load of rejection your way because you are poz, just spit, don't swallow!

It's a Virus, Not a Crime! Criminalizing HIV Nondisclosure: Effective HIV-Prevention Method or Fanning the Flames of the Pandemic? By Bob Frascino, M.D. October 31, 2010

In my last blog entry, "A Telling Tale of Trick or Treat," I mentioned a gaggle of horned-up hotties in a Jacuzzi who might very well wind up exchanging bodily fluids prior to exchanging detailed medical information, such as HIV status. I discussed some of the reasons disclosure is such a thorny issue: rejection, stigma, possible dissemination of confidential information, etc. So what could happen to those hotties if they chose not to disclose -- or to delay disclosure until mutual trust was established with a partner?

Well, that would depend on what state or country the hot hot tub of hotties was located. In Iowa, an HIVer who had an undetectable viral load was sentenced to 25 years in prison following a one-time sexual encounter during which he used a condom! WOWZA! An HIV-positive woman in Georgia was given eight years for failing to disclose her viral status even though her HIV status had been published on the front page of the local newspaper (how's that for disclosure?!) and two witnesses testified her sexual partner was well aware of her HIV-positive status.

Please note these prosecutions are not for HIV transmission, but rather for failure to disclose one's HIV-positive status prior to intimate contact between consenting adults who both agreed to do the unsafe dance with no pants.

Making matters even worse, criminalization of HIV has now expanded beyond the boudoir (whoa! did I really say boudoir?) into far distant realms. For example, an HIV-positive guy in Texas is now serving 35 years for spitting at a police officer, and a positively charged Michigan man was charged under that state's anti-terrorism statute with possession of a "biological weapon" following an altercation with a neighbor! So HIV is now linked to bioterrorism in the eyes of Lady Justice? OMG!

As the number of these cases grows, so does the debate surrounding the criminalization of HIV. The debate lines are clearly drawn and delineated as follows:

Why Should HIV Nondisclosure be Criminalized?

Intentionally not disclosing HIV infection to sexual partners puts the partners in harm's way. Without forced disclosure, more and more people will be infected with HIV; in essence, the public health would be jeopardized. Why Should HIV Nondisclosure Laws Be Overturned?

HIV criminalization laws do nothing to reduce the rate of new HIV infections. Such laws undermine HIV-prevention efforts by deterring people from being tested. ("Hey, if I don't get tested and don't know my status, I can't be charged or prosecuted.") They increase fear and stigma surrounding HIVers. They result in punishment (often severe) under circumstances that are not blameworthy and where no harm (and in some cases even potential harm) was done. Such laws are often applied unfairly and at best inconsistently. There are laws already on the books that can be used to prosecute the extremely rare cases where someone transmits HIV with the intent to do harm. Despite the visceral response and what, at first glance, may seem like a reasonable concept to force HIV disclosure with nondisclosure laws, on more careful reflection it becomes evident that the criminal law is an ineffective and inappropriate tool with which to address the problem of HIV exposure. There is no evidence to support that criminal prosecutions for HIV nondisclosure offer any benefit in terms of HIV prevention. On the other hand, it is clear these actions have negative effects, including disincentivizing HIV testing and knowing one's status; spreading misinformation about HIV-transmission risk (the Texas guy in jail for 35 years for spitting at a cop is a good example); increased discrimination against HIVers; and invasion of privacy.

Studies have shown that the vast majority of HIVers practice safer sex and/or disclose their HIV status to sexual partners. It is also an important public health priority for everyone to take personal responsibility, whether they know their HIV status or not, to ensure that HIV and other STDs are not transmitted. Criminalization places the responsibility for preventing HIV transmission disproportionately on HIVers.

HIV nondisclosure criminal laws fail to acknowledge many complicating factors surrounding HIV disclosure, including:

Awareness of HIV Homophobia HIV stigma and discrimination Health reasons that might impact ability to disclose (psychiatric illness, cognitive dysfunction, psychological impairment, fear of retaliation and/or physical harm, etc.) HIV nondisclosure criminalization cases often attract sensational media coverage. (The case of Nadja Benaissa, an HIV-positive German pop star who recently barely escaped a prison sentence for nondisclosure, is an example.) Portraying of HIVers as potential criminals results in increased stigmatization. Perhaps even more important is that given the lack of awareness of -- and in some cases frank bias against -- HIV/AIDS, HIV transmission and HIVers among some police, prosecutors, judges and correctional institutions, the criminal justice system is not the appropriate venue for addressing HIV-exposure issues. HIV/AIDS is an individual- and a public-health issue. There are public-health mechanisms in place to address communicable diseases. Interventions aimed at preventing the spread of HIV should be public-health and human-rights based. Strengthening policies and initiatives that have been proven to reduce HIV transmission, such as increasing HIV/AIDS awareness and education programs, encouraging testing, increasing access to support services and safer sex/harm-reduction materials, and providing clean needle exchange programs, should be the public-health focus. Criminal charges do nothing to stem the spread of HIV, but do divert resources and public attention away from these proven public-health policies and programs.

Utilizing criminal law to prevent HIV transmission is based on faulty assumptions about the efficacy of this approach and does not address the many complex factors associated with unsafe behaviors and HIV disclosure. It undercuts the most basic HIV-prevention message: to know your HIV status and take responsibility for your own sexual choices and health. Studies have shown that getting HIV tested and learning one's HIV status leads to increased adherence to safer sex techniques. Criminalization of HIV nondisclosure is counterproductive in containing the further spread of HIV, particularly because it markedly decreases willingness to access testing and learn one's HIV status.

This topic comes up frequently in The Body's Safer Sex and HIV Prevention Expert Forum. Here is a link to a small sample of what can be found in the chapter in the archives devoted to HIV disclosure. Check it out!

The concept we must always remember is a simple one: HIV is a virus, not a crime!

Three Scary Beliefs That Defy Fact, Reality and Common Sense (1) Obama Is a Muslim. (2) Palin Should Be President. (3) Americans Believe Criminalization of HIV Nondisclosure Prevents HIV Infection. By Bob Frascino, M.D. November 29, 2010

Did you ever notice that some survey statistics just seem outrageously stupid, such as "24% of Americans believe Obama is a Muslim"? Other surveys' statistics seem downright scary, such as "47% of Republicans think Sarah Palin is qualified to be president." I recently came across another survey statistic I found equally as shocking -- and concerning! An overwhelming majority of HIV-negative and untested men in the United States (70% and 69% respectively) support criminalization of HIV nondisclosure! WOWZA! Obviously these folks have not read my last few blogs ("A Telling Tale of Trick or Treat: Remember to Spit, Don't Swallow," October 20, 2010; and "It's a Virus, Not a Crime!" October 31, 2010).

To those of you who did read them and especially to those who posted comments, many thanks. I particularly wanted to acknowledge Sean Strub (founder of Poz magazine) and his incredible work with the Center for HIV Law and Policy's Positive Justice Project. Please follow the link for more information on this vital endeavor. Sean, thanks for your tireless work on behalf of us all. The positively charged community never adequately thanks its heroes. You, my friend, definitely qualify. Consequently, I'll take this opportunity on behalf of the entire virally enhanced community to extend our heartfelt appreciation.

To Steven of Fort Lauderdale, regarding your comment "it truly is amazing how much fear can tip the scales of lunacy!" I couldn't agree more. Just look at some of the Looney Tunes fluffernutters who just got elected (or nearly elected) to Congress!

To James Masten of New York, your statement: "as a clinician in the field for twenty years, I concur that continued stigmatization of people living with HIV undermines prevention efforts" captures one of the strongest reasons criminalization of HIV nondisclosure is so detrimental and counterproductive to HIV-prevention efforts.

To Realize of Los Angeles, sorry your "ex" transformed from affectionate, sultry seductress (did she really ask you how does someone get you into bed?) into a slanderous, sinister wicked bitch of the west! Your story certainly dramatically proves the point that HIV disclosure can be fraught with risks -- and that you should think before dating anyone with a history of multiple personalities.

While I'm responding to comments from my recent blog, I should advise Felix of the Big Apple that "safe only" is not code for "I'm HIV positive." Rather, "safe only" means "whether you are positive or negative I only play safe and I'm not interested in you if you choose to do otherwise." The code for "I'm HIV positive" is "I'm HIV positive."

I know, I know, it's not such a difficult code to crack, but after all Felix, some of the folks on Craigslist are bi-curious, confused, married, closeted, guilt-ridden dudes who voted for Bush -- twice. Needless to say, the "code" needs to be highly transparent and completely obvious for such an uninformed and clueless group. If you disclose your HIV status in your online profile or before your NSA [no-strings-attached] horned-up Mr. Hunky-Spunky shows up on your front stoop, you don't have to worry about the proper timing of your revelation. However, if that's not your preference, it's best to advise your stud of your virally enhanced status well before you begin the dance with no pants. Check out The Body's forum on safer sex and prevention. We have a chapter in the archives devoted to HIV-disclosure issues.

To Elizabeth, I agree "... secrets gnaw at the soul." Good luck with your new blog and your "Christian fundamentalist in-laws"! I think you'll need more luck with the latter than the former. (Have you considered wearing to Thanksgiving dinner one of those tee-shirts that says, "So many right-wing Christian fundamentalist zealots; so few lions"?)

Finally, to Dave, Marco and Leigh of VA, Mexico City and Montreal respectively, you're welcome and I adore you too! Let's all be BFFs, OK?

OK, back to today's topic and the disturbing survey results. This study was published in last month's issue of AIDS Care (Horvath, KJ et al. AIDS Care 22:1221-1228, 2010). It was also alarming to note that two-thirds of gay men in the U.S. believe it should be illegal for an HIVer to have unprotected anal sex without disclosure. Support for HIV nondisclosure criminalization correlated with:

HIV-negative or unknown HIV status Less education Heterosexuality Living in a state perceived as hostile toward LGBT issues Fewer episodes of unprotected anal sex Voting for Bristol Palin on "Dancing with the Stars" OK, I made that last one up, but the rest are absolutely true.

The statistic in the study I found most surprising and disturbing is that 38% of HIV-positive men endorsed criminalization for HIV nondisclosure. What's up with that???

There can be no doubt these results are nearly as disturbing and ill-reasoned as the results of the recent congressional elections! Nondisclosure criminalization laws place strong reliance on HIV-status disclosure as an HIV-prevention method. This has been shown to lack scientific basis, credibility and common sense (just like many Tea Party candidates).

I've now spent three consecutive blogs on this topic. Yes, I do think it's that important. We must inform many and reeducate others of the fact that HIV nondisclosure criminalization is counterproductive to HIV-prevention efforts. It's going to be one of those time-consuming and always-challenging "need to change hearts and minds" campaigns. We all have our work cut out for us. So let's get those conversations started and the draconian counterproductive laws repealed before a gaggle of Mama Grizzlies tries to enshrine this lunacy in the Bill of Rights. Yeah, I know, that's not where criminalization laws would be "enshrined," but many of the new GOP Congress people haven't a clue about so many aspects of the Constitution, Bill of Rights or government in general. Who knows what they might try to do!?! We must not let them "refudiate" common sense and scientific facts.

Finally, loyal readers, I promise to return to sex for my next blog topic. So stay tuned you horn-dogs (and bi-curious, confused, married, closeted Craigslisters).

Dr. Bob

Thanks to you I went to get tested - negative!
HIV transmission through eye splash

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