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PREP Bottom, Supposed Negative Top; Transmission Risk?

Jan 8, 2019

Hi Damon,

This is somewhat of a follow up to a question you answered in Feb of 2018 (Can someone pass on hiv if they are on PrEP? Feb 1, 2018)

I'm a somewhat closeted, bi-sexsual male who has had more than a few non-condom encounters with guys who say they're on PREP and a few who said they were HIV Negative. Along the lines of sero-sorting, I don't actually seek out HIV+ counterparts. In these instances I've been the top. I"m due to get my latest test but am somewhat resigned to a fate of learning I'm HIV Positive.

I seem to understand your answer in the original question as 'those how don't have HIV can't transmit it.' Can you expand on this answer, specifically how this pertains to folks like me in this position? BTW, I am scheduled for my next round of testing in the next 14 days. Just have managed to convinced myself I can't be anything but Positive. I know the general 'odds' for myself (circumcised white-male) but I guess I'm just looking for some sort of clarification rolling into my next testing battery.

Cheers and Happy New Year

Response from Mr. Jacobs

Happy New Year to you, and thank you for writing in.

Okay I found the question you are referring to from February 1, 2018 and don't see the quote (http://www.thebody.com/Forums/AIDS/SafeSex/Q246557.html). But the part about people living with HIV with an undetectable viral load and are not capable of sexually transmitting HIV is something I write about here frequently, and teach when I give talks on the subject.

Let's start with the facts about "U=U", aka, Undetectable=Untransmittable. This refers to the conclusion of several studies over the past 10 years demonstrating that someone who is HIV+, and undetectable for about 6 months or more, cannot sexually transmit HIV to other humans. I'm going to borrow this next quote from the Prevention Access Campaign website, which also has a lot information and resources to review:

"The conclusion is based on the overwhelming force of real world and research evidence including HPTN 052, PARTNER, PARTNER 2, Opposites Attract, and the Swiss Statement.For i nstance, in HPTN 052 there were ZERO transmissions between 1,763 mixed-status couples when the HIV positive partners were on ART with undetectable viral loads. In the PARTNER study, there were ZERO transmissions out of 58,000 condomless sex acts between people with HIV on ART who had undetectable viral loads and their HIV negative partners. In PARTNER 2, which was the extension of PARTNER and studied men who have sex with men, there were ZERO transmissions out of 77,000 condomless sex acts between people with HIV on ART with undetectable viral loads and their HIV negative partners. In the Opposites Attract study, there were ZERO transmissions out of 17,000 condomless sex acts between HIV positive undetectable and HIV negative male partners. Since the advent of combination therapy, there have been no confirmed reports of anyone with an undetectable viral load sexually transmitting HIV." [https://www.preventionaccess.org/faq]

So with that in mind I respectfully challenge you: As a bisexual top who prefers condomless sex - who are you more likely to acquire HIV from? (1) A partner who is living with HIV and on treatment medications or (2) A partner who tells you he is HIV negative and may not even know he is carrying detectable HIV?

This is why I strongly criticize and outright discourage the practice of sero-sorting as a way to stay HIV negative. Not only it is it hurtful and stigmatizing to people living with HIV, but it simply doesn't work! Most people who acquire HIV believe their partner is HIV negative at the time they acquired HIV.

So what is a semi-closeted circumcised bisexual top to do with this information? Well, accepting your non-likely fate of becoming HIV positive need not be on your list of options.

--One option you have is to use PrEP yourself. PrEP is for any person of any gender or sexual orientation who could potentially be at substantial risk of acquiring HIV. Condomless sex is on the list. If you are in the U.S. you can find a list of PrEP providers at www.PrEPlocator.org. Or outside the U.S. many providers are listed at "Please PrEP Me" (https://www.pleaseprepme.global).

--Another option: As you alluded to in your question, the chances of acquiring HIV as a circumcised top are less than 1% so there's that too (https://www.poz.com/article/HIV-risk-25382-5829). Less than 1% is not zero, there are some men who have acquired HIV solely from topping. But I can tell you those instances are fairly rare, and certainly do not demand a resignation that you will inevitably become HIV positive if you only top.

--One more: As mentioned above - If you're REALLY worried about getting HIV as a top, then fuck HIV positive people who are undetectable. You cannot acquire HIV from them and they would be the partners you would be safest with if you're not using PrEP.

Psychologically I understand what you're doing here. Back in the days before HIV treatment, before we had undetectable viral loads, I had to mentally prepare myself to be HIV positive every time I got tested. I had to position myself cognitively as someone who already was HIV positive because that was the only way I could do the mental acrobatics required to ask for an HIV test and then wait two weeks for the results.

But times have changed! We have PrEP now. We have U=U. We have rapid tests. There are so many ways you can be proactive while simultaneously enjoying condomless encounters AND protect yourself from HIV.

I encourage you to talk to your provider or someone about accessing PrEP. You can also join our discussions on these subjects in the PrEP Facebook group 24/7 at: https://www.facebook.com/groups/PrEPFacts/

Thank you again for writing in, I hope this information helps you to experience pleasure and empowerment in your decisions.



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