July 20, 2010
Table of Contents
Dear PWNers -- We wish you were all here in Vienna with us. For those of you who aren't, we wanted to share a few highlights and key themes of the conference in the first 24 hours. More to come!
The Centers for Disease Control and Prevention (CDC) released a study yesterday showing a strong correlation between socioeconomic status and HIV prevalence among heterosexuals in urban areas. The CDC's analysis showed that poverty was the single most important demographic factor associated with HIV infection among inner-city heterosexuals.
These findings were not surprising to your PWN reporter: in the words of several of our Steering Committee members: Isn't this what we've been talking about all along? The U.S. HIV epidemic is characterized by a series of inequities that limit access to effective HIV prevention, timely testing, and adequate care and supportive services.
In the United States, poverty and race are inextricably linked, and this is particularly true for women affected by HIV. Lifting As We Climb: Women of Color, Wealth, and America's Future, a report released by the Insight Center earlier this year, documented an enormous economic disparity between Black, Latina and Caucasian American women in wealth, also defined as "net worth" -- or the total value of one's assets minus debts. According to the report, "single Black and Hispanic women have one penny of wealth for every dollar of wealth owned by their male counterparts and a tiny fraction of a penny for every dollar of wealth owned by white women." Specifically, excluding vehicles, single black women have a median wealth of $100 and Hispanic women $120 respectively, while the median wealth of single white women is $41,500. Partially due to lack of economic opportunity, housing and food insecurity, limited social mobility, and the fact that health care is largely tied to employment in the U.S., women living in poverty (largely Black and Latina women) are disproportionately vulnerable to poor health outcomes overall, including HIV acquisition.
It is our hope the U.S. domestic HIV response will use this data to operationalize a seamless HIV prevention and care system that accounts for and intervenes on structural and social drivers of the HIV epidemic; including racist, homophobic, and sexist policies and practices; community viral load; stigma and discrimination against people living with and vulnerable to HIV; and a failing economic and health care infrastructure. Jobs not Jails! End HIV Stigma! Stop Criminalizing Sex Workers and Drug Users! Health Care Renewal Zones for Healthy Cities NOW!
The conference opened Sunday evening with a mediocre panel but a lively opening action. Hundreds of activists staged a die-in and dropped a giant "Broken Promises Kill" banner to demand Obama deliver on his campaign promise to increase PEPFAR funding and pay the U.S.' fair share of Global Fund dollars. Activists have also focused attention on ensuring accountability from other donor governments, following a Kaiser Family Foundation report that donor nations flat-funded the AIDS response over the last year. Congratulations to the organizers for a successful, well-attended and well-publicized action!
The Office of National AIDS Policy, with leadership from the Department of Health and Human Services, hosted a session Sunday presenting the National HIV/AIDS Strategy and offering next steps for implementation and community involvement. The session included participation from key federal agency leaders, including Assistant Secretary of Health Howard Koh. Congresswoman Barbara Lee paid a surprise visit, and the session closed with a panel of community advocates including multiple representatives from the Coalition for a National AIDS Strategy and two PWN representatives.
Women aren't supposed to have sex after an HIV diagnosis enters our life. But most of us do -- and Monday's serodifferent couple symposium in the Global Village shed some light on this often-silenced aspect of our lives.
Even in 2010, sexual and reproductive health care providers and HIV advocates often seem surprised when an HIV-positive woman or a woman with an HIV-positive male partner shows up pregnant. How did you do it?
Just to lay that question to rest once and for all: most of us "do it" the way everyone else "does it". Some of us use turkey basters, condoms flipped inside out, fertility treatment. But the question is more complicated than you may think, and the answers are certainly more nuanced than anyone usually hears. HIV positive women or women with HIV-positive male partners are generally asked a "yes or no" condom use question. It is not generally acceptable, even post-Swiss consensus statement, to admit we don't always use protection, and further -- that in some cases, this is a conscious decision by both partners. Among the community working with men who have sex with men (MSM), a variety of risk-reduction strategies have been acknowledged and, while controversial, enjoy the privilege of honest dialogue. Examples include serosorting, pull out before ejaculating, bottoming only, etc...
But what we fail to delve into are the myriad and complex ways women take on and manage risk every day according to our desire, priorities, intentions, social and cultural pressure, knowledge and awareness of transmission or acquisition risk, perceived threat of violence, economic situation, and gender norms. And that these characteristics can change over time, sometimes from day to day, moment to moment, sexual encounter to sexual encounter, and relationship to relationship.
What women are rarely, if ever asked, is: What other strategies (in addition to condoms) do you use to minimize risk?
I met an HIV-positive female physician and scientist yesterday, recently out of a 22-year sero-different relationship in which condoms were used 100% of the time. Towards the end of their relationship it came up that her male partner had gone outside the relationship for sex. His alleged reason? "During all those years you insisted on condom use I did not have a satisfying sexual relationship." This doctor is now in a second, sero-different relationship, with an HIV-negative male physician she's known for years. Both have a good understanding of the scientific literature and data, including the Swiss study, and have made a joint decision not to use condoms, 100% of the time.
Women's and couple's sexual realities and decision-making may be colored by factors relating to our emotional and sexual needs, including: our desire for sex, intimacy, the desire to sexually satisfy our partners, and our desire for relationship sustainability.
Many of us take additional factors into account when deciding- sometimes with our partner's equal knowledge, participation, and understanding, and sometimes not. It can depend on cultural norms about sex and gender roles, our partner's knowledge about HIV exposure risk, and our comfort level about communication on subjects relating to sex, bodily fluids, and relationship.
Risk management strategies used by heterosexual sero-different couples include:
Couples may choose to abstain from sex or use condoms during menstruation.
Couples may choose to abstain from sex or use condoms during a visible herpes outbreak or when skin lesions of any kind are present.
Couples may choose to forego condoms if the positive partner's viral load is undetectable.
Couples may use condoms purely to prevent pregnancy; perhaps at times of the month when the woman is more fertile.
Couples may choose to forego condoms when the woman is more fertile to achieve conception.
Couples may find that consistent condom use is correlated with increased enjoyment of sex, better communication, and greater intimacy with partners.
And some couples jointly decide that weighing all options, the risk of the negative partner acquiring HIV is less important than the perceived quality of life and quality of intimacy and relationship available by foregoing condoms.
These are not mutually exclusive and many of us employ a spectrum of strategies on a daily basis. While it may be an imperfect effort towards zero onward transmission, and it may be politically unpopular to admit -- these are the complex realities of people's lives. Individuals and couples make a diversity of choices every day about sexual health and wellness.
Alarmingly, there is a paucity of research and data collection in the area of sexual and risk reduction decision-making by heterosexual sero-different couples, even though, according to Kristin Dunkle from Emory's School of Public Health, the majority of HIV-affected couples globally are serodifferent (36.3 -- 81.1% in Africa); and somewhere between 43% and 93% of new infections in Africa are estimated to occur within cohabiting couples.
Asha Persson the National Centre in HIV Social Research, Australia was principal investigator on the Straightpoz study, a qualititative, longitudinal, cohort study of HIV-positive men and women with HIV-negative partners. Twenty couples were involved in the study. The gist of her data: i) unprotected sex is common even though NONE of the couples interviewed in 2009 had been informed by health workers about the Swiss statement on suppressed viral load and reduced transmission ii) couples are using a variety of strategies to reduce transmission risk; iii) emotional and relationship dynamics are a key piece of the picture (example: I don't use a condom to prove I really love her"). Couples attempting to conceive were especially surprised not to have been informed about the Swiss statement.
The bottom line: while providers and the HIV prevention community may be uncomfortable acknowledging that some people affected by HIV have unprotected sex; the Swiss data and similar studies are an important source of information for couples practicing safe sex AND those choosing not to, and ought to be well-communicated and disseminated to assist people in making informed choices. Research into and honest dialogue about the choices, behavior and rationale of heterosexual HIV-affected individuals and couples are key to our understanding of how to prevent HIV, ensure a diversity of pleasurable prevention options are available, and to ensure a high quality of life for people living with HIV.