Falling in love is never easy, but forming a lasting relationship can be even more difficult. For many the early stages of a romance are a combination of excitement, panic and the urge to vomit, a constellation of feelings that Hallmark conveniently labels as "love." But as relationships develop, a myriad of questions begin to arise: Will his mother like me? Does he always whistle when he pees? Will he judge me for watching Here Comes Honey Boo-Boo? Over 30 years into the HIV epidemic, the relationships formed by gay men and other men who have sex with men (MSM) often face another set of questions: Is he HIV-positive or negative? Is he going to ask if I am positive or negative? True, 30 years of HIV prevention efforts and advocacy have enabled many men living with HIV to be open about their HIV status, and it is certainly true that discussions around HIV are far less stigmatized than they were in the 1980s. But while we have been inundated with messages telling us to "talk about HIV with your sex partners," for some such discussions are fraught with anxieties over blame, judgment or abandonment.
But for others, the lack of discussion around HIV with their sex partners may arise from a surprising gap in knowledge. Recently published work by Bradley Wagenaar and colleagues from the Rollins School of Public Health in Atlanta shows that among a sample of 426 MSM aged 18 to 29, 21 percent were not definitively aware that sero-discordance (where one member of the couple is HIV-negative and the other is HIV-positive) is possible. That is, 1 in 5 men surveyed thought that if two men were having sex and one was HIV-negative, then the other must also be HIV-negative. This new evidence suggests that gay men may make assumptions about their partner's sero-status using their own HIV status as a barometer against which to guesstimate their partner's HIV status. And the logic perhaps makes sense: If I know I am negative, and we have been having a lot of sex together, then he must be negative too, right?
Avoidance of discussion of and assumptions about HIV status are particularly worrisome in light of the fact that gay men and other MSM are the only risk group in the U.S. to be experiencing an increase in HIV infections. While over the last 30 years of the epidemic we in public health have focused our prevention messaging on the risks of casual sex, recent studies (Goodreau 2012, Sullivan 2009) show that in fact, between one third and two thirds of MSM are infected by their main partners. This high proportion of new infections experienced within relationships is shaped by having more sex with main partners and trust and desires for intimacy that make condom use less likely with a main partner. Add to this unwillingness to talk about HIV or a myth that your partner's HIV status must be the same as yours and you are faced with a high-risk situation for HIV transmission.
True, gay men do talk about sex in their relationships. The results of a recent survey with 732 MSM aged 18 to 75 published by Gass and colleagues showed that 90 percent of MSM report discussing sexual agreements -- in which they set rules for sex within and outside of their relationships -- with their main partner, and 64 percent decide to be monogamous. But given that the prevalence of HIV among gay men in the U.S. is almost as high as the prevalence among heterosexual couples in African countries with the worst epidemics, there is a high risk that men are entering relationships in which one or both are already HIV-positive. And monogamy doesn't protect you if your partner has undiagnosed HIV and neither of you has felt able to initiate a discussion around HIV.
There is a solution, however. Since 2008, Dr. Patrick Sullivan and I at the Rollins School of Public Health at Emory University have been developing an innovative HIV prevention strategy: couples HIV testing for gay men. Couples' testing allows both partners to get counseling and learn the results together. This simple act removes the need for uncomfortable conversations about HIV status, prevents risky behaviors based on assumptions of status, and allows the couple to work together on a prevention plan built on both their HIV statuses. With funding from the National Institutes of Health and the MAC AIDS Fund, we have worked with community-based organizations to test over 300 male couples so far. The response has been overwhelming, and we are finding that typically 1 in 10 male couples -- in some places it's as high as 1 in 5 -- is newly identified as sero-discordant. That is, a significant number of couples are finding out for the first time that one of them is HIV-positive: without testing together, these couples may have continued to have unprotected sex, increasing the risk of HIV transmission in the relationship. The aim of testing together is not to stigmatize the HIV-positive member of the relationship (in fact, about 80 percent of couples receive results indicating they are both HIV-negative) but to allow male couples to find out their HIV statuses together and form a plan for moving forward with their relationship together, and for sero-discordant couples this plan may involve a range of options, from condom use to HIV medications to lower viral load. This simple act of removing the unease of discussing HIV or dispelling myths around shared HIV status has the potential to significantly stem the spread of HIV. For more information on where you can receive couples testing, visit www.testingtogether.org.
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