Does Mandatory HIV Disclosure Reduce Risk?

Hey there Guys,

This morning I was alerted to an opinion piece by New Zealand’s Dominion Post. Opening with the provocative title “Nothing But Truth For HIV Lovers“, it was pretty much downhill from there. To quote:

The Aids Foundation supports the right of HIV-positive patients to conceal their condition from their sexual partners provided they use proper protection. It could not be more wrong.

They go on to discuss a recent court case where a female was awarded damages for “mental trauma after discovering she had been having unprotected sex with an HIV-positive man”. This has been based on the plaintiff’s statement that she was not able to fully consent without the disclosure and was thus the act was a sexual violation.  The Dominion goes on to opine:

The Aids Foundation claims that allowing sexual violation charges against people who know they have HIV but fail to tell their sexual partners will increase discrimination and lead to a “significant decrease” in testing. That is a cop-out. The Court of Appeal case was not about the rights of people with HIV, but the rights of those with whom they wish to have sex to have a full understanding of the possible consequences.

I beg to note that it appears the female had made the decision to have unsafe sex on the information she had. HIV aside, if she had fallen pregnant would this too have been a sexual violation? This case highlights the risk of assumptions frequently made by people in the throws of passion. You cannot tell someone’s HIV status by visual inspection; if you are HIV negative and wish to stay that way it’s important to practice safe sex all the time and to not drop the ball when you feel it should be ok.

In Australia laws around disclosure of HIV status vary from state to state. For up to date information be sure to check out this summary at the AFAO website.

As noted at The Australian Society Of HIV Medicine’s website:

Public health analysts argue that mandatory disclosure of HIV status prior to sex undermines the ‘mutual responsibility’ message fundamental to HIV prevention in Australia. In short, people should not expect HIV-positive people to disclose for a variety of reasons, including:

• It is estimated some 30% of men who transmit HIV to men through sexual contact are unaware of their HIV status: they cannot disclose.
• Behavioural research into serosorting has identified instances of miscommunication, where an HIV-positive person believes an HIV-negative person has communicated their HIV-positive status – and vice-versa.
• Recent findings from the e-male study demonstrate that using a condom with casual sexual partners is more likely if there is no disclosure.
• Some people are unwilling to disclose their HIV status, as once disclosed that information can and does travel. Notably, HIV Futures 6 reports that 51.4% of HIV-positive respondents had had their HIV status disclosed without their permission. Fear of disclosure may be particularly relevant to some who have not disclosed to family and friends and who are not generally out about being HIV positive.
• Some people do not disclose fearing rejection. Van de Ven found some 80% of HIV-negative men said they always or sometimes avoided sex with people they think are HIV positive , and unpublished data from the Positive Health study shows that as many as 27% of HIV-positive men surveyed have been sexually rejected due to their HIV serostatus.
• The decision not to disclose (which may be considered or spontaneous) may be informed by other decisions to use safer sexual practices or the belief that having a low viral load equates to low risk of transmission.

That analysis points to the centrality of mutual responsibility and safe sex messages when advising patients, in addition to advice on disclosure. All that being said, HIV disclosure is mandated in New South Wales and Tasmania, and may be a defence against a criminal offence of HIV exposure or transmission in all Australian states and territories

I think it’s very important to note that the time of infection is extremely risky due to:

1. The viral load is usually at its highest when just infected. This increases the risk of infecting other people significantly
2. Due to the delay between infection and the creation of HIV antibodies, the “window period”, the standardly offered HIV tests can come back negative, giving a HIV positive person the wrong impression that they are free of the virus.

Adding to the mix that there is a percentage of the population who do not get tested for HIV, it’s important to take someone’s disclosure of being HIV negative, or my particular favourite “clean, D&D free” with a grain of salt. Sexual behaviour is a team sport and both parties should be able to be part of the condom negotiation. If I’m having sex with a partner and they offer bare back sex I am more than comfortable to say “nah I only play with condoms”. If they make an issue of it I say goodbye, if they don’t then condoms it is.

One of the problems I have with the arguments presented by the Domion Post is that they put the full responsibility of transmission of HIV onto only one of the people having sex when it’s everyone’s job to make sure they are protecting themselves against transmission of HIV and other potential infections.

Outside of my work as a doctor I do not ask people their HIV status. Firstly because it’s none of my business but more importantly I understand just how difficult it can be for many HIV positive men. Have a look at this video that was recently shared on The Healthy Bear Facebook page.

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While the message is sent via dark humour the painful sting is evident. I’ve said it many times, if safe sex works when you don’t know your partners status why are there suddenly problems when we do? Yet another reason I don’t ask people’s status.

I choose to practice safe sex all the time, I know how to use condoms and I feel confident that they work well. If someone chooses to tell me they are HIV positive I understand what a hard thing it must be to do so I usually say something like “thanks for letting me know, let’s get to it eh 😉 “.

As noted above with people electing not to have HIV testing added to the significant risk of  unprotected sex during seroconversion I would urge people to take responsibility for their sexual health. Not everyone knows their status which can demonstrate the folly of sero-sorting, choosing only HIV negative or HIV positive partners, as a way to prevent infection.

So guys what are your thoughts on mandatory reporting of HIV status? I’d love to hear your opinion.

Yours in good health.

Dr George