The HIV prevention implications of linking responsibility with disclosure

One of the main reasons that UNAIDS,² as well as HIV prevention experts³ and other commentators^4,5,6,7,1,8 find the linking of disclosure with responsibility for sexual risk-taking particularly objectionable is because disclosure is an unreliable HIV prevention method.

In a 2006 article questioning the effectiveness of United States criminal laws obligating disclosure of known HIV-positive status prior to sex, Carol Galletly and Steve Pinkerton point out that for such laws to have the desired outcome: “HIV-infected persons must be aware of their positive HIV status; second, HIV-positive persons must possess the skills needed to enable them to disclose their serostatus under all social and environmental circumstances; third, HIV-positive persons must choose to disclose their serostatus to all potential sex partners despite the sometimes substantial disincentives to doing so; and fourth, prospective partners, once informed, must either forgo sex entirely or practice safer sex.”⁴

The first point alone suggests a major HIV prevention obstacle: the majority of people who are infected with HIV do not know they have the virus.^9,10 In addition, as explained below, not all people aware they are living with HIV are willing or able to disclose their HIV status every time they have sex that risks HIV exposure. If their sexual partners fail to recognise this, and think instead that HIV-positive sexual partners should and will always disclose their status, they may fail to take steps to reduce their risk of becoming infected.

Research amongst gay men from high-income countries^{11,12,13,14,15,16} suggests that most HIV-negative and untested men think that men with HIV should disclose their status before having sex and that if they don't disclose they are, by default, not infected.

Studies from the United Kingdom^12,13 have found that there may be an important relationship between how HIV-negative and untested individuals perceive the role of HIV in their lives and what they expect from sexual partners with regards to disclosure of known HIV-positive status. Those who felt that HIV was not relevant to their lives, and did not consider themselves at risk, tended to expect to be told by a sexual partner when that partner was HIV-positive and were more likely to reject an HIV-positive partner. On other hand, those who acknowledged that HIV risk was a part of their lives were more willing to accept shared responsiblity for HIV prevention and to respond sensitively to their sexual partner's disclosure of their known HIV-positive status.

Although it is not possible to know how generalisable the findings are to other settings, they clearly demonstrate the potential for cognitive and emotional awareness of HIV risk to inform both perceptions of responsibility and expectations of dislosure.

He won't use condoms. It has been three years we will be together, and he just won't. I let him have his way now. I don't even talk about it anymore. I can't say no to sex. I've already tried, and it doesn't work. And I don't want to keep fighting with him. So I don't even bring condoms up anymore. (HIV-positive woman in Wisconsin, United States¹⁷)

However, even if an HIV-positive individual has acted 'responsibily' and disclosed their HIV-positive status to their sexual partner, this does not necessary mean that safer sex will ensue. A 2007 study of 55 HIV-positive women in the United States, all of whom had disclosed their HIV-status to their partners, found that ten of the women who had attempted to initiate condom use engaged in unprotected sex regularly at the insistence of their male partners. It concluded: “These findings suggest that HIV-infected women like those in our study do not carelessly engage in sexual risk; rather, they are well informed and deeply troubled by sexual risk.”¹⁷

A wide-ranging 2004 review of studies in this realm concluded that, “human relationships and sexual interactions are vastly complex, with myriad motivations, incentives and risks involved. Deceptively simple HIV prevention interventions such as encouraging disclosure will probably never succeed on their own.”³