The HIV prevention implications of linking responsibility with disclosure

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Disclosure as a prevention strategy, in the end, has several pitfalls: it presumes that both prospective sex partners are certain of their sero-status; it tacitly transfers responsibility for safer sex to HIV-positive people; and it raises the prospect of becoming involved in legal process. The belief that HIV-positive people invariably know their sero-status and will disclose it may encourage HIV-negative people to be less consistent in practising safer sex and to expose themselves to greater risk.

Social scientist Barry Adam and colleagues, Canada, 2008.1

One of the main reasons that UNAIDS,2 as well as HIV prevention experts3 and other commentators4,5,6,7,1,8 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 countries11,12,13,14,15,16 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 Kingdom12,13 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

References

  1. Adam BD et al. Effects of the criminalization of HIV transmission in Cuerrier on men reporting unprotected sex with men. Canadian Journal of Law and Society 23(1-2):143-59, 2008
  2. UNAIDS/UNDP Policy brief: criminalization of HIV transmission. Available online at: http://data.unaids.org/pub/%20BaseDocument/2008/20080731_jc1513_policy_%20criminalization_en.pdf, 2008
  3. Simoni JW and Pantalone DW Secrets and safety in the age of AIDS: Does HIV disclosure lead to safer sex? Top HIV Med 12 (4): 109-114, 2004
  4. Galletly CL and Pinkerton SD Conflicting messages: how criminal HIV disclosure laws undermine public health efforts to control the spread of HIV AIDS Behav. 10: 451-461, 2006
  5. IPPF, GNP+, ICW Verdict on a Virus: public health, human rights and criminal law. Available online at: www.ippf.org/en/Resources/Guides-toolkits/Verdict+on+a+virus.htm, 2008
  6. Burris S, Cameron E, Clayton M The criminalisation of HIV: time for an unambiguous rejection of the use of criminal law to regulate the sexual behavior of those with and at risk of HIV. Social Science Research Network, 2008
  7. Jürgens R et al. Ten Reasons to Oppose the Criminalization of HIV Exposure or Transmission. New York: Open Society Institute, 2008
  8. Reeders D The impact of criminalisation on community-based HIV prevention. in Cameron S and Rule J (eds), The Criminalisation of HIV Transmission in Australia: Legality, Morality and Reality, NAPWA, 2009
  9. Marks G et al. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 20(10):1447-50, 2006
  10. WHO Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Geneva, 2009
  11. Dodds C et al. A telling dilemma: HIV disclosure between male (homo)sexual partners. Sigma Research, available online at: www.sigmaresearch.org.uk/downloads/report04e.pdf, 2004
  12. Keogh P et al. Morality, responsibility and risk: Gay men and proximity to HIV. Sigma Research, London, 2006
  13. Weatherburn P et al. Multiple chances: findings from the United Kingdom Gay Men's Sex Survey 2006. Sigma Research, 2008
  14. Gorbach PM et al. Don’t ask, don’t tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle. Sex Transm Inf 80: 512-517, 2004
  15. Lake R Don’t ask, don’t tell? Disclosure and HIV. HIV Australia 6 (4), 2008
  16. Zablotska I et al. Gay men’s current practice of HIV seroconcordant unprotected anal intercourse: serosorting or seroguessing? AIDS Care 21, 2009
  17. Stevens PE and Galvao L “He won’t use condoms” HIV-infected women’s struggles in primary relationships with serodiscordant partners. Am J Public Health 97 (6): 1015-1022, 2007
This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
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This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.