How do gay men come to trust that “Undetectable = Untransmittable” (U=U)? Australian researchers conducted in-depth interviews with men who were in relationships where one partner had HIV and the other did not in order to find out.
The interviews were done three years ago, after the presentation of the first results of the PARTNER study, but before most HIV organisations had stated clearly that HIV-positive people who have an undetectable viral load do not transmit HIV to their sexual partners.
The study is most relevant to couples, but the interviewees have some interesting comments about applying U=U when meeting casual partners.
The researchers spoke to 21 men – ten who were HIV positive and eleven who were HIV negative. Most of the couples lived together and had been together for between one and five years. Just under half the couples were monogamous.
Most couples had a history of taking great care to avoid HIV transmission. Over time, they learnt about the possibility of relying on an undetectable viral load as a prevention measure.
In general, when the subject of sex without condoms came up, it was the HIV-negative partner that initiated the discussion.
The HIV-positive partners were often apprehensive and anxious about the idea, and the HIV-negative partners often needed to reassure them that they were making a well-informed decision, asserting their responsibility for their own sexual health.
Though couples agreed together to stop using condoms, HIV-negative partners ultimately made the decision because they were the ones ‘at risk’. One partner living with HIV said: “It was a mutual decision, but the ball was pretty much in his court”.
Some couples tried sex without condoms, but the partner living with HIV wanted to return to them. In negotiating these kinds of situations, partners usually made compromises when the other had strong feelings.
The men talked about factors that helped them get used to relying on an undetectable viral load. The experience of receiving consistent test results while having sex without a condom was often important. Test results made the concept of relying on an undetectable viral load less abstract – both the HIV-negative partner’s results showing he still did not have HIV and the HIV-positive partner’s results showing he was still undetectable.
One man said:
“As each year went on, you tended to worry about it less because I’d been with [my partner] for a while and had many incidents of unsafe sex, and I was still negative, so I could see that the risk wasn’t high. The worry about catching something became less.”
Being in a strong, communicative relationship was important. One HIV-negative partner said:
“I know his personality and he’s structured and organised. But I also know that he takes responsibility for his part in my health and so I have faith and trust in him that if there was an issue with bloods, we would talk about it.”
It was a different case with casual partners, as an HIV-negative man explained:
“[My partner] and I have trust and an understanding. But when you first meet someone and they tell you that [they are undetectable], then I’m like,‘Yes, but I only just met you. So I don’t know your history. I don’t know who you are.’”
The couples had worked out these strategies for themselves. Drawing recommendations from them for other couples, the researchers advise they discuss the following issues and negotiate a clear, spoken agreement covering:
- monogamy – or otherwise
- the possibility of not using condoms within the primary relationship but maintaining condom use and/or PrEP (pre-exposure prophylaxis) with any casual partners
- regularity of viral load and HIV testing
- regularity of STI testing for non-monogamous couples
- the importance of medication adherence
- ongoing communication about test results – and this agreement.