The Era of Undetectable
What does the word ‘undetectable’ mean to you? My guess is that it means something different to each person. I immediately gravitated towards this article because it has been a point of frustration and trepidation in many of my educational outreach attempts. It speaks to the very core of the problem and why the usage of this word is so dangerous in the wrong environment and context. I applaud the author of this article for doing such a wonderful job at deconstructing the concept and rebuilding it in terms of social responsibility and the ultimate premise that we have to look out for ourselves because no one else will. First I must apologize for the delay in getting you a new article. The previous weeks have been a whirlwind of bustling errands and trying to cultivate relationships with people both of the community and in my social life.
So why would this seemingly innocent topic cause me much turmoil? I will go out on a limb here and give a very simplistic answer of ‘ignorant misconception.’ I use this term with a bit of bias because I am still enraged at the sheer unwillingness of certain individuals to listen to reason. While there are two sides to each story, keep in mind that health care professionals, while not perfect, ARE here to promote public and individual health.
At my previous job, I had cultivated many relationships with my patients—some of which were very superficial and some of which were deep. I enjoyed this dichotomy and respected each individual’s right and preference to engage me in whatever social interaction they saw fit. One particular individual, let’s call him HD, was attracted to me and would tend to be very open with me as far as his sexual preferences and activities. For those of you who know me, it takes a lot to shock me and hearing details of someone’s sexual prowess does not bother or shock me. In fact, I felt that his willingness to talk to me about this aspect of his life was promising in that he would also be likely to talk to me about other private matters which would position me to help him even further should he ever need it. He had since moved away, but we continually kept in touch. One day in a Facebook chat (as I hang my head in shame), we entered a discussion ultimately about bareback sex. My personal position on this issue is that bareback sex is an amazing and intimate thing to share between two people committed to each other, both of whom have been tested for the cornucopia of communicable diseases and pose minimal risk to transmit disease to the other person. Yeah…. In a perfect world. Truth of the matter is that even I have made mistakes when it comes to this, whether it be bad judgment or in the heat of the moment when all logic and rational thought goes out the window. Back to my friend HD… We had been talking about his treatment regimen, how he was tolerating it, his ‘numbers’ (CD4 and VL) and his overall health. He had been so proud of doing so well on therapy and finding the regimen that was working so well for him. Our conversation then shifted to his sexual escapades and in hearing how many partners he had recently, I could hear the elation in his voice. It was as if he had regained a part of himself that he had lost while trying to figure out the regimen that would be right for him. In one simple and brief statement I remember saying “Please tell me you are being safe.” In retrospect, it was a poor choice of words on my part and adding into the mix that this was a chat, where tone and expression are both lost in the alphanumeric shuffling of characters. However, I do feel that our relationship had matured to the point that he knew I was asking for the sake of concern, not only for him but for his partners as well. After the deafening silence, he immediately went on the defensive and became incredibly angry, accusing me of judging him. The sensitivity bomb had exploded and there was no recanting my statement. No matter what logic or empathetic statement that proceeded, he was not going to listen. That was the day my friendship/relationship with HD ended.
While I lament the loss of my relationship with said individual, I do not regret being an advocate for safe sex. It was around this same time that the first reports of cephalosporin-resistant Neisseria gonorrhoeae in the USA had been released and not only was I concerned for his safety, but also living in a highly homosexual-based area, it put everyone at an even bigger risk. There are so many factors involved here (social stigma, education, personal boundaries, etc.), so I cannot begin to explain the psychological workings of everyone, but I think with such a sensitive topic, we need to all remain open to hearing things we might otherwise be uncomfortable with for the sake of our health.
So by now you might be questioning the link between this story and the title of the article. The reason that I chose to illustrate my point with that story is because HD had finally achieved “undetectable viral load” and at that point he felt that he was able to practice unsafe sex without risk.
This is where the ‘ignorant’ part comes into play. I realize that the term ignorant makes me sound judgmental, but hear me out. In life we are all given an individual hand to play, and each play that we make is usually a calculated and precise, weighing the good vs. the bad. How do we make such a decision? What information is available to us when we make this decision? Who actually makes the decision? These questions are the basis for my explanation. We, as individuals, are ultimately responsible for the decisions we make and we must acknowledge that the decisions we make have repercussions, not only for us, but for anyone involved. Sex is no exception to that rule. Using the most basic model of sex (one on one); both parties involved are responsible for their own decisions. I won’t even try to tackle the belief that there lies a corresponding moral obligation to consider the other party’s well-being. This being said, it should be up to each person to ensure their safety and in doing so will likely maximize the safety of the other party. Unfortunately, the word ‘undetectable’ has gone from being a term used to report the virologic status of a patient to a term relating to the safety of having unprotected sexual relations.
The word ‘undetectable’ means ‘the inability to detect the existence of something’ (dictionary.com). Currently, the tests used to measure viral load in HIV-positive individuals are sensitive enough to detect 40-50 copies/mL and anything under that limit is considered ‘undetectable’. It does not mean that an HIV-positive individual cannot transmit the virus to an uninfected party; it only means that the level of virus in the bloodstream is lower than current technology can detect. A logical conclusion would be that the lower the amount of virus in the blood, the lower the risk of transmission and this conclusion is actually correct. The article I cited in the beginning claims that there is a 96% reduction of transmission by being undetectable. I’ve actually heard this figure as high as 98%, but that is irrelevant. Let’s assume that the 96% risk reduction is true. That means that there is still a 4% chance of transmission. Is that a chance that you want to take? Are you comfortable in playing those odds?
In my many years in the field I have encountered many individuals with varying degrees of opinions on this topic. Some people have told me that it is the other person’s responsibility to ask. Some have told me that it is each other’s responsibility to have the discussion and then there are those people who think that if it is not discussed that anything goes. Surely you can see how dangerous these conflicting views can be, especially when combined with the excitement and ‘urgency’ of the biochemical rush of dopamine in the brain (responsible for pleasure).
I think that Mr. Curry’s article hits a literary homerun and speaks directly to the problem here. We need to not be complacent in thinking we are winning the war on HIV/STIs (sexually transmitted infections). As long as new infections are emerging, then we are clearly not winning. For anyone reading this article who may be new to the gay community (or to sexual relations in general), please be responsible with your health and your life. When I came out to my mother, one thing she said to me that has ALWAYS stuck with me was “be smart with your health and your life—you only get one!” With the emergence of antibiotic-resistant bacterial infections, the dwindling numbers of promising antibiotics in development, lack of a cure for several STIs as well as the overtaxing of the US healthcare system, we as individuals need to be more cognizant than ever in keeping ourselves healthy and ultimately happy.