In recent years, increasing emphasis has been placed on understanding the risk of HIV transmission when the viral load is undetectable and no condom is used. However, limited qualitative research has been done to understand how knowledge of an undetectable HIV status informs gay men’s sexual decision-making.
We set out to learn about gay men’s experiences of being diagnosed with an acute or recent HIV infection. Our study took place from 2009-2013, during a time when a new test for detecting HIV during the early or ‘acute’ phase was introduced in Vancouver, British Columbia.
We interviewed 25 men with an acute (13) or recent (12) HIV diagnosis up to four times over the course of approximately one year.
During these interviews, men were asked to talk about a range of experiences, including their sex lives, since being diagnosed with HIV. We did not specifically ask men about having an undetectable viral load; instead, the significance of this emerged as men spoke about their diagnosis and their social and sexual lives over time.
Sexual Activity and Risk Management
Almost all of the men interviewed talked about how changes in HIV viral load over time affected their sexual decision-making.
Participants reported that knowing their viral load influenced decisions to return to sexual activity. For example, one man explained not wanting to engage in sexual “play” until he knew he was “undetectable”:
“They [sexual partners] would be open to it, but I didn’t want… personally I didn’t feel comfortable, so I didn’t play until I knew I was undetectable. I had started my meds already, but until I knew I was undetectable on my meds, then I didn’t start playing”.
Men who spoke about starting sexual activity again before having an undetectable viral load described taking a number of steps to “be responsible” and maintain both their comfort and the health of their sexual partners.
Another man talked about low viral load as part of his overall HIV risk management strategy:
“I don’t view…I don’t view the diminution of risk from starting treatment as license to be less careful. I more see it as something that suppresses the risk even further”.
Emotional and Psychological Milestone
Being told of their undetectable viral load was described as a significant milestone for most participants. Men said “getting to” a suppressed viral load made them more comfortable when having sex and disclosing their HIV status, as well as increasing their sexual freedom and decreasing concerns about transmission.
One participant described the multiple sexual, emotional and psychological benefits of his continued HIV treatment:
“Once the doctor says to you that you are undetectable and you are, like, well on your way, and when you find out that you are this healthy, I mean, how do you go wrong? Where do you go wrong with that? Do you know what I mean? You feel like, “Okay, I can live again. I can go date guys.”…So mentally and emotionally, in so many different ways it relieves that block knowing, okay, I can tell you I am HIV positive, but I am undetectable which means it’s a lot harder to get it from me.”
Beyond sexual activity, men reported additional impacts from knowing their undetectable HIV status. One participant explained that having an undetectable viral load:
“was the milestone of, number one, accepting that I actually have this condition and number two, taking proactive steps to manage it. […] In a very vague sort of way, you could sort of say that being undetectable means I am normal again.”
Sexual Possibilities and Rejections
Men also discussed that having an undetectable viral load is its own category of HIV status among some gay men. For example, one man said that when hooking up online “….most guys, they put ‘undetectable’, actually, instead of that they’re ‘positive’”.
A few participants described rejection from prospective sexual partners online, not because of their HIV positive status, but because they were not “undetectable”.
Need for Guidance
Some men reported continued sexual caution around how to interpret being told they now “can’t pass it [HIV] on”. A number of participants identified the need for clear information for people living with HIV to support them in negotiating the possibility of transmission between HIV-positive men. For example, one man noted:
“There is very [little] information for positive people about how damaging it can be to have unprotected sex with other HIV people”.
For many participants, knowing their undetectable status became part of their sexual decision-making process and their identities as HIV-positive gay men. The significance of being undetectable was discussed in multiple ways, including:
- an aspiration or goal to achieve
- a rationale for starting or continuing treatment
- a signifier of a return to normalcy post-diagnosis
- a source of emotional and mental comfort
- a facilitator of HIV-status disclosure
- a category enabling sexual possibilities and/or rejections
- for some, a source of discomfort, contention or confusion requiring further public health guidance.
For more information
For further information about these findings please see the full article:
Grace, D., Chown, S. A., Kwag, M., Steinberg, M., Lim, E., & Gilbert, M. (2015). Becoming “Undetectable”: Longitudinal Narratives of Gay Men’s Sex Lives After a Recent HIV Diagnosis. AIDS Education and Prevention, 27(4), 333-349. http://guilfordjournals.com/doi/abs/10.1521/aeap.2015.27.4.333
Or contact Daniel Grace at Daniel.Grace@utoronto.ca
This research was carried out as part of a larger program of research with the Canadian Institutes for Health Research (CIHR) team in the Study of Acute HIV Infection in Gay Men, in partnership with our community partners, Positive Living BC and Health Initiative for Men.