Reevaluating reinfection. (last word).

For a long time one mystery about HIV transmission was just that: a mystery. Could someone already infected with HIV get reinfected with a different strain that would make treatment more difficult? The reason this was hard to prove was quite simple: It would be unethical to reinfect someone to test the hypothesis, and very few cases existed where reinfection had provably occurred.

But we now have evidence that it's absolutely possible. A recent report in The New England Journal of Medicine tells the story of a man who contracted a strain of HIV-1 that's prevalent in Southeast Asia (called clade AE) and subsequently also contracted a strain in Brazil (clade B) of a type more prevalent in the United States. The good news is that both strains proved highly susceptible to current medications and the reinfection occurred while the patient was off meds. The bad news is that the new viral strain clearly accelerated disease progression, as the patient's immune system didn't seem to recognize the new virus and fight it effectively.

The science is fascinating, but the implications for our health are just as important. In the past five years or so, more of us have enjoyed a new lease on life with HIV. Death rates have plummeted; new treatments have improved the quality of life for HIVers in ways that few of us imagined a decade ago. Gay men with HIV are no longer sexual pariahs, and some of the treatments (testosterone replacement therapy among them) have even made some HIVers beefier than their seronegative peers. One way some men helped combat the spread of HIV was by dating or having sex with only other pozzies. But the poz-poz experience wasn't just about containing the epidemic. For long-term survivors, there was and is something psychologically liberating about sex without the fear of giving someone else HIV--or simply sex with a man who gets the HIV experience, who understands.

It was, I think, inevitable that this complicated mix of feelings--liberation, relief, responsibility, escape--would lead to an HIV-positive subculture of affirmative HIV-positive sex. And it was also inevitable that some of this would lead to leaving condoms behind. I wrote about the liberation of my first-ever condom-free sex with another HIV-positive man in my last book, Love Undetectable. It was part of my psychological and emotional healing process--to return to the sexuality that HIV had stigmatized and to celebrate it once again. It was an act of comfort and defiance. For many it still is. We worried somewhere in our minds that we could be reinfecting each other, but there was no proof--the meds kept the virus under control, and with honesty and disclosure, we believed (rightly, I think) that we were being ethical in our sex lives.

There are some strong arguments why this kind of sex is still, to my mind, defensible. HIV-positive men on meds with minimal viral loads are not very infectious. Studies of serodiscordant couples in Africa found that even with unprotected sex, infection took place only where viral loads exceeded a certain significant level. The meds themselves almost certainly help prevent reinfection as well. Besides, reinfection is nowhere near as grave a matter as infection, and the new strains of HIV may actually be less potent than previous ones. And so on.

But we now also have more information, and it's worth absorbing. Ethically and medically, condom-free sex between two disclosed HIV-positive people is not the same as unsafe sex with someone whose HIV status is unknown. That's why crude denunciations of bare-backing strike me as dumb and unhelpful. But even with two openly HIV-positive people, the chance of undermining our own survival should lead us to rethink what we are doing and why. Even when we disclose, even when we freely choose in private, danger still lurks. These trade-offs--between liberation and longevity, intimacy and health, known pleasures and unknown risks--are not easy. And our judgment is often clouded by the urgency of passion or need as well as the desire to put this epidemic, with all its terror and constraints, behind us. But we have now been warned. The science is clear. And we almost certainly need to adjust.