Nearly everyone infected with HIV wants to avoid passing the infection along to others, whether a primary, one-time or in-between partner. We have different beliefs and practices, however, in how best to meet this goal, and one area of some controversy is whether or not one has a duty to disclose one's HIV status to every partner one has sex with. Some folks advocate that such is the clear responsibility of every HIV+ person every time. After all, condoms and other safer sex practices can fail. Others argue that disclosure of one's HIV status is not necessarily a precondition for protecting one's partners, and that one can, in fact, act safely toward others and not disclose, at least not before first sex.

This issue affects how prevention messages are crafted and delivered in our emerging work to help each other live powerfully but safely, also known as prevention for positives. It also affects the norms of discourse and behavior we each choose to reinforce and follow in our circles of everyday life. Below, I review two recent research studies that covered this issue, in part, and invite your comments as to where you would fit in or differ from these study populations reported practices, and what you think on the issue in general. I plan to follow up next month with a review of two more studies of this issue and a discussion of their implications.

A Study from the Early 1990s

Rich Wolitski (an out gay and HIV+ researcher at the Centers for Disease Control (CDC) in Atlanta, formerly of Long Beach) and his colleagues looked at 87 men three months after they had received HIV+ test results for the first time. These men were from a much larger sample of mostly white, Anglo gay and bisexual men in Seattle, Denver, Dallas and Long Beach.

Three months after testing positive, 89% of the HIV+ men had disclosed their status to their primary partner if they had one and 34% had disclosed their status to their non-primary partners. All together 53 out of 87 men had primary partners and 50 out of 87 reported one or more non-primary partners (the median number of non-primary partners over a three-month period was two, but the range was from one to 90).

With primary partners, there was not much difference in practicing safer behaviors between those who disclosed and those who had not, but the number of the latter was very small.

With non-primary partners, the proportion that reported risky practices was higher than with primary partners, but once again there was not much difference between the disclosers and the non-disclosers. Among the disclosers, 69% (ahem) reported insertive oral sex (getting blown) compared to 53% of the non-disclosers. Thirty-five percent of the disclosers reported unprotected receptive anal sex (getting fucked) versus 46% of the non-disclosers, and 53% of the disclosers reported fucking someone else without a condom compared to 42% of the non-disclosers. None of these differences were statistically significant, so we can say that disclosure was not associated with the practice of safer or protected sex one way or the other in this group.

One weakness of the study is that it did not ask whether or not the participants knew the HIV status of the partners with whom they had unprotected sex, though one might assume that with most non-primary partners during this time frame, the issue was not discussed.

A Study from 5P21 In 1995-1997

Gary Marks, now at the CDC and formerly at the USC School of Medicine, did several studies of the relationship between disclosure and safer sex among male clients of the 5P21 outpatient HIV/AIDS care clinic at LA County/USC Medical Center. An article at a leading AIDS scientific journal reports on a study of 206 HIV+ men in 1995, 1996 and 1997. Based on self-reports of their behavior during the previous three months, 41% identified were classified as gay, 35% bisexual and 24% heterosexual. The group was ethnically diverse: 21% white Anglo, 39% Latino and 40% African American with a median age of 37.

These men were drawn from a systematic sample of men approached in the waiting room or checking in at the reception desk, of whom 91% agreed to participate in the survey. These 206 were those who met the criteria of being at least 18 years old, speaking English or Spanish, knowing of their HIV status for at least six months, and being sexually active with someone of HIV-negative/HIV-status-unknown in the previous three months. Each participant completed the surveys privately and anonymously.

In their most recent sexual encounter (65% of which were in the preceding one month), 75% of the men engaged in safer sex and 25% engaged in unsafe sex, defined here as unprotected anal or vaginal intercourse. A little more than half (52%) disclosed their HIV status to their (HIV-negative or -unknown) partner and 48% did not.

The interesting fact is that the proportion of those who engaged in safer sex was not significantly higher among the disclosers (78%) than among the non-disclosers (73%). Marks therefore categorized the respondents into four groups: the 40% who disclosed and engaged in safer sex (informed protection), 35% who did not disclose and engaged in safer sex (uninformed protection), 12% who informed their partner and engaged in unsafe sex (informed exposure) and 13% who did not disclose and engaged in unsafe sexual behavior (uninformed exposure).

He also looked at correlates of each of these patterns (using informed protection as the baseline), and found that uninformed protection was more likely in participants whose partner was HIV-unknown (as opposed to known to be HIV-negative), in those who had tested positive in the previous three years (as opposed to earlier), and in participants who had low emotional involvement with their partner. Informed exposure was more likely in participants who had used alcohol or drugs before sex (which was also 70% correlated, unsurprisingly, with their partners similar pre-sex use of alcohol/drugs). Uninformed exposure was more likely in participants whose partner was HIV-unknown, who knew of their own status only recently, and in those who used alcohol/drugs before sex.

Though he cautions that the findings of this study need to be replicated in other populations before being regarded as definitive, Marks drew the conclusion that disclosure is not necessary for safer sex to occur nor is it sufficient to ensure safer sex. This is not to say that disclosure is unimportant, as it stands to reason that disclosure allows a partner more information and greater potential to help ensure his or her own protection. This finding does however point to the need not to assume that disclosure is enough, and supports the need to address other psychosocial factors involved in choosing safer sex, especially alcohol and drug use, and the assumption some make that if someone's status is unknown, that means they are probably positive anyway.

Next month, I plan to review two studies that deal with this key issue of the assumptions we make about the serostatus of our partners, and about other factors that seem to correlate with a higher likelihood of engaging in sexual practices that put our partners at risk, including alcohol and drug use, a history of childhood sexual abuse, and perceptions of a relatively lesser degree of responsibility for protecting one's partners.

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ÆGiS is made possible through unrestricted grants from Boehringer Ingelheim, iMetrikus, Inc., the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2001. This material is designed to support, not replace, the relationship that exists between you and your doctor.