One of the main reasons that UNAIDS,2 as well as HIV
prevention experts3
and other commentators4,5,6,7,1,8 find the
linking of disclosure with responsibility for sexual risk-taking particularly objectionable
is because disclosure is an unreliable HIV prevention method.
In a 2006 article
questioning the effectiveness of United States criminal laws obligating
disclosure of known HIV-positive status prior to sex, Carol Galletly and Steve
Pinkerton point out that for such laws to have the desired outcome:
“HIV-infected persons must be aware of their positive HIV status; second,
HIV-positive persons must possess the skills needed to enable them to disclose
their serostatus under all social and environmental circumstances; third,
HIV-positive persons must choose to disclose their serostatus to all potential
sex partners despite the sometimes substantial disincentives to doing so; and
fourth, prospective partners, once informed, must either forgo sex entirely or
practice safer sex.”4
The first point
alone suggests a major HIV prevention obstacle: the majority of people who are
infected with HIV do not know they have the virus.9,10 In addition,
as explained below, not all people aware they are living with HIV are willing
or able to disclose their HIV status every time they have sex that risks HIV
exposure. If their sexual partners fail to recognise this, and think instead
that HIV-positive sexual partners should and will always disclose their status,
they may fail to take steps to reduce their risk of becoming infected.
Research amongst
gay men from high-income countries11,12,13,14,15,16 suggests that
most HIV-negative and untested men think that men with HIV should disclose
their status before having sex and that if they don't disclose they are, by
default, not infected.
Studies from the
United Kingdom12,13
have found that there may be an important relationship between how HIV-negative
and untested individuals perceive the role of HIV in their lives and what they
expect from sexual partners with regards to disclosure of known HIV-positive
status. Those who felt that HIV was not
relevant to their lives, and did not consider themselves at risk, tended to
expect to be told by a sexual partner when that partner was HIV-positive and were more likely to reject an
HIV-positive partner. On other hand, those who acknowledged that HIV risk was a
part of their lives were more willing to accept shared responsiblity for HIV
prevention and to respond sensitively to their sexual partner's disclosure of
their known HIV-positive status.
Although it is not
possible to know how generalisable the findings are to other settings, they
clearly demonstrate the potential for cognitive and emotional awareness of HIV
risk to inform both perceptions of responsibility and expectations of
dislosure.
He
won't use condoms. It has been three years we will be together, and he just
won't. I let him have his way now. I don't even talk about it anymore. I can't
say no to sex. I've already tried, and
it doesn't work. And I don't want to keep fighting with him. So I don't even
bring condoms up anymore. (HIV-positive
woman in Wisconsin, United States17)
However, even if
an HIV-positive individual has acted 'responsibily' and disclosed their
HIV-positive status to their sexual partner, this does not necessary mean that
safer sex will ensue. A 2007 study of 55 HIV-positive women in the United States,
all of whom had disclosed their HIV-status to their partners, found that ten of
the women who had attempted to initiate condom use engaged in unprotected sex
regularly at the insistence of their male partners. It concluded: “These
findings suggest that HIV-infected women like those in our study do not
carelessly engage in sexual risk; rather, they are well informed and deeply
troubled by sexual risk.”17
A wide-ranging
2004 review of studies in this realm concluded that, “human relationships and
sexual interactions are vastly complex, with myriad motivations, incentives and
risks involved. Deceptively simple HIV prevention
interventions such as encouraging disclosure
will probably never succeed on their own.”3