Understanding the promise of biomedical prevention for couples of mixed HIV status: workshop report

As has been widely discussed, we sit at a historic turning point in scientific understandings of HIV infectiousness with increasing proof now available that antiretroviral treatment can effectively prevent the sexual transmission of HIV.

Much of the social research on this development has suggested, however, that people with HIV and those at high risk of acquiring HIV – particularly gay men – remain largely sceptical of the potential of HIV treatment to prevent transmission.

Yet the promise of biomedical prevention can hold considerable appeal for those in serodiscordant relationships.

A research workshop hosted at UNSW Australia in May 2015 discussed some of these complexities with reference to emerging results from the first qualitative study of the needs and experiences of couples of mixed HIV status.

Led by the Centre for Social Research in Health (CSRH), YouMe&HIV explores how the emerging HIV ‘treatment-revolution’ is shaping sexual practices, risk perceptions, service engagement and the everyday realities of living serodiscordantly, among gay and heterosexual couples in metropolitan and regional NSW.

The study commenced in 2013, running for three years. During 2013 and 2014, in-depth interviews were conducted with 38 participants in serodiscordant relationships, including 18 HIV-positive and 20 HIV-negative partners.

Given the rapidly evolving nature of this area, the workshop was conducted to provide an opportunity for service providers and stakeholders to be involved at the early stages of research findings rather than at the post-report end, so that the sector input could inform the focus and recommendations of the research report.

Workshop participants had policy, practice or research expertise relating to serodiscordant couples.

The workshop was a joint event by CSRH, The Kirby Institute and the Australian Research Centre In Sex, Health And Society (ARCSHS).

Facilitator Graham Brown (ARCSHS), provided an overview of the HIV Futures data on serodiscordance across time.

This was followed by a presentation from Ben Bavinton (The Kirby Institute) on Opposites Attract, a cohort study of gay men in serodiscordant relationships, and several in-depth and work-in-progress analyses of the YouMe&HIV qualitative data by Asha Persson and Christy Newman (CSRH).

Emerging findings were reported in relation to the distinctive themes of ‘pharmaceutical citizenship’, ‘trust in HIV medicine’, ‘attitudes to PrEP’ and ‘making families’, providing the basis for lively discussions among the workshop participants.

The promise of biomedical prevention was an overarching theme across the day, starting with Asha’s exploration of the way couples with mixed HIV status are making sense of the emerging global strategy of HIV ‘treatment as prevention’ (TasP).

Her presentation posed the timely question: can TasP de-stigmatise serodiscordant sexuality away from its historical moorings in discourses of risk? The potential of treatment to reframe the meaning of serodiscordance was clearly valued by the couples who took part in the study.

As Christy’s subsequent presentation noted, study participants also appeared highly trusting of HIV medicine more generally, largely speaking positively about the benefits of treatment and their experiences engaging with care providers.

Those who had conceived, or were interested in conceiving children, reported mixed experiences of the understanding and support provided by services. However, this was recognised by study participants to be a rapidly changing field, and one which was also responsible for a ‘baby boom’ among families affected by HIV in Australia.

Although many study participants were aware of pre-exposure prophylaxis (PrEP), interest varied widely, with half the couples seeing PrEP as irrelevant because they considered serodiscordant sexuality as safe due to TasP, regular testing and, for some, condoms.

Others thought that PrEP could play a role in enabling condomless sex and enhance their relationship.

While it is timely to recognise the many benefits of treatment for those who are currently in, or open to exploring, a serodiscordant relationship, a number of issues were also raised and debated during the workshop discussions.

Implications for changing understandings of and approaches to disclosure was a concern for a number of workshop participants, as was the recognition that those people who are not able to successfully achieve viral suppression – for varied reasons – are not likely to benefit in the same way.

Questions were raised about how services could effectively engage both partners in a serodiscordant couple when most service activities are necessarily focused on (and funded to support) the positive partner.

Differences in the needs and experiences of couples identifying as gay or straight were also examined, as were the complex influences of cultural background and geographic location.

A valuable conclusion that emerged from the workshop discussions was that TasP can be incredibly empowering and liberating for couples, enabling a welcome sense of social and sexual belonging and ‘legitimacy’. We also need to stay vigilant that TasP does not become a one-size fits all solution, or a blanket norm that can place coercive obligation on couples and people with HIV more broadly, creating new forms of exclusion and stigma, as well as overshadowing issues such as mental health, immigration, and other social complexities around HIV.

The opportunity to discuss the emerging findings of the study with colleagues in the sector provided insights that will help us ensure the final results are directly pertinent and useful as we navigate the new opportunities and challenges of TasP across communities.

Dr Christy Newman and Dr Asha Persson are Senior Research Fellows at the Centre for Social Research in Health (CSRH), UNSW Australia.

Dr Graham Brown is Senior Research Fellow at the Australian Research Centre in Sex, Health and Society (ARCSHS), La Trobe University.

Dr Jeanne Ellard is a Research Fellow at ARCSHS.

Ben Bavinton is Associate Lecturer at The Kirby Institute, UNSW Australia.