‘Was My Agency Violated?’

Q:

My partner, a transfemme person, engaged in safe sex with someone who disclosed her status as HIV positive with zero viral load. This was when we were on a break, and according to my partner, they exchanged saliva and did not have any other contact with each other’s sexual fluids. Less than a month later, my partner and I reunited, and had unprotected sex and have since continued our relationship. However, at the time that we reunited, they had not gotten tested yet (the test happened a month later, and came out negative). I did not think to probe further, I just assumed it was a regular test since they had engaged with multiple people sexually during our break. When I found out about this in an unrelated conversation about breaches of trust between us involving this same person they had the aforementioned encounter with, I confronted them about it. They were initially defensive. The reason given: the other person’s confidentiality, the ‘super safe’ sex, and the negative test (which came a month later, after we had already begun to have sex again). The thing is: she is not someone they know well, and they are barely friends outside of this equation, and moreover, disclosed her HIV status in a sidelong mention about something else on the date, almost as as aside, according to my partner’s account (I would personally prefer to have more time to think through any safety concerns I have, however real or imagined). And even if, as they claim, they had good reason to trust her self-declaration (zero viral load) I feel that this trust is not transferable to me because I don’t know her. I feel like my agency to make my own choices about my body has been treated like a joke, and I’m shocked at my partner’s audacity to put my health at risk based solely on their risk-analysis. I am now finding myself unable to trust them or forgive them. Am I wrong to feel like I don’t know who my partner is anymore? I know, or at least knew them to be a good feminist, who would avoid an obvious pitfall like stripping real agency away from female-socialised people like me and I don’t understand how some stranger’s ‘confidentiality’ comes before my safety.

A:

This is a complex situation. I’m glad I picked it up since I’m trans, have experienced HIV scares and live in a country with intense HIV education (South Africa). I’m going to split my answer into a biomedical component to address risks and sexual activity, and the murkier moral component about the right and wrong of this. Strap in.

HIV transmission, risk, and you

The biomedical side is actually simpler for me to address. What I’ve gathered from your write-in are facts you trust and debatable narratives (mostly coming from your partner).

The facts you can reasonably trust are:

• Your partner had sex with someone with disclosed HIV+ status.
• You and your partner had unprotected sex less than a month after their possible HIV exposure.
• Your partner received a negative result from an HIV test taken more than a month after possible HIV exposure.

The more uncertain narratives you’re facing include:

• The truth of the ‘zero viral load’ declaration, and your partner’s recounting of it to you.
• The type and volume of bodily fluid exchange during your partner’s sexual encounter.

When faced with uncertainty, the best things you can lean on are the facts. For the purposes of my writing, I’m going to assume that your partner is telling the truth about having sex with someone who disclosed HIV+ status because I really don’t see why they’d lie about that.

HIV transmission risk from certain forms of contact

Taking your partner’s statement about salivary exchange only and no other fluid exchange at face value actually leads to good data. Oral-to-oral transmission of HIV is vanishingly rare. The few cases that do exist are exploratory and debatable. Those cases often include other factors like open mouth sores or actively bleeding gums that increase the risk. Oral-to-oral HIV transmission is so rare that a verifiable case would constitute a defining event in medical history. Vaginal-to-oral transmission is also incredibly rare.

From one trans woman to someone dating a trans woman: I don’t know what genital configuration your partner has, but if they have a penis and used it insertively without a condom, the risk skyrockets to ‘typical’ rates. Stanford gives the estimated risk of HIV transmission during penile-to-vaginal penetrative sex as 0.04 to 0.08% per sex act (presumably unprotected). This is not high for a single act of unprotected sex, but I think we’d all prefer to live a life where the risk percentage was closer to zero.

These figures I’m citing (from various sources) don’t assume an undetectable viral load. Having an undetectable viral load (AKA viral suppression) effectively reduces transmission risk to zero. Viral suppression occurs when circumstances (usually effective treatment) suppress the viral load so much that it becomes undetectable to standard tests (even standard lab tests). At that point, infection shouldn’t have any noticeable effect on bodily health and would only be detected by specialized high-sensitivity tests. It’s kind of the ideal HIV management for people who are HIV+: The disease is present and incurable, but it’s so weakened that it can’t realistically harm the person.

I’ll note that your partner calling it ‘zero viral load’ is technically inaccurate. Viral suppression pushes the viral load so low that it becomes undetectable by testing. The virus exists, but tests are not sensitive enough to spot it and transmission is effectively impossible.

Oral-to-oral HIV transmission is almost nonexistent and the few documented cases usually involve added risk factors like open mouth sores, a highly progressed case of HIV (higher viral load), or active bleeding. Oral-to-genital transmission is also rare enough that most HIV resources I’ve encountered consider it a non-issue except in the presence of open sores and bleeding. If your partner’s account (salivary exchange only, viral suppression in their partner) is true, the likelihood of HIV transmission would be very, very low. Also, your partner is way out of the window for post-exposure prophylaxis (PEP). PEP is only considered effective within 3 days of exposure. If they were on pre-exposure prophylaxis (PreP), then the risk of contracting HIV during a single sex act would have been nearly non-existent.

HIV test validity and window periods

The period between possible exposure and detection by an HIV test is known as the window period. HIV takes time to establish itself in the body and duplicate to the point of being detectable by tests. Some tests are more sensitive than others at detecting infection—I’m using the data from that link for my discussion. These figures are best estimates based on population studies, and there’s always room for variation due to anatomical differences, methods used, and error.

Laboratory tests are the most sensitive. Incorrect results from correctly performed laboratory tests are very rare, and they’re commonly used to confirm or refute a rapid test result. They are more expensive and time-consuming. According to UK guidelines, a current-generation laboratory test can safely be considered accurate 45 days after exposure. Testing sooner than that may yield a false negative result, with risk of falsehoods rising the sooner the test is done after exposure.

Rapid tests like those used for quick screening, or by people at home are less sensitive. The data I linked states that current and older generation rapid tests detect about 50% of infections between 20 and 40 days. They reach near-perfect (99%) detection rates about 60 days after exposure. The UK guidelines further mitigate risk by stating a 90 day window period for rapid tests. That is to say, under UK medical guidelines, a rapid test should be considered highly accurate if performed 90 days after exposure.

Taking your timeline at face value, your partner’s HIV test would have occurred in the window period. During this period, there’s a considerable chance that the test would not have detected HIV if HIV was already present. This worst-case scenario presumes they’ve contracted HIV. Which isn’t very likely from a single sexual encounter, much less an encounter that involved no penile penetration.

Taking the encounter they described at face value, their risk of HIV infection would have been very, very low. Think ‘unusual medical case study’ low. That also means transmission risk to you (since you’ve resumed unprotected sex) is even lower. If they contracted HIV during their encounter, it would take time before their viral load builds up enough to pose a meaningful risk to you.

If you want greater certainty, I’d request your partner take a follow-up HIV test later on. If it’s a rapid screening test, it should be taken about 90 days after possible exposure. If it’s a laboratory test, 60 days after possible exposure is fine. You could consider a rapid screening test for peace of mind, I suspect that would turn up negative.

A test taken during the window period is a step in the right direction, but not fully reliable. Both of my HIV scares involved an early test and a follow-up test months later. Requesting a follow-up HIV test from your partner would be in line with standard medical practice after possible HIV exposure. If they respond negatively, you’d be right to feel concerned and more importantly, end sexual activities due to the uncertainty of risk involved.

Much is said about safe sexual practice and risk mitigation. When someone has sex with someone else with a disclosed sexually transmissible condition under questionable circumstances, they stop being a safe sexual partner. The status of a safe sexual partner can only be restored by taking appropriate steps to screen for the condition and minimize risk.

The emotional and moral question

The HIV education section of your question was the easy part. Can you believe it?

Right away, I think you’re right to be upset about this.

People have a right to privacy about their infection status for any condition, but more so for highly stigmatized conditions like HIV. It’s medical information. It can result in unfair discrimination or direct harm.

However, the right to medical privacy and infection status only applies at full strength when the affected person poses no meaningful risk to others. When someone’s medical status can adversely affect others, it’s no longer just their business. It’s the business of everyone involved.

This is why businesses could deny service or entry to COVID-positive people during the pandemic. It’s why airports can deny entry or enforce additional screening on people with elevated body temperatures. It’s why schools (in many jurisdictions) can deny entry to students who have a diagnosed lice infection. All of these examples are situations where actors discriminate against people based on suspected infection status. They’re usually considered ‘right’ and legal for the reason I outlined above. Medical information stops being sacred when other people can be exposed to risk.

I understand why your partner considers their sex partner’s HIV status worthy of protection. HIV+ status is highly stigmatized and since you don’t have a close relationship to the person, you would not be entitled to know it under ordinary circumstances. However, having sex with an HIV+ without verifying their claim of suppressed viral load, and then having unprotected sex with you means that you are now involved in this chain of risk. This is now your business, and the person responsible for this situation is your partner. If I were the HIV+ person in your scenario, I’d be remarkably pissed at your partner’s conduct because my medical information had to be disclosed after a sex partner created a chain of risk leading to another person.

I also think you’re right to be worried that your partner proceeded with their sexual encounter based solely on a verbal assurance of suppressed viral load. They took an informed risk based on the evidence presented. They’re allowed to do that—to decide where to draw a line about acceptable risk in sex. However, resuming unprotected sex with you means that they imposed their decision onto you without consultation. Once again, it’s your business because your partner has created a chain of risk that leads to you.

HIV+ people deserve respect and consideration like everyone else. Assuming she was honest, the HIV+ partner behaved correctly. She disclosed relevant medical information ahead of a sexual encounter and allowed their partner (also your partner) to consider it as part of informed consent. I do not advocate treating HIV+ like pariahs who must have folders of evidence to prove themselves ‘worthy’ of participating in society. But it is fair to take HIV+ disclosure into consideration before having sex. Some people would hear that info and rule out certain sex acts (vaginal/anal penetration). Others might request a screening test from their partner to verify the claim of viral suppression. Others might proceed with a barrier contraceptive like condoms. Lastly, people can exercise their right to consent and decline sex with an HIV+ partner. It’s not my place to decide which decision is right.

But you’ve correctly pointed out that your partner’s boundaries for risk are not your boundaries for risk. In choosing to not clearly disclose their recent sexual history with an HIV+ person to you ahead of unprotected sex, your partner didn’t adequately account for your health and emotional needs. In my opinion, you’ve been dragged into a chain of risk because your partner did not follow best practices for safe sex. Depending on the circumstances, the chain of risk could extend to the others they sexually contacted during your relationship break.

My response to you is a long one because you’ve found yourself in a long and difficult situation. It warrants depth and care. I think you’ve been mistreated. This situation is hard to forgive in part because your partner has not been forthright about their actions. Forgiveness is much easier when the person who did something wrong discloses everything, admits wrongdoing, and expresses remorse.

It’s also hard to forgive your partner because the situation is ongoing. They haven’t left the window period of HIV testing, so neither of you knows their HIV status with a high degree of certainty. Based on your account, the actual risk of HIV transmission to your partner is very, very low. But there is risk and it should be factored into your decision-making.

I’ll once again advise a follow-up HIV test for your partner. Ensure the test happens after the window period passes for an accurate result. In the meantime, any sex between you and your partner should follow good practices for mitigating HIV risk. That means condoms. Barrier methods. If necessary, sex acts with high rates of transmission risk (penetrative anal and vaginal sex using organs) should be ruled out. Sexual contact should not happen if any open wounds or blood is visible. These precautions will minimize risk until a follow-up test can verify that your partner (and even you) are HIV negative.

But honestly? I don’t think your relationship’s sex life is the real priority here. This incident has clearly revealed some serious fractures in how the relationship handles trust and communication. That’s the real mountain ahead of you. All I can do is wish you luck, because I think I’ve gone on long enough.

You can chime in with your advice in the comments and submit your own questions any time.