The Rift in the Porn World About How to Approach HIV (original) (raw)

As porn performers often stress, maintaining their sexual health is vital to their livelihood. To that end, adult industry organizations have established protocols—and individuals have taken additional precautionary steps—to keep porn actors safe from sexually transmitted infections (STIs).

The Free Speech Coalition (FSC), an industry body that manages a testing system used on most mainstream straight porn sets, says its protocols have prevented any HIV transmissions on compliant sets since 2004, although measuring its success in controlling other STIs is trickier.

But over the last few years, a rift has crystalized within the porn world over how to approach HIV. Those on one side of this divide are convinced the FSC’s system is not sufficient to protect them from the risk of on-set transmissions. Those on the other believe the system works fine, and, if anything, it ought to be expanded to allow certain groups of HIV-positive, or “poz,” people to work with performers who consent to have sex with them.

The two sides appear to have radically differing interpretations of recent developments in HIV management research, activism, and language. And this is not just an adult industry debate. On the subject of HIV prevention, said Carl Dieffenbach, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases (a branch of the National Institutes of Health), “the adult film industry is a microcosm of the United States.”

The Current Screening System

The FSC took over managing sexual health protocols for the mainstream, straight porn world in 2011. It has since developed a set of testing guidelines known as the Performer Availability Screening Services (PASS) system. The guidelines have shifted over the years, but as of today, performers in the system test every two weeks for HIV, chlamydia, gonorrhea, syphilis, Hepatitis B and C, and trichomoniasis at a handful of clinics that partner with the FSC. If performers test positive for any non-HIV infection, a central database visible to agents, studios, and other performers automatically flags them as unavailable for work until they test negative. It also flags them if they have gone more than two weeks without being tested. If they test positive for HIV, it blackballs them from working in the PASS-compliant section of the industry ever again. Unlike old systems of bringing copies of a recent test to a set, this database system protects performers’ real identities and medical information—and prevents test doctoring to hide results, an issue that has led to outbreaks of STIs like syphilis in the past.

PASS is ultimately a voluntary system. Studios have to opt in to requiring performers to get PASS tested in order to perform on their sets. And not all performers in the porn world work with or on PASS-requiring studios and sets. While it is the norm for mainstream straight porn studios and some indie studios as well, PASS has not caught on in the gay porn world thanks to a variety of practical issues and longstanding cultural divisions between these two wings of the industry, or in other most other nations’ porn scenes thanks to differing medical privacy laws.

This system is also not foolproof. As performer-producer Lance Hart pointed out in an interview with Rewire.News, people in the industry test “positive for gonorrhea and chlamydia pretty frequently while only having sex with other people that are cleared in the PASS system.” This is likely because it is possible to contract and become infectious with certain diseases within PASS’s two-week testing window. PASS-standard urine tests for chlamydia and gonorrhea also can’t detect oral or rectal infections, which can still spread to a partner’s genitals.

These are problems faced by non-porn performers, too, as routine tests usually do not involve oral or rectal swab tests for chlamydia or gonorrhea either. And most non-performers do not get tested as frequently as performers, making it just as easy—if not more so—for them to transmit asymptomatic diseases between tests.

(A few entities argue that transmission rates of these diseases in the porn world are higher than the national average. But these claims are disputed, pinning transmissions to performers’ porn careers is difficult, and comparisons to the general population are tricky.)

But given the amount of time it usually takes between initially getting infected and becoming able to infect others with HIV, most of the sexual health experts we spoke with say the PASS is a decent tool for minimizing transmission risks.

“You would have to get infected with HIV within a day of testing negative,” said Dieffenbach, and become infectious just before your next test, for the PASS system to fail. Something like this did happen in 2014 (on a non-PASS-compliant set), leading to one in-industry transmission. “But you’re probably more likely to get hit and killed [while driving] on the Los Angeles freeway,” Dieffenbach added.

But a few years ago, two related performer advocacy groups, the Adult Performers Actors Guild (APAG) and the International Entertainment Adult Union (IEAU), started to argue that the PASS system was flawed and dangerous. PASS’s standards, key members of the groups noted, only dictated the use of HIV tests that detect copies of the virus in the blood. These tests usually reliably detect infections within two weeks of transmission, which is a fast turnaround compared to other tests. However, they can miss an infection if one’s viral load is low enough. Many poz people adhering to treatment regimens have undetectably low loads—as do a few rare people off of treatment. The APAG, IEAU, and others in the industry argue that low loads leave a hole for some undetectable poz people to lie about their status and work freely in mainstream porn. They believe that such hidden poz performers pose a threat to their partners on set and off.

“This is going to trickle down into society,” said IEAU founder Phyllisha Anne, as porn stars sleep with civilians. “Before you know it,” she argued, “we [will be in] an AIDS epidemic like Africa.” (While sub-Saharan Africa bears about 70 percent of the global burden of HIV cases, the disease is not uniformly prevalent across every African nation, or even every region or demographic within nations with high prevalence rates. Some African nations have a lower HIV prevalence rate than the United States.)

Undetectable as Untransmittable

As Cameron Kinker of the Prevention Access Campaign, an organization promoting access to sexual health information for people living with HIV, points out, a slew of recent, robust research has led hundreds of public health bodies around the world to embrace the idea that having an undetectable viral load (or under 200 copies per milliliter of blood; modern tests can register the presence of HIV based on as little as 50 copies per milliliter) for at least six months means that one cannot transmit the virus to an HIV-negative partner. Many of these entities have translated this into the educational slogan Undetectable = Untransmittable, or U=U for short.

But Anne and her allies say that activists and researchers who promote the U=U message are “delusional” and putting people at risk. The IEAU claims that the Centers for Disease Control and Prevention (CDC) doesn’t support the idea that an undetectable load is untransmittable.

The CDC’s stance, as agency spokesperson Paul Fulton clarified to Rewire.News, is that someone with a sustained undetectable load has “effectively no risk of transmitting HIV to their HIV-negative sexual partner. This translates to an effectiveness estimate of 100 percent,” although there is always a slim theoretical, if thus far unobserved, possibility for a transmission.

Anne and company also believe that, even if someone with an undetectable load can’t transmit HIV to a partner, undetectable status is too volatile to provide safety. If poz people “didn’t eat right or take [their] pill at the exact same time every single day,” Anne asserts, they can become infectious again rapidly.

This stance, too, seems to fly in the face of scientific consensus. In order to actually become infectious again after being undetectable for months on end, the public health experts Rewire.News spoke with say, a person with an undetectable load would have to do more than have an off day. They would likely need to stop treatment entirely for at least two weeks.

“It usually takes longer,” said Paul Volberding of the University of California – San Francisco’s Gladstone Center for AIDS Research: “A month or two.”

Public health experts also say that anyone concerned about the sliver of theoretical risk of sex with a poz person with an undetectable load can take other measures to mitigate it. Traditionally, that has meant using condoms, which are still the only way to reliably prevent most other STIs like chlamydia, gonorrhea, and syphilis. Anne says, however, that condoms are often unavailable to performers, as the adult industry maintains that scenes featuring them don’t sell as well as scenes selling the fantasy of condom-free, unconcerned sex on the spot with anyone. So today, addressing one’s HIV risk means going on pre-exposure prophylaxis (PrEP) drugs like Truvada. First approved by the U.S. Food and Drug Administration in 2012, PrEP reduces the risk of getting HIV when having sex with a poz partner by about 99 percent—a greater effective rate than condoms. The CDC has long recommended that all porn performers explore getting onto PrEP.

The IEAU supports people getting onto PrEP if they want to, says Anne, and provides it for union members in Los Angeles. The FSC is also trying to bring PrEP navigators to sets to help stars find free or low-cost prescriptions; these drugs, purchased at market value, can be prohibitively expensive for many. And researchers are working on long-term dosing PrEP drugs, adds Dieffenbach, which will hopefully be on the market within five to ten years.

Still, based on a core belief that U=U is a dangerous message, and that experts have been reckless in interpreting new science, the APAG and IEAU have been pushing for new testing protocols using both viral load and antigen and antibody tests. The latter tests take longer to detect infections, but ping even when one has a low amount of virus in their system thanks to the fact that the agents a body produces to fight HIV persist at usually detectable levels even when its viral load is low. They want to make it standard for performers to test two to three times before initially being allowed into the talent pool, or back into it after a break of over two weeks, to be sure that no one in the industry has HIV. (Not even this would provide certainty about a performer’s status, though. Volberding points out that people who are in treatment for HIV and have had a low viral load long enough will have low levels of antibodies and antigens too.) “If you have HIV,” Anne said, “you no longer have the right to be in porn” and need to be weeded out.

The FSC initially opposed adding these new tests to PASS because they worried they’d make testing, which most performers pay for themselves, more expensive and drive low-income folks out of the system and on to unregulated sets—all without providing any additional protection.

To the APAG and IEAU, the FSC’s initial concerns about their proposals seemed sinister—like a plot to protect PASS-compliant studios’ pocketbooks over performer safety. The fact that many within the FSC have embraced U=U messaging only adds to their suspicion. So does the fact that, in recent years, key members of the FSC have started to push back on HIV stigma, the marginalization of poz individuals based on the fear or belief that they are inherently dangerous.

HIV stigma can manifest not only in interpersonal relationships, but also in issues like employment and housing discrimination. As bodies like UNAIDS have warned, dread at the prospect of facing this stigma can suppress testing and treatment rates, which increases the risk of transmissions and the lethality of the virus in those who contract it.

However, members of the APAG and IEAU have claimed that, by attempting to push back on this stigma—and at times linking it to histories of homophobia or unscientific fear—the FSC has been “demonizing [those] who choose not to take the risk” of working with poz people when they believe they’re just being logical and safe.

Fear Over Evidence

Tensions between the APAG and IEAU, and the FSC peaked in January, when the latter body hosted a panel for industry insiders to discuss HIV science. There, a performer advocate invited to speak by the FSC proposed—to the immediate consternation and strong backlash of APAG and IEAU members—creating a new PASS Plus system, which would exist parallel to the PASS system, and would not blacklist poz performers with undetectable viral loads HIV-negative performers could opt in to working in that talent pool, accepting that they might work with poz but undetectable co-stars, then wait and test before reentering the mainstream talent pool if they chose to do so at any point.

The PASS Plus system, advocates have argued, would reflect the new scientific reality that, with proper treatment, HIV is now a controllable and livable, albeit incurable, infection—like herpes or syphilis, neither of which can get one kicked out of the adult industry. It would also extend PASS’s securities to poz performers already working in the adult industry on gay or indie sets that embrace U=U messaging, but that use more piecemeal and often less secure testing protocols. Many FSC officials and allies view it as unfair that poz performers are functionally forced to work on only these sets. Some also believe it may be legally necessary to open the PASS system up to poz individuals. Poz people have workforce discrimination protections, enshrined in laws like the Americans With Disabilities Act, that could theoretically allow them to sue over total exclusion from the PASS-regulated sector of the porn industry if there is any possible way of safely accommodating them.

For now at least, APAG and IEAU’s stance on HIV and how to manage transmission risks seems to be winning. Earlier this year, the two testing centers that work with PASS, Talent Testing Services and Cutting Edge Testing, opted to add free antibody and antigen tests to their PASS-compliant testing regimens. Once the FSC knew the tests would be free, it came out in support of them; it recently mandated HIV antigen and antibody testing PASS compliance.

“In the six months since the antibody test was included” at testing centers though, adds Mike Stabile of the FSC, “there have been no additional HIV positive cases,” which would seem to dispel the core APAG and IEAU concern that poz folks were hiding in the PASS pool.

The IEAU, Anne says, is also on its way to opening up its own testing centers in California and Florida, two porn production hot spots.

However, the fact remains that people with low HIV viral loads would pose such a negligible-to-nonexistent risk under even the current PASS testing system, and risk mitigation tools like PrEP are so effective and accessible that no sexual health expert Rewire.News spoke to for this article saw any reason undetectable poz people shouldn’t be allowed to work on mainstream porn sets.

Kinker thinks it could even be a social good for them to do so openly. Porn has such a huge impact on sexual culture, he says, that featuring openly poz folks could help push back on stigmas that cast and castigate them as irredeemably toxic. It could spark conversations about or portray them as what they actually are in the modern medical era: people living with a serious, but ultimately controllable, chronic condition.

The risk of transmission is so low that Dieffenbach and Volberding were actually confused as to why the industry would need a separate testing pool and protocol, like the one proposed in January, for poz people with undetectable and untransmittable viral loads and those game to work with them.

The notion that people with HIV are inherently dangerous and that we need to be especially concerned about HIV as a risk “has been hammered into people’s heads for over 30 years,” Kinker said. That’s especially true in an industry like porn, which experienced the full force of the epidemic in the ‘80s and ‘90s and has been scarred by that history. That fear, Hart says, is hard for most people—even those who try to keep up with sexual health science—to let go of. It is probably not going to be overcome by relatively new concepts. Even the poz community, Dieffenbach said, “has in places been very slow to embrace this U=U message,” thanks to grim memories and old fears.

If some individuals don’t feel confident in the takeaways their peers and public health experts are drawing from recent science, then that needs to be respected, performers say. Even when beliefs are grounded more in emotion than factual analyses, they cannot be ignored or discounted. Everyone in the industry deserves to feel safe, says Riley Reyes of the Adult Performer Advocacy Committee, a performer’s group that is open to efforts to create a space for openly poz people in mainstream straight porn.

Eventually, the fear that’s fueled recent misunderstandings and debates around HIV and poz people in the porn industry, and the wider world, will likely fade. That may allow for the eventual creation of something like the PASS Plus system, which could one day evolve into the new industry standard for everyone.

For now, though, the fear-motivated side of the debate prevails, for better or worse.

“It will take years of success stories for people to believe in the U=U narrative,” or in PrEP and other new HIV advances, “enough to entrust their health to it,” Reyes said.

CORRECTION, September 30, 1:10 p.m.: The FSC acknowledges that the advocate presented the Pass Plus idea as an FSC-backed plan. However, while the FSC notes that its members and allies have had may discussions about how to create a system accessible and welcoming to poz performers, the Coalition has never officially outlined or backed a specific proposal.