I spent last week on the Sunshine Coast at the Australasian HIV&AIDS Conference, the first time the event has been held face-to-face in three years, and it was fantastic to have in-person conversations with so many of my friends and colleagues after so long. I want to get down a few thoughts about some of the themes that emerged in those conversations, about HIV disclosure, PrEP use, and where (and with whom) we situate “responsibility” in relation to HIV stigma and the serodivide.

A lot of this discussion was sparked by a fantastic keynote by Kane Race on the first day of the conference, critiquing the increasing role of “undetectability” discourse in the HIV response (including the U=U campaign), and the limits of that discourse when it comes to reducing HIV stigma.

I was roped into live tweeting the keynote for the organisation I work for—I’m terrible at live tweeting and it was a challenge to capture such a complex discussion, but it might give you a sense of some key points.

Kane argued this focus on undetectability redirects attention away from structural analysis and towards the “infectivity” of the person living with HIV, “undetectable” ironically rendering them detectable. Undetectability therefore becomes a “redemptive” state, which in turn raises the spectre of its opposite, one of sexual transgression. He also raised the fact that a focus on undetectability criminalises people living with HIV in new ways, something we’ve seen in recent expansions of public health law in Australia to require PLHIV take “reasonable precautions” to prevent HIV transmission.

It’s a tough sell to critique U=U in a room full of public health folk, but everyone I spoke to about Kane’s keynote loved it—it was clearly tapping into something already bubbling away in everyone’s minds.

Another major point of discussion came out of research presented by Martin Holt that a huge proportion of PrEP users (and even more for non-PrEP users) said they wouldn’t have condomless sex with someone with an undetectable viral load. In the early days of PrEP in Australia, many of us held onto the promise that it had the potential to reduce HIV stigma among HIV-negative MSM, so this was depressing to hear.

Discussions elsewhere in the conference (I’ve forgotten who this came from, apologies) looked at the ways PrEP users ask “are you on PrEP” as a way of serosorting.

All of this then raises a confronting question: what is PrEP actually *for*?

It has certainly driven down new HIV notifications (in Australia at least) but some commented during the conference that PrEP is now becoming, in effect, a treatment for HIV anxiety. The impact of PrEP on HIV anxiety is well documented, but if PrEP users are still serosorting, what does that actually mean?

A related question, and one I’m exploring in my own research: what is the relationship between HIV stigma and HIV anxiety? It would be interesting to know more about whether PrEP uptake did actually reduce HIV anxiety among HIV-negative MSM, and if that then correlates with a reduction in serosorting practices among those men. (Another question I’d love to ask PrEP users, a hypothetical: if you *weren’t* on PrEP, would you still serosort?)

In a conference session about HIV stigma there was a (rightly) exasperated question from the audience: what’s the point of all this work, the paradigm shift of the biomedical prevention revolution, if HIV-negative MSM are still stigmatising PLHIV? While should PLHIV have to keep bearing the burden of stigma reduction? Folk have very good cause to be angry about this!

The data Martin Holt presented indicates that knowledge about U=U does have an impact on people’s willingness to rely on it, which gives some hope that there’s a role education can play.

But in the context of Kane Race’s arguments, what does that education look like? Do we effectively have to sacrifice the wellbeing of PLHIV (via a focus on disclosure) at the altar of anti-stigma education so that HIV-negative MSM can stop stigmatising, and even then, for potentially negligible gains?

I guess because I’m a hopeless optimist I want to believe that change can come about when we talk openly about things and try to understand each other better, and so discussing HIV status is a good thing. But increasingly, and in the wake of these conference discussions, I’m turning towards the view that maybe we just need to dissolve the idea of disclosure altogether.

U=U education will clearly continue to be important—its positive impact on the wellbeing of PLHIV has been reported. But in wondering how to respond to the frustrated questioner in the stigma session, I’ve been thinking about other approaches to combating HIV stigma that might put the onus back onto HIV-negative MSM.

Perhaps as well as convincing HIV-negative PrEP users that U=U works, we need to be convincing them that *PrEP* works.

Where do prospective PrEP users currently get information about PrEP? In theory the prescribing clinician could have a role to play, and while we hear stories all the time that PrEP-related stigma is still rampant in clinical settings, I’m sure many clinicians are playing a positive role in this education. (As a side note, it would also be great if we could encourage clinicians to talk to people about U=U when they prescribe PrEP.)

A couple of years ago the organisation I work for played a key role in removing the requirement for clinicians to make “risk assessments” (asking people about their sexual behaviour in order to assess eligibility) before prescribing PrEP. This is a good thing—more accessible healthcare is more equitable healthcare.

But if not in clinical settings, where are conversations about PrEP taking place?

I was an “early adopter” of PrEP in Australia—I’ve been on and off it since 2015. At that time, communities of gay, bi and queer men were engaged in heated debates about whether or not PrEP was a good thing.

The promise of an end to HIV anxiety (not to mention PrEP’s HIV-prevention benefits) seemed almost magical. But PrEP’s critics, and those undecided, had concerns. Would rates of other STIs shoot up? Would it make the straights think we were even more irresponsible? Would there be side effects? Were we becoming slaves to the pharmaceutical industry? Was throwing away decades of condom education disrespecting a generation of the dead?

I’d been reading and talking about PrEP, and as a journalist at the time, writing about it, for a good couple of years before I decided to start taking it. Looking back, I can’t underestimate the role that conversations with other queer male friends played in my thinking about it. Perhaps most importantly, my views were influenced by conversations I had with HIV-positive friends, and their own views on PrEP.

Chatting with a couple of former colleagues at the HIV conference last week, one of them called early PrEP adopters “PrEP boomers”, several generations removed from those starting on it today, a “PrEP gen Z”. We started PrEP in the thick of the “PrEP debates”, and while I can’t know for certain, new PrEP users may not be having those conversations at all.

I love this generational framing—one not defined by age, but by what our community conversations about PrEP look like at the time a person started using it. We need to know more, of course, but it may indicate that PrEP is becoming decontextualised from community and sociality, and from relationality itself.

The implication of this is that the *actual* promise of PrEP and the biomedical prevention revolution has been realised. HIV prevention is now biomedical, and biomedicine has given us all it is capable of giving us: HIV prevention.

It’s worth saying that to a degree, this was the whole point. The appeal of PrEP as a HIV-prevention tool was that it meant we didn’t have to think about HIV prevention during sex. We removed HIV prevention from interaction, we made it invisible. PrEP gave us exactly what we wanted, a reduction in HIV notifications, but not all the things we hoped would go along with it.

I’m exaggerating a bit here. While a huge chunk of PrEP users said they wouldn’t have condomless sex with someone with an undetectable viral load, about as many said they would. If this is one measure of HIV stigma, we seem to be making some progress.

I suppose I’m gesturing towards education as a path forward here, but more specifically I think I’m talking about a return to relationality and community contextualisation as a foundation for reducing HIV stigma. Education in a vacuum isn’t enough.

All that said, I do still think biomedical prevention has a role to play. PrEP users I’ve interviewed for a research project consistently told me that while talking and learning about PrEP played a significant role in reducing their HIV anxiety, it wasn’t until they actually started taking PrEP that the anxiety was nearly—or in some cases completely—eliminated.

Maybe taking PrEP is a kind of full stop on the end of a sentence about community; it is receiving communion at the end of mass, confronting HIV stigma an experience of transubstantiation.

I’m left with a lot of questions—as anyone who has worked in a “community organisation” knows, helping people feel connected to community in some form is challenging and fraught. How can we do that better?

There’s a paradox here, too: how do we recontextualise HIV within the social without centring the exact surveillance of positivity (virality, “detectability”) that we’re trying to avoid by recontextualising HIV within the social?

I don’t have much to offer about where we go next, but it felt like something broke through at the conference last week, a frustration with the current state of biomedical prevention that I hope can lead us to somewhere productive and new. We owe it to anyone experiencing HIV stigma to try.