Kutscher E, Greene RE. A Harm-Reduction Approach to Coronavirus Disease 2019 (COVID-19)—Safer Socializing. JAMA Health Forum. Published online June 2, 2020. doi:10.1001/jamahealthforum.2020.0656
Spring in Central Park this year looks different. The park is disproportionately full of gay men wearing speedos, tanning, and listening to music. However, this year the blankets between the men are 6 feet apart. Couples share blankets, yet friends remain on their own. Hand sanitizer is next to every picnic arrangement. When a person comes or leaves the park, they wear a facemask. Central Park has become the center of a new type of social interaction: safer socializing.
As gay men and physicians on the frontlines of coronavirus disease 2019 (COVID-19), we have seen a tension grow between our personal and professional communities regarding social distancing. Early in the pandemic, the lesbian, gay, bisexual, transgender, queer (LGBTQ) community adhered strictly to home isolation guidelines. However, as the pandemic has continued into its third month in New York City, the abstinence-only approach to social interactions is becoming more difficult to sustain. As demonstrated in Central Park, the LGBTQ community is adept at evolving during a pandemic.
The parallels between HIV/AIDS and COVID-19 are substantial: they are both novel viruses that can spread rampantly through preexisting social networks and cause a devastating death toll, affecting our city in profound ways. Both viruses have highlighted how outcome disparities arise from our health care system failing to protect the most disenfranchised communities.1,2 In both pandemics, fear and stigma have spread in parallel with the viruses.
In the early days of HIV/AIDS, public health officials encouraged, and many in the LGBTQ community followed, an abstinence-only approach to the virus. With unknown transmission risks around HIV, all sexual activity had to cease. A community founded on sexual liberation suddenly feared that sex could cause death. With emerging evidence on HIV transmissibility and treatment, the abstinence-only approach to prevention gave way to a harm-reduction approach. With this approach, decisions about sex were based on the risk of acquiring HIV as well as the degree of satisfaction, leading to what is now known as safer sex.3 This approach included emphasizing engaging in lower-risk activities, such as mutual masturbation, limiting the number of sexual partners, and using condoms. Advances in effective antiretroviral therapy, viral-load monitoring, and the knowledge that undetectable is untransmittable have changed these assessments of risk over time. With the introduction of preexposure prophylaxis, many gay men have finally felt relief from the inevitability of contracting HIV and gained freedom from equating sex with death.4 What does the history of AIDS have to do with COVID-19?
Our friends and family (many of them cisgender, straight, white, and affluent) are asking us when will things return to normal. They are facing fears of death from their daily activities for the first time. In a pre–COVID-19 era, those with privilege largely lived in a world of minimal risk. Now, even going grocery shopping feels risky. Many of these friends remain locked inside, scared to accept delivered foods, and planning ways to leave New York City.
Just as the LGBTQ community had to embrace a new normal in the era of HIV/AIDS, we must all begin to embrace a new normal in the era of COVID-19. The days of zero-risk social interaction are gone. Many individuals and communities have contributed to slowing the rampant spread of COVID-19—flattening the curve—through abstinence of social interaction. As state and local governments seek to reopen the economy, we must also seek ways of safer socializing.
The logical framework for safer socializing is harm reduction, a theory that abolishes the all-or-nothing approach to risk and disease, acknowledging that abstinence-only is not possible for everyone. Originally a strategy developed to decrease the risk of contracting HIV among those injecting drugs, the fundamental concept is simple: in a world where our behaviors put us at risk for illness, how can we get the most satisfaction while minimizing our risk of disease acquisition or spread?5
A harm-reduction approach to COVID-19 reflects what we saw in Central Park: going places with substantial space and air circulation, staying 6 feet apart, wearing facemasks when closer than 6 feet, and performing frequent hand hygiene.6 It also requires staying inside if individuals have a fever, other COVID-19 symptoms, or a recent exposure to an individual with COVID-19. All decisions in a harm-reduction approach must be thoughtful, intentional, and negotiated. We must obtain the consent of our social partners before any interaction and establish guidelines for safety. We must not judge others who come to different conclusions about what risk is tolerable to them.
Privilege continues to play a significant role. Young, healthy individuals may be less at risk of serious infection with COVID-19, but they can cause significant disease in others. Individuals who must continue to work in service jobs often have limited choices regarding what risk they will tolerate to maintain a livelihood. Individuals living alone or with depression may need to leave their home and socialize for their own mental health. Black and Latinx communities have already experienced disparities in enforcement of social distancing guidelines.7
We are entering uncharted territories where limited evidence exists to guide personal behaviors. As physicians, we must share accurate information to help patients make informed decisions. As data on COVID-19 testing and immunity develop further, a clearer picture about creating social cohorts based on disease or immunity status may develop—perhaps a new form of serosorting.
To be clear, we must do everything possible to protect populations at risk. However, we must also learn to live our lives in the age of COVID-19. We must create a new normal that allows us to evolve our behaviors based on evidence. We must create a world where those with privilege do not stigmatize others for seeking meaningful interactions. As we move beyond social abstinence, we must accept the new realities of our changed lives and modify our behaviors to keep ourselves and others safe.
Corresponding Author: Eric Kutscher, MD, Internal Medicine, NYU Langone Health, 550 First Avenue, New York, NY 10016 (Eric.Kutscher@nyulangone.org).
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank our patients for their strength and insights into the experience of living with coronavirus disease 2019 and our husbands for their support as we fight this pandemic.
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