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Stopping Therapy: New Questions Arise
May 1, 2001

The new guidelines pose many questions for couples in a mixed-status relationship. We practice unprotected oral sex--never allowing precum or ejaculate to be secreted into the mouth--and never unprotected anal sex. He was diagnosed one year ago, started on HAART therapy, and has since experienced debilitating side effects even though the meds have kept his viral load down. His CD4 count is probably higher than mine at close to 1000. He is stopping medications to give his system a break. Should we then be more cautious during sex? The toll on his psychological health has been tremendous, and he is experiencing depression and debilitating loss of self-image. Although cautious and fearful, I hate to see the person I love go through so much pain, so I will support him, of course, in his decision. Please let me know what your thoughts are on this. Thank you for your continued help.

Response from Dr. Remien

The risk that you take in practicing unprotected oral sex is minimal, but not zero. You are not alone in deciding that it is an "acceptable" level of risk for you, as a couple. Many couples feel that the risk is low enough that it is not worth the loss of intimacy and pleasure to use protection for oral sex, particularly when precum and ejaculate is avoided. And even though there is "some" evidence that a low (or undetectable) viral load is associated with a reduction in level of "infectiousness," there are also no guarantees with that. A number of studies have shown there to be a lack of correlation between viral load of blood and viral load of genital secretions (including cum). So HIV can still be transmitted even when one has a very low or undetectable viral load in their blood.

The bottom line is that all individuals and all couples must decided what level of risk they are comfortable with. This is often not easy to determine. The decision must be made by both of you, after weighing the pros and cons. Take the information you have, consult with a doctor if you need to, then discuss the issues and see what you both decide. Continue to enjoy the sex you have, but also continue to take care of each other, which includes keeping you HIV negative.

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