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Superinfection: Fact or Fiction?
May 15, 2004

Dr. Sherer,

I want your honest answer to the concept of superinfection. I asked my doctor and he seems to feel if two hiv-positive sex partners have an undetectable viral load, there isn't a great deal of risk of this.

My question is: what are the hard facts on this phenomenon? Wouldn't potent HAART interfere with a "superinfection" of someone who is already hiv positive?

Response from Dr. Sherer

There is pretty compelling evidence that super-infection is a fact.

It is also true that an undetectable viral load greatly reduces the chance of HIV transmission, though not completely. Even when plasma viremia is completely suppressed, there is evidence that replication and viral evolution (including the generation of new resistance mutations) can progress in reservoirs which harbor HIV, such as the central nervous system and the gonads. So the risk is greatly reduced, but not to zero.

HIV physicians are concerned about superinfection because cases have been documented in which a person with HIV who was well controlled on an ART regimen acquired a virus with one or more resistance mutations to that regimen, and their viral loads rapidly increased, and their CD4 cell counts fell, i.e. they had regimen failure.

So, as a general rule, physicians are still recommending that people with HIV follow safer sex guidelines, even if they themselves are well controlled, and their partner is well controlled, out of concern for the possibility that a new virus may disrupt the delicate therapeutic balance of a given regimen.

To be clear: I view this as a strong but relative recommendation, like so many others that we make, that you as a PLWHIV have to make up your own mind about. In the unlikely circumstance that two partners were carrying the same virus (ideally, wild type with no mutations), and they were on the same regimen, started at the same time, and both were undetectable, they would seem to have the least likely chance of a disruption of their clinical and virologic conditions in the event of a transmission following unprotected sex. Too little is known still about individual variations in the evolution of resistance, particularly in reservoirs, to be very confidant with this statement.

Greater degrees of risk would occur with partners who had infections in different time periods; different initial regimens; the presence of multiple regimens, and one or more virologic failures in either partner; the presence of a non-B clade virus; either partner having exposures with multiple partners; and other factors.

I advise you to follow up on these questions with your doctor. The final choice, of course, belongs to your and your partner. My own opinion is that the circumstances in which I might agree with your position are pretty uncommon. For example, if we are talking about 'partners', rather than one partner, I would not agree.

There are also other STDs to be concerned with, and hepatitis.

And I would argue the point from the other side. What's the problem with safer sex? Satisfying intimacy can involve latex. Maybe your ideas about condoms and safer sex could use some updating.

There is a well documented pheonomon called 'the Hooray effect', i.e. a person with HIV finds out their viral load is undetectable, and they are more likely to have unprotected sex. For the reasons above, this is not a good idea.


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