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Oral Sex and Resistance
Mar 1, 2008

Hello Doctor

Please please can you answer me my question, both my partner and I are HIV positive and I'm on medication and he is not, I'm doing really well CD4 of 500 and undetectable VL, I'm on Sustiva and Kivexa. Anyway since our diagnosis we rarely have sex (his decision not mine) anyway, this morning we were both "in the mood" and had oral sex which then was leading to sex (with a condom) but I was horrified when I noticed blood after he had inserted me - less to say that this stopped us in out tracks, any way as the day has gone on I've started to worry incase he gave me oral sex and because I'm on medication would this (with blood been present) make him become resistant to the drugs I'm on? This might sound irrational to you but its really bothering me, please can you advise?

Many thanks

Annie UK

Response from Dr. Sherer

Your concerns are not irrational at all. Transmitted HIV drug resistance is a fact: At present in the US, 7-12% of patients with recent or chronic HIV infection who have never been treated with ART have at least one drug resistance mutation.

Similarly, HIV 'super-infection', in which a person with HIV acquires a second, different strain of HIV by having unprotected sex with a person with HIV, is a fact.

For unclear reasons, it has been difficult to prove super-infection in the US, and it appears that its occurrence is infrequent; in one study in the US, it appeared to occur only in 1/10,000 exposures. Nonetheless, it is well-documented to occur. The highest frequency that I have seen was documented in the Rakai cohort in Africa, in which 7 of 85 couples (both HIV+) who had unprotected intercourse over a period of 12 months.

For this reason, most HIV clinicians advise their patients who have HIV+ partners to continue to follow safer sex guidelines and use condoms. In your case, it is possible that your partner, who is not on ART, could acquire your virus and, possibly, drug resistance (if any were present).

Having said that your concerns are valid and that transmission from you to your partner is possible, there are also reasons to reassure you both that this is less likely in your case. First, you used a condom, so in spite of the presence of blood, the risk of a transmission is very low. Second, you are on ART and fully suppressed. The evidence is very strong that the risk of transmission decreases greatly (though not to zero) when your viral load is below detection. In the episode that you describe, since your partner is not on ART and so has a greater likelihood of having a higher viral load, you are more at risk to have acquired his virus than his risk to acquire yours.

And although you are right to note that the presence of visible blood increased his risk of acquiring your virus, that increase is extremely small because of the fact that you and he used a condom.

I want to urge you to take these concerns, and your partner, with you to your next doctor visit and discuss them all, with these observations in hand.

I will also go a bit further on this subject for you and your boyfriend. In my experience, most people living with HIV find a way to remain intimate and sexually active in the best sense. And so they should! You are both still human beings who need love, intimacy, affection, touch, and the occasional orgasm. If you let HIV stand between you on this score, you are ceding too much ground to it. Your goal should be to make having HIV an ordinary nuisance, like having diabetes or hemorrhoids, and get rid of the horror and the shame. No way you should let the little bugger dictate your actions in the bedroom. As long as you treat the situation with a little respect, and learn how to play safely with latex, you and he both will be fine. What would be the point of extending your lives with ART if love and sex were not a part of them?


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