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Is safe sex necessary if both partners are +
Dec 28, 2005

My husband and I are both positive and I was infected by him. Our Dr. says we must have safe sex or we can make each other sick. Is this true? It seams weird. Also I saw people were having trouble getting insurance after that were diagnosed +. I work for Anthem and they cover pre-exhisting conditions like HIV. I had no problem adding my husband to my policy, even thought he had been positive for over 6 years.

Response from Dr. Frascino

Hello,

Your doctor is cautioning you against the possibility of superinfection or reinfection. Even if you were initially infected by the same strain of HIV, the virus can evolve differently in each person. Consequently, over time your virus may be quite different from your husband's. I'll post several articles and a question from the archives that address this topic. I hope you'll consider this information carefully.

Stay well.

Dr. Bob

How safe does HIV+ couple have to be? Aug 26, 2004

Dr. Bob,

You inspire and console many, and are appreciated by the positives and negatives in this fight.

Ok, here is my question, I have been dating another HIV+ man for over a year and we have entered a committed relationship. We are both in our 50's and look forward to a great long life together. Both of us are on a drug regiment and have undetectable viral loads. We both have a good T-cell count and both of us are very healthy. If we live in a committed and monogamous lifestyle, how dangerous would un-protected sex be if we both have the HIV virus already, and are both compliant on our drug regiments?

We are very happy with our current safe sex practices, but are curious what you would say to this question.

P.S. Our doctors are evasive, first telling us about the risks of super infection, but then eluding to the fact that it would be unlikely.

Thanks! Curious in Boston

Response from Dr. Frascino

Hello Curious Boston Boys,

Actually your doctors are right on target. There is indeed a risk of superinfection. Cases of superinfection have now been well documented. The question of how often it occurs remains unanswered. That might explain your doctor's seemingly "evasive" comments. In reality we don't have a lot of information about the frequency of HIV super-infection because it's not all that easy to document without rather extensive and costly analysis.

Certainly the major concern is the acquisition of a more virulent (aggressive) strain of HIV, or one that is resistant to some of the drugs in your current regimen.

As two consenting adults, only you and your partner can decide if you are willing to take this risk. You mention you are "very happy with your current safe sex practices." All I can do is advise you that the risk of superinfection is real, very significant, and potentially devastating. Even though the chance of HIV transmission is decreased by having undetectable viral loads, HIV superinfection is not a risk I would not be willing to take personally. Good luck, Boys. There may be some more information on this topic presented at an HIV/AIDS medical meeting in your hometown scheduled for February 2005. Stay posted to this site and I'll keep you posted as well!

Dr. Bob

Re-Infection: Is It a Concern for People Living With HIV? May 2004

Re-infection is a term used to describe a new or secondary infection by a virus that has already infected a person. In most viral diseases, re-infection with the same virus doesn't occur because once the immune system conquers the original viral infection, it creates immunity against that virus. Re-infection occurs almost constantly, however, in some types of infection, such as the cold or flu viruses, because each new version of those new viruses is substantially different from the last. This is why a person may develop immunity to the flu strain that is common in one year, but still be at risk from the strain that becomes dominant the next year.

The question of re-infection with HIV has long been debated. There is no theoretical reason to think re-infection isn't possible, since the immune system never fully conquers the initial HIV infection. Still, many people, including many physicians, clung to the hope that re-infection with HIV either does not happen or that it only happens rarely. This view is the basis of the belief held by some HIV-positive people that having sex or sharing needles with another HIV-infected person poses little or no risks. Many if not most virologists, however, have long believed that re-infection is both possible and perhaps even likely. What is not known are the individual short- and long-term clinical consequences (which may vary from person to person for wholly unknown reasons).

For many years, there were no clear cases of re-infection presented at scientific conferences, but this did not mean such re-infection wasn't occurring. Instead, we know that finding and documenting cases of re-infection is extraordinarily difficult, if for no other reason than that no structured program has looked for them. Finding a case of re-infection has largely been a matter of chance. Yet, several observations over the years support the notion that re-infection is possible, including observations of sex workers in Africa infected with several different recombined "clades" of HIV as well as detailed genetic analysis of a few people's virus suggesting that re-infection was possible. This research is very difficult to conduct. Perhaps the only simple example of re-infection is in western Africa, where people are routinely found who carry both HIV-1 and HIV-2. At the very least, this proves that having HIV-1 does not protect a person from infection with HIV-2.

Recently, there has been considerable media attention about a few well documented cases of suspected re-infection with two versions of HIV-1. The most interesting case, presented by Dr. Bruce Walker, was the result of an almost accidental observation. While researching the effects of Structured Treatment Interruption (STI) in some newly infected volunteers, Walker's team was intrigued by one particular case in which the volunteer responded well to two initial cycles of STI. After each, the person's viral load remained undetectable for several months without treatment. Shortly after a third STI, however, the viral load remained low for only a brief period and then suddenly soared upward. The team wondered what made things different this time? After conducting extensive genetic analysis, they found their answer: the volunteer had become infected with a second, slightly different strain of HIV. Most striking, and discouraging, was that the genetic makeup of the new infection differed by only 12% compared to the original infection. Despite this small difference, the second infection had completely escaped control by the immune system, breaking through the suppression achieved against the original virus. This discovery, while important enough in regards to re-infection, also had discouraging implications for vaccine development, suggesting that as little as 12% variation between viruses might be enough to make a vaccine fail.

Several questions remain in regards to re-infection. Will re-infection lead to more rapid disease progression? Will re-infection with HIV result in transmission/acquisition of drug-resistant HIV that will limit a persons' anti-HIV treatment options? Both of these concerns are theoretically possible, and both have now been demonstrated in case studies. Currently there is not a large amount of data to assess the actual risk to the individual. Although only a little data currently exists and it is extremely difficult to gather more, it does not lessen the real potential for re-infection or its consequences.

There are several reasons why people living with HIV would want to maintain safer sex activities. While the clinical implications of re-infection remain unknown (and will likely be unknown for many years to come), there is some evidence of harm and no evidence of harmlessness. We also know for certain that safer sex does protect against many blood-borne infections that are major causes of life-threatening diseases and death in people with HIV. These likely include CMV, some forms of hepatitis virus, genital herpes, possibly the JC virus (cause of a particularly destructive condition known as Pml), to name a few.

Ultimately people living with HIV need to consider this information and make informed decisions about safer sex for themselves. In the early 1980s many did not want to believe that HIV was caused by unsafe sex. Many people have dearly paid the price for that belief. The optimal outcome here is for people not to fight against data and shy away from acknowledging the potential consequences of re-infection. Some people will come to a conclusion that it's better to be safe than sorry. Others will choose the risk of being sorry rather than safe and will continue to participate in unsafe sex with positive partners. What matters most is that people make a conscious decision based on the available information.

HIV Superinfection 5% in Newly Infected Gay Men

Coverage provided by Keith Henry, M.D.

February 9, 2004

Dr. Smith and colleagues presented their experience looking for cases of HIV superinfection in the cohort of HIV-positive patients that they followed after identification of primary infection. The topic of superinfection is important for several reasons. First, it provides important insight into protective anti-HIV immunity. The issue is whether the innate anti-HIV immunity that evolves in an infected person can prevent infection with a second strain of HIV. That is important clinically since a few anecdotal reports have suggested that superinfection can lead to more rapid deterioration of a patient's immune status. It is also important from the public health perspective with implications for the potential efficacy of a vaccine to prevent infection.

Several definitions need to be clarified. Co-infection describes when someone is initially infected with two strains, while with superinfection a patient is infected with one strain and then with another strain. Superinfection has been observed in some chimpanzee models and has been inferred from recombination analysis but is still a rarely documented clinical event.

Smith reported the results of a retrospective analysis of trials of primary infection in a cohort of 78 men who have sex with men (MSM) during their first six months living with HIV infection. These men were not yet on antiretroviral therapy. Samples of virus underwent pol gene sequencing and if isolates didn't cluster then env sequencing was done.

Three cases of possible superinfection with another type B virus were identified and then confirmed by clonal sequencing of env and pol sequences. All three men had a change in the reverse transcriptase sequence that could impact drug sensitivity. When those three patients were evaluated six months after acquiring the second strain, a negative impact on the CD4 count and RNA level was seen.

The 5% rate of superinfection is about the same rate as at risk infection initial infection in high-risk populations in the U.S. The interpretation was that there was no protection afforded by the initial HIV infection against superinfection. Dr. Smith said that the lab approach may underestimate the true rate of superinfection due to sensitivity issues with the assays used. It seems to me that a group of MSM with fairly recent HIV infection may represent a group with a higher than average risk for acquiring additional HIV so that extrapolation to the general MSM population may overestimate the overall risk. Whatever the actual rate is, these data add to the literature about superinfection and support enhanced emphasis on harm reduction counseling. A question from the audience highlighted that of the three cases reported, two had been previously reported in other reports. Clearly the topic is of interest and more studies looking at the rate and impact of superinfection are needed.



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