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pos partner pull out method
May 26, 2006

Hello there. I am neg male bottom and my partner is a pos male top. We have had unprotected anal sex (i the recipient), where he pulls out well before ejaculation--He has an undetectable viral load on truvada, norivir, and rayataz. He has also practiced this same sexual act with another partner for 3 years (in the past) and his partner never seroconverted, and still many years after their relationship is negative. I feel safe and i've been tested every four months so far in our relationship and i'm still negative. What is the risk associated with undetectable viral load and pulling out. Does precum have any virus in it, if he is undetectable?

Response from Dr. Frascino

Hello,

This issue is quickly becoming one of those QTNDs (Questions That Never Die)! I'll repost a few recent similar questions from the archives below. If you have additional concerns after reading those (and the archives), write back, OK?

Please stay well.

Dr. Bob

Lube as Harm Reduction? Apr 25, 2006

Ciao Dr. Bob. I keep hearing anecdotally that more and more gay men are using lubricant, but not condoms, for anal sex. The idea seems to be that for those who don't want to use condoms, lube is a harm reduction measure in that it prevents the tearing of rectal tissue that can contribute to HIV transmission. (I hear that some men also are combining use of lube with pulling out before cumming.) But how valid is this assumption? Can't HIV be spread via unprotected anal intercourse without there being any tearing? I thought the rectum was permeable enough to absorb infected semen without the tears that produce bleeding.

Cosa ne pensi, dottore?

Giorgio in NYC

Response from Dr. Frascino:

Hey Giorgio,

That some folks (gay or straight) are not using condoms is a disturbing trend most likely related to our outdated HIV-prevention programs coupled with some misleading information disseminated by the sex-phobic abstinence-only groups, i.e. Bush and Company. That said, it is indeed true that lubrication can reduce trauma to delicate vaginal or anal/rectal membranes. Consequently, this is a harm-reduction technique. Pulling out before cumming would theoretically also decreased the statistical risk for HIV transmission; so once again it, too, can be considered a harm-reduction strategy. The critical point here is that there is a quantum leap between these harm-reduction strategies and the safety provided by using a latex condom properly. Can someone transmit or acquire HIV if they use copious lube and pull out before blastoff? Absolutely! However, HIV cannot permeate intact latex. No way. No how.

Can HIV be transmitted via anal sex without "tearing?" Absolutely. Mucous membranes contain cells that can transport HIV across the membrane and into the blood stream.

Giorgio, when you hear folks talking about their harm-reduction strategies, I'm counting on you to speak up and tell them the facts, OK?

Stay safe. Stay well.

Dr. Bob

undetectable VL. Risks of unprotected sex with neg partner. May 15, 2006

I have been poz for 3 yrs and on meds the whole time. I have an undetectable viral load and high CD-4's. I never miss a dose of my meds. I am with a neg partner. He likes to have unprotected anal sex (insertive and receptive) with me without ejaculation into him on my part. We know there is some risk involved with this but are comfortable with it. I know there are small amounts of HIV in my semen even with an undetectable VL in my bloodstream. Are there any hard statistics on transmission risks in this situation, with undetectable viral load and no ejaculation into the neg partner? Is there really enough HIV in my pre-ejaculate/semen to put him at a great risk for infection, or can we be reasonably sure that there is an acceptable low risk of infection?

Response from Dr. Frascino:

Hello,

Your facts are correct:

1. There is risk involved in magnetic couples having unprotected anal sex, even with an undetectable viral load.

2. Yes, your semen may have a different viral load (VL) than the VL measured in your blood.

Now to your questions:

1. No, there are no hard statistics on your particular situation, because there are too many variables to control for. Also, because we know this type of exposure does carry some degree of risk, it would be unethical to conduct a clinical trial to determine exactly how risky. We can say the risk is real.

2. Can you be reasonably sure there is an acceptable low risk of infection? Although ultimately that would depend on how you define "acceptable low risk," the general answer to your question is no.

Your basic premise that an undetectable plasma viral load decreases the risk of HIV transmission is true. In addition, pulling out before ejaculating also decreased the overall risk of transmission. The important question, however, is that taking these "harm reduction" measures into account, is unprotected anal sex safe enough? Based on our current knowledge, the answer would have to be no.

If despite this information, you and your partner remain comfortable with the risks associated with unprotected anal sex, I would suggest you consider enrolling in a PrEP study. These are clinical trials designed to investigate where pre-exposure prophylaxis (PrEP) is effective in reducing the risk of HIV transmission. You can read about these clinical trials in the archives. They involve the negative partner taking Truvada (Viread plus Emtriva) on a chronic basis. I must emphasize we do not know if this is an effective strategy or not. However, it may afford your negative partner some degree of protection.

Good luck.

Dr. Bob



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