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Can my doctor refuse to start me on meds?

Feb 8, 2008

Hi Dr. Frascino I tested poz in 2004, and my t cells have steadily declined from 1400 to 700. My last viral load was 15,000. I recently started dating someone who is HIV neg. I'm ready to start meds both from a personal health standpoint (even though I don't meet current treatment guideline criteria) and to reduce the risk of transmission to my negative boyfriend. Also I'm confused because I have friends with higher t cell counts whose physicians started them on HIV meds, and I know serodiscordant couples where the poz partner had normal t cell levels but was started on meds to help reduce the risk of transmission. I am supposed to see my doctor tomorrow to talk about starting meds. In the past he has told me that with my current lab results, starting meds is "not recommended". It may not be recommended, but is me starting meds prohibited? Can he refuse to start me on meds if I ask? If he refuses to start me on meds, should I find another doctor? I like my doctor and want to work with him on this issue, but the bottom line is I want to start meds.

Response from Dr. Frascino


Starting medication outside the recommended guidelines is certainly not prohibited! Your HIV specialist is correct to inform you of the current recommendations for beginning antiretroviral therapy. However, it's worth noting those guideline recommendations have continued to change significantly over the years and there are always extenuating circumstances for when to recommend beginning treatment. Everyone's situation is unique. Your wish to decrease potential transmission risk to your seronegatives mate by driving your viral load to undetectable levels is supported by recent data summarized in the Swiss Report (see below). What you and your HIV specialist need to discuss is risk-to-benefit ratio of having you begin treatment now. This would include a possible increase in long-term side effects and toxicities related to the potent antiretroviral medications. Hopefully after a thorough discussion of the pros and cons, you and your HIV specialist will come to a consensus of what's the best course of action for you right now.

Good luck.

Dr. Bob

Sex With Undetecable People Is Safe Feb 8, 2008

Will the Body Post Update Information on Undetectable Poz Sex?

Experts Say Positive People on Effective HIV Meds Arent Sexually Infectious The Swiss Federal Commission for HIV/AIDS has issued the first-ever consensus statement saying that HIV-positive people who are effectively on antiretroviral therapy, and who do not have any other sexually transmitted infections (STIs), cannot transmit HIV during sex, reports Read More

For more news from POZ please visit

Response from Dr. Frascino


"Will The Body post updated information on undetectable poz sex?"??? Darling, apparently you haven't been paying attention to recent posts in the archives. See below.

Dr. Bob

Unprotected sex (SWISS REPORT) Feb 6, 2008

I am currently working as a Community Health Educator...I work directly with MSM and PWP clients on individual level interventions. The goal is to have MSM and PWP implement risk reduction practices in their sexual behaviors. One of the greatest challenges that I am presented with, is that many of my clients who are HIV + are practicing unprotected sex with other HIV + individuals. Most of my clients are aware of the risk in becoming exposed to the different strains of HIV. But because most of them are in treatment and have increased their CD4 counts as well as reached an undetectable viral load, hence they have no concern about safer sex practices among other HIV+ partners. I have noticed that many of the men who practice these behaviors are constantly sick with allergies, colds, fatigue, aches, and side effects to their medications. Because a large percent of the population I work with are positive long term survivor aging men: they affiliate their conditions to these factors. Has a study been conducted in respect to unprotected sex among seroconcordant partners? Are these men compromising their health in other ways other than the possibility of STDs or by contracting a different strain of HIV? How can I elaborate on these two issues if so? Today one of my clients presented me with an article from the that heads, Patients with HIV could have sex without condoms Is this information accurate?

Thank you


Response from Dr. Frascino

Hello MM,

Seroconcordant partners practicing unprotected penetrative sex are placing themselves at risk for STDs, including possible dual HIV infection, as you point out. However, there is no evidence to suggest they are compromising their health in other ways. In particular there is no evidence to suggest or reason to believe that sex would cause "allergies, colds, fatigue, aches and side effects to their medications."

Regarding the Swiss study, see below.

Dr. Bob

Swiss study in POZ Magazine sayingExperts Say Positive People on Effective HIV Meds Arent Sexually Infectious Feb 3, 2008

Hi, I think your great and I read your forum as often as I can ... I just read the Jan 30th update of POZ and they published a Swiss study that HIV-infected person on antiretroviral therapy with completely suppressed viraemia (effective ART) is not sexually infectious, i.e. cannot transmit HIV through sexual contact. I wonder if you have seen this and wht you think.. Does this mean if there is a condum break or god forbid forgetting the protection in the throws of passion - we ( I don't need to freak out- I'm a female who's positive)? Let me know what you think of this study

thanks so much

Response from Dr. Frascino


See below.

Dr. Bob

Positive People on Effective HIV Meds Arent Sexually Infectious (SWISS REPORT) Feb 3, 2008

What do you think about the news (published in yesterday, January 30, 2008): Experts Say Positive People on Effective HIV Meds Arent Sexually Infectious?

This is especially significant for people like me, which happen to be in a sero-discordant relationship, Not for the sake of letting go of safer sex practices during intercourse, but for the sake of feeling more relax during foreplay and the occasional unprotected nibbling or oral sex. Is oral sex with an HIV positive person, taking HAART and testing undetectableconsidered safe now???

Response from Dr. Frascino


We've known and preached for some time now that having an undetectable HIV plasma viral load significantly decreases the risk of HIV transmission. That's excellent news for folks like you and me, because of our magnetic coupling (sero-discordant relationships). However, based on the scientific data presented to date, I'm not yet ready to make the quantum leap to claim that "positive people on effective HIV meds aren't sexually infectious." (See below.)

Dr. Bob

Transmission where viral load is undetectable (REALLY A NEW QUESTION, I PROMISE!) Feb 2, 2008

Hi Dr. Bob,

Have you seen the story, reported today, that Swiss researchers are saying that HIV "cannot" be transmitted from an HIV-positive sex partner to an HIV-negative sex partner -- at least when they are in a stable relationship? There are a few caveats, of course, but on its face it sounds like a pretty bold and nearly absolute statement.

Here is a link to the story:

I would love to hear your opinion!

Response from Dr. Frascino


Oh yes, I've seen it. In fact, the phone has been ringing off the hook since it hit the broader media markets. The statement in the Bulletin Des Médecins Suisses was made by the Swiss AIDS Commission after careful review of four studies that focused heavily on heterosexual couples and vaginal sex. The report suggested HIV-positive folks on potent and effective antiretroviral drugs who are adhering to their treatment regimen and who have suppressed their HIV plasma viral load to an undetectable level for at least six months and who do not have other concurrent sexually transmitted infections, are not sexually infectious, i.e., they cannot transmit HIV through sexual contact. This really is not such astounding news. We have been saying for quite some time that suppressing the HIV plasma viral load reduces the risk of HIV transmission significantly. To say that it completely eliminates this risk is still premature in my opinion. The current report did not provide information about anal sex. Also how does one know with certainty that his HIV plasma viral load is suppressed to an undetectable level at the time he/she wants to have commando fusion sex with a horned-up hottie? Viral loads can very quickly rise for a variety of reasons, including non-adherence to anti-HIV therapy, concurrent illness, vaccinations, emergence of drug resistance, etc. Are these risks an HIV-neggie is willing to take to avoid using a condom? In other words it will be very difficult to "certify" that your sex partner actually meets all the criteria listed by the Swiss report.

Certainly this report will generate much discussion as to its implications for doctors, magnetic couples, HIV-positoids, HIV-prevention efforts, the legal system, etc. I welcome the discussion, but I'm not looking forward to the flood of questions related to this story that are this very moment cramming their way into my inbox.

Dr. Bob

SWISS REPORT Feb 5, 2008

Dear Dr. Bob,

Thanks for your prompt response. I understand your caution about such a "controversial" consensus statement by The Swiss Federal Commission for HIV/AIDS. However, this latest international news about HIV/AIDS is especially significant for people like me, which happen to be in a consensual serodiscordant relationship. Not for the sake of letting go of safer sex practices during intercourse, but so we can feel a little more comfortable during foreplay and the occasional unprotected nibbling during oral sex. During my 20 years of surviving AIDS I have had a couple of consensual monogamous relationships with HIV negative men and met several serodiscordant couples that have been together for 10, 15 and even up to 20 years, without the HIV negative partner ever testing positive. Like the article clearly states: "The situation is analogous to 1986, when the statement HIV cannot be transmitted by kissing was publicized. This statement has not been proven, but after 22 years of experience its accuracy appears highly plausible.

I am aware this fact has been well known for years by the scientific community working on HIV research, as well as many Physicians specializing on HIV/AIDS & Infectious Diseases in big "gay meccas" like New York City and San Francisco and their respective AIDS Service Organizations, but fear of controversy and loosing essential federal founding (most specially during this past 8 years of republican dictatorship) has kept this information in the dark in the United States. I do agree more studies are needed in the US to better understand this subject, but to label the conclusions of the Swiss expert researchers as "premature" is condescending and naive from our part, to say the least. Lets not forget that historically, the USA has not been on the forefront of HIV research (even though we will like to believe so) the Europeans are. In the US, we have been successful at developing treatments (through our money hungry Pharma-Industry), but not at researching the cause and effects of HIV itself.

I think this new information should be taken into account, most specially when providing testing and face-to-face counseling to people with questions about serodiscordant relationships and safer sex practices.

Mahalo for your time and efforts working to understand and serve our HIV+ community.

Much aloha,


Response from Dr. Frascino

Hello Fernando,

I disagree with your statement that "fear of controversy and losing essential federal founding has kept this information in the dark in the United States." What???? As an HIV/AIDS physician, educator and activist, I can assure you we are not afraid of controversy in either the medical or activist communities! Federal funding for some excellent HIV-prevention programs has been cut to help fund Bush's wrong-minded abstinence-only programs, but that has nothing to do with the information in the Swiss report. That report is nothing more than a review of four previously published and readily available studies resulting in a consensus statement from one group. Within hours of the group posting their statement, I and many other HIV experts were flooded with questions about it. There is no cover-up or suppression of this data or information.

Regarding my opinion of the Swiss report, I expressed concern, because the research focused heavily on heterosexual couples and vaginal sex as opposed to anal sex. Consequently, to make a definitive statement that "positive people on effective HIV meds aren't sexually infectious" is, in my opinion, premature. I stand by my opinion and assure you it is not based on fear of controversy or fear of losing federal funding (or, as you call it, "federal founding").

Fernando, be reasonable. We are all on the same side here. I too am HIV-positive and in a serodiscordant relationship.

Below I will print some "hot off the press" reactions to the Swiss report from several international HIV/AIDS groups (UNAIDS and WHO). I agree with them. (Or should I say their just-published opinions agree with my previously stated position?)

Dr. Bob

UNAIDS, WHO React to Swiss Claim About Antiretrovirals, HIV Transmission

February 4, 2008

UNAIDS and the World Health Organization last week responded to a claim by a Swiss state commission that HIV-positive people taking antiretroviral drugs cannot transmit the virus during sex under certain circumstances, AFP/ reports. The organizations said that they "strongly recommend a comprehensive package of HIV prevention approaches, including correct and consistent use of condoms" (AFP/, 2/1).

The Swiss AIDS Commission on Wednesday in a report based on four studies said that couples with one HIV-positive partner do not need to use condoms to prevent HIV transmission provided that the HIV-positive partners are adhering to their treatment regimens, have suppressed HIV viral loads for at least six months and do not have any other sexually transmitted infections. Several HIV/AIDS advocacy groups and scientists expressed concern following the release of the report, noting that the research was focused on heterosexual couples and vaginal intercourse rather than anal sex (Kaiser Daily HIV/AIDS Report, 1/31).

UNAIDS and WHO in a joint release said that HIV-positive people "who are following an effective antiretroviral therapy regimen can achieve undetectable viral loads" at certain points during treatment and that research "suggests that when the viral load is undetectable in blood, the risk of HIV transmission is significantly reduced." The organizations added that despite these findings, "it has not been proven" that suppressed viral loads "completely eliminate the risk of transmitting the virus. More research is needed to determine the degree to which the viral load in blood predicts the risk of HIV transmission and to determine the association between the viral load in blood and the viral load in semen and vaginal secretions." In addition, further research should "consider other related factors that contribute to HIV transmission," including coinfection with other STIs, UNAIDS and WHO said.

According to the groups, a comprehensive HIV prevention strategy also includes:

Delaying first sexual activity;


Decreased number of sexual partners;

Avoiding penetration;

Safer-sex practices, including the use of male and female condoms; and

Early and effective STI treatment (UNAIDS/WHO release, 2/1).

Just to let you know....
Church Lady got you on this one! (CHURCH LADY AND HER BIBLE RULES)

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