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Prevention and Testing
Jun 17, 2008

Hello Dr. Bob My husband is HIV+ and I am HIV-. He got tested when we first became sexually active because I said I wouldn't party without the balloons unless he was free of STDs (he had been honest with me about some prior years of promiscuity, but I would have insisted anyway).

He got his positive result, and we've been having a healthy sex life since.

We got married a year and a half ago, and recently read the Swiss study (you know the one :-). We talked to my OB/GYN and his HIV specialist and since we meet all the criteria, they are in agreement that I would be at a very low risk for contracting HIV through unprotected sex.

I seem to remember something about a test for a certain receptor that can tell me if I would even be able to contract HIV at all. Does that test actually exist or is it a myth cooked up by denialists?

We are not willing to play Russian Roulette with our health, but if we can party sans balloons, we're ready for it!

Thanks for all your work!

Response from Dr. Frascino

Hello,

Thank you for your question. Unfortunately I really don't have anything new to add to what I've already posted about these two issues. Consequently, I'll reprint below just a small sampling of information in the archives.

Briefly, I do not agree with your Ob/Gyn and HIV specialist on this issue. Plus, even if you accepted their interpretation of the retrospective data in the Swiss Report, are you really willing to accept even a "very low risk for contracting HIV through unprotected sex" when the consequences can be so catastrophic and the risk is so easily avoided by continuing to use the party balloons? It's not a risk I personally would accept nor advise others to consider. However, like all risk decisions, the choice is yours. But do remember the old adage, "Better to be safe than sorry." OK?

As for Delta 32-mutation testing, this is still done primarily only in research settings.

Good luck! Stay safe. Stay well.

Dr. Bob

Being Undectable for 3yrs what are the chances of me passing HIV on - sex wise?? May 31, 2008

Hi Dr Bob,

I have been undectable for 3yrs now and my cd4 count is 770, I am on Saquinavir, Ritonavir, Kivexa, Lyrica and Zamadol. I was diagnosed 6months a go with Neuropathy which is under control now. The question is i have had partners who want bare back sex with me, and yes i have done it!! Yes they are all neg and still are, but i just dont understand what i can and cant do being Undectable?? Cheers.

Response from Dr. Frascino

Hello,

Here's what we know. Using potent antiretroviral drugs to drive plasma HIV viral load to undetectable levels significantly decreases the risk of HIV transmission. However, what we do not know is if the risk becomes so low that it's essentially nonexistent. Most HIV specialists, yours truly included, would continue to strongly advise against bareback sex for several reasons. First, many of us feel HIV transmission may still be a very real possibility, even with an undetectable viral load. Second, there is no way to guarantee someone is undetectable at the time of sex, as HIV viral load may increase dramatically for a variety of reasons (development of resistance, concurrent infections, recent vaccine, poor adherence to medication dosing, etc.). Third, bareback sex puts both partners at risk of a wide range of STDs other than HIV that can affect the course of an HIV-positive person's illness and cause the neggie all sorts of discomfort. Fourth, barebacking can lead to unwanted pregnancy.

Remember, it takes two to do the unsafe sexual tango! My very strong advice to you personally is don't take the risk! Someone also needs to advise your clueless horned-up buddies that they are playing a dangerous game of sexual Russian roulette every time they decide to go Commando-Rambo by forgoing the latex condom.

Be well. Stay safe. Keep your partners safe.

Dr. Bob

What does undetectable accually mean (SWISS REPORT) Apr 18, 2008

I'm a woman with HIV and my virus load is undetectable now. My husband wants to start having unprotected sex again ( we had unprocted sex for a year before I got tested) He is HIV negative and not worried about getting the virus. Is it okay for us to have unprocted sex as long as I'm undetectable?

Response from Dr. Frascino

Hello,

Here's what we know. The risk of transmitting HIV is significantly decreased if the HIV plasma viral load is suppressed to undetectable levels using antiretroviral drugs. Everyone agrees on that. What we don't know for certain is that the HIV-transmission risk under these circumstances is completely nonexistent. There has been ongoing controversy about the "Swiss Report," which suggested that HIVers whose plasma viral load had been suppressed on antiretrovirals for six months and who did not have any concurrent STDs were in essence noninfectious. The report was based on a retrospective analysis of several published reports (see below). Personally I feel the jury is still out (way out!) on this subject. Also HIV plasma viral loads can suddenly and unexpectedly increase for a whole variety of reasons concurrent infection, development of resistance, vaccinations, etc. As the viral load goes up, so does the risk of viral transmission. Consequently I would not recommend unprotected sex, even if one's viral load is suppressed. In my opinion, the risks are at this point still too high and the consequences too great.

Dr. Bob

Pos to neg transmission (SWISS REPORT AGAIN) Feb 9, 2008

I recently saw two Swiss study's cited and indicating ( Under certain simple circumnstances) that if a poz man is "undetectable, being adherent on protease inhibitors, that there would be virtually no chance of hiv transmission to a neg monogamous partner. Can you comment on this? Thanks,...Jim

Response from Dr. Frascino

Hey Jim,

I have commented! See below.

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 Aidsmap.com. Read More

For more news from POZ please visit POZ.com.

Response from Dr. Frascino

Hello,

"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 swissinfo.ch that heads, Patients with HIV could have sex without condoms Is this information accurate?

Thank you

MM

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 says..an 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

Hi,

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 POZ.com 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

Hello,

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:

http://aidsmap.com/en/news/4E9D555B-18FB-4D56-B912-2C28AFCCD36B.asp

I would love to hear your opinion!

Response from Dr. Frascino

Hello,

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,

Fernando

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/Google.com reports. The organizations said that they "strongly recommend a comprehensive package of HIV prevention approaches, including correct and consistent use of condoms" (AFP/Google.com, 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;

Fidelity;

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).

No HIV in 8 years (DELTA 32) Nov 1, 2007

To Whom It May Concern:

Thank you for your time in reading this. I am writing to ask a question. A good friend of mine is a homosexual male. I have personal knowledge that my friend has had receptive anal sex with over 1,500 men over the past 8 years. My friend frequents hot spots in local parks and public restrooms, and finds sexual partners on the internet. According to my friend (and I find this information credible), over 90% of his sexual encounters were unprotected and most of these men have ejaculated into his rectum. Some of the men who have ejaculated in my friends rectum are HIV positive.

Notwithstanding the fact that my friend has had unprotected sex with this many men, a recent HIV test was negative.

Having had unprotected anal sex this many times and with some known HIV-positive men, why hasnt my friend become HIV positive? Is there anyone, perhaps a research institute, who would be interested in a blood sample of my friend for further analysis? It seems like somebody would be collecting this type of data.

Thank you so much in advance for your response,

Concerned with finding a cure as fast as possible

Response from Dr. Frascino

Hello,

Thanks for your post and interest in helping to find a cure as fast as possible.

If your story about your friend is indeed accurate, he is one lucky boy. He's also a boy with significant psychological issues who is courting disaster with his self-destructive and irresponsible behavior. I'm quite amazed he found 1,350 guys (90% of 1,500) willing to have unprotected anal sex with him. Is he a closeted Republican Congressman or clueless rightwing religious zealot perchance? Oh, never mind. Is it possible he could have avoided infection, despite his activities at the hot spots? Yes, it is. Not every HIV exposure leads to HIV infection. Thankfully! Your friend might even have some genetic predisposition against HIV infection. (See below.) The bottom line, however, is that he's putting his bottom at risk with every unprotected poke he gets and sooner or later he's going to lose the STD/HIV sexual Russian roulette game big time. My advice is that you try to convince your good friend he needs help. We don't need his blood, but he definitely needs counseling and a change in behavior ASAP.

Dr. Bob

HIV+ Resistant Sep 12, 2007

Dear Bob,

Six month after he left me, My boyfriend send me a letter to tell me he had been tested positive and had developped aids. We had been together for two and a half years. We had unprotected sex many times, almost daly. He thinks he was infected throughout our relationship. I received loads from him in my mouth as much as in my ass. I got tested when I received his letter and was diagnosed negative. I got tested every year since then and still negative. It has been five years now and I have had other relationship with many partners. Is it possible that I am immune against the virus. That my body is protected against it. Is there a test we can take to see if our immune system can fight the virus on its own. If so where can I take such a test. I live near Montreal in Quebec, Canada. Thanks for your time. Cheers, Eric

Response from Dr. Frascino

Hello Eric,

Are you immune to HIV? No, most likely not. What you are is damn lucky! I urge you not to push your luck by assuming you are immune. That's playing sexual Russian roulette and ultimately you will lose.

I will reprint below some information from the archives concerning the Delta 32 mutation. This is an evolving story. Even with the mutation you would not be immune to all types of HIV.

Stay safe. Stay well.

Dr. Bob

delta 32 Mar 17, 2007

Dr. Bob ...

I think I may have heard everything now! So, I'm on Craigslist just 'poking' around and I see this guy who wants to have sex - but, he only does it bb. Now, here is where it gets wacky! He's HIV Negative and says, "I just got tested in January, but, I just do that so guys will know the right answer. I don't worry about HIV ... I'm delta 32."

What does that mean? I went to a link, that he provided, and it talked about smallpox, and the plague.

What gives? Is this guy a bit crazy or is he really "safe?"

Can you shed some light, my friend?? :)

Thanks!! Oh and P.S., I thought I found Prince Charming ... But, it wasn't him! I'm still looking! You have any cute friends in Orange County?

QS

Response from Dr. Frascino

Hey QS,

So you were poking around Craigslist looking for some poking?

Delta 32 is a bit complex to explain, but I'll give it a shot. First, some background. HIV can only infect certain cells that have specific "receptors" on their surface that allow HIV to enter. HIV attaches to CD4 receptors. However, CD4 alone isn't enough for viral entry. Another protein called CCR5 is also needed. CCR5 is called a co-receptor. Some folks have a mutation in the CCR5 gene called CCR5-delta 32 mutation. This mutation changes the configuration of the CCR5 protein such that HIV cannot bind to it. Genes, of course, are inherited. If you inherit a CCR5-delta 32 gene mutation from both parents, your chances of becoming HIV infected are dramatically reduced. This occurs in about 1-3% of Caucasians. If you inherit one CCR5-delta 32 mutation (from just one parent), it will confer some protection against acquiring HIV and may make HIV disease less severe if you do become infected. Current estimates are that 10-25% of Caucasians may have a single CCR5-delta 32 mutation.

So should Craigslist Delta-32 Boy "not worry" about HIV? Absofrickinlutely NOT! It is downright dangerous to assume you are safe if you have the CCR5-delta 32 mutation. It is not a guarantee of HIV immunity. HIV is much too smart for that. Some strains of HIV use proteins other than CCR5 as co-receptors to enter CD4 cells.

As for the bubonic plague (Black Death) and smallpox link, it appears that the CCR5-delta 32 mutation may have arisen to protect folks in Europe from these illnesses. The mutation affords protection from these ailments and could have arisen via an evolutionary process. (Yes, right-wing religious wing-nuts, evolution does indeed exist!)

So if you happen to hook up with Delta-32 Boy, you might want to give him a science lesson along with his poke.

Finally, hotties in Orange County? Sure, I know some Prince Charmings in that zip code, but unfortunately none are currently single. So I guess you'll just have to continue kissing those toads until your prince arrives.

Good luck.

Dr. Bob



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