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Mixed Status Infection Odd's
Jun 28, 2008

Dear Dr. Bob,

I have read many of your answers on this site for the past 4 years. Not only are they informative with basic information, they provide many of us with the type of treatment that goes beyond just taking HAART medications. Your honesty, caring, and sincerely loving attitude towards so many people is something no pharmaceutical company can ever patent or distibute.

I tested positive a little over 4 years ago. I started my medications immediately upon discovery. I take one Atripla pill per day and consider myself extremely healthy in every regard. I have consistently tested undetectable since I first started taking my medications ( some changes over the years as different and better options became available ). My T-Cell count has always been around 600 with a CD4 percentage of 32 %. I have never had any other STD's . I do not smoke, do drugs of any kind, and my alcohol consumption is basically nothing per year. Honestly, other than being HIV positive, I am probably far healthier than most guys - and especially those my age ( 60 ).

In the past year, a younger male and I fell very much in love. We dated non-stop for 6 months and I have honestly never been happier in my life. That situation has recently changed though due to some major concerns he has about being involved with someone who is HIV positive. He is negative, much younger, and is still not out to his family or close friends. I am fully aware those basic fears by themselves, the fact that he only dates older men, are enough to handle in explaining to his family - much less also disclosing the fear of contracting HIV by itself. I have tried to be as supportive emotionally in all of his coming out issues and other events as if I would even if we were not dating. I love him deeply and am having huge depression and other emotional issues over our relationship change. I cannot deny that I have not thought many times about suicide as the loss of my happiness and relationship with him has left me with a huge hole in my heart that I am sure will never be filled again. It isnt like this is puppy love for me at some young age and that I will have many other opportunities like some younger guy. We fell in love by talking on the telephone for hours at a time a full month before we ever met in person. I only disclosed my HIV status at the time when we met and prior to any sexual activities that would have ever infected him. Once I told him my status, although he was scared, he cared for me so much -he continued to date me for the following six months. We have recently attempted to maintain or build a friendship only. However , my heart will not allow me to just go back to that status, especially when I know he is attempting to have his sexual needs fulfilled with people that may not care for his long term physical or emotional needs or health.

We have always practiced safe sex during the time we have been together. He has expressed that since he is far more sexually pleased by being a bottom in a male to male relationship, ( somewhat of a change in priorities or attitude since we originally met ) that since I am the HIV positive person, he would always be so concerned over possibly being a top and infected that he is not sure he could ever relax enough to enjoy it with me. He has been a long term sufferer of both ADD and OCD. He finally went to a therapist a few months ago to discuss his fears of being in a relationship with me due to the ongoing panic attacks and stress he was feeling. He did not discuss this increased stress or panic situation with me prior to informing me that - although he loved me deeply - he thought he needed to change the relationship to allow him to seek fully satisfying sex from others that were not HIV positive. He has been now placed on Lexapro for stress and anxiety issues. His therapist made him have that discussion with me ( about his stress and possible change of our relationship ) as a condition of the therpaist increasing his dosage to overcome the stress and anxiety. Although that medication helps him with those issues, he now has serious sexual side effects from that medication.

I have read and furnished to him many stories and articles you have written or that were on the site about pro's and con's of mixed status couple dating. I have given him as much information as I can regarding my status as a form of education and to try and educate him as much as possible that the risk of HIV infection for him is significantly reduced due to my undetectable viral load and strong t-cell count. He may read or acknowledge what I am saying, but his fear from HIV infection is so strong at this stage, that I am not sure much of anything will ever change his mind. I have pointed out to him the fear of catching HIV, hepatitis, herpes, or many other STD's from guys that would never disclose their correct status honestly is a much higher risk of long term male relationships than having someone that loves him as much as I do and who has been totally honest with him from the beginning. I am sure those things scare him also, but like far too many people, just thinking about HIV by itself seems to mean something else to them in terms of fear. I have explained to him that as long as I continue to take my medications as religiously as I do, the likelihood of me ever dying from some OI is pretty rare. I have even explained that by me using a latex condom, and by me not even ejaculating into the condom ( by use of a constriction ring to prevent that from occuring ), the risk of him ever being infected by me was virtually nil. After all, it is the virus in my fluids that can hurt him - and as long as no fluids enter his body - he has got to be pretty safe in my opinion. No ejaculate and use of condoms every time would certainly be a pretty low risk event by me looking at things from a logical standpoint. Sadly, we both know that Fear of any kind, regardless of whether it is concerning HIV, or other things - is not always controlled or helped by using logic.

I fully understand his fear and more than anything, I want him to have a full loving relationship with someone that does not scare him. I am also fully aware that many men will either cheat on their significant others or have unsafe sex behind his back. Hence, there is no long term guarantee that just by changing sexual partners or any action he takes will produce a non threatening situation to him. He can either choose Love now with someone whose character and honesty and trust he totally knows, or he can hopefully Look for love with someone that he may never know how their future actions with them may affect him. Although I love him with all of my heart, and it is killing me to think he may not be in my life the way I want him to be, I am just trying to give him all of the correct information as much as possible in order to make sure he is making the best decision based upon facts - not out of uninformed Fear alone.

I am sorry for having taken so long to explain what my basic question is. I have seen in your comments many times, where you have used certain odds or statistics or things to explain certain risks that all of us must take each and every day as we go through life. I have seen you use the facts that driving in a car has its risk, flying, lightning strikes, etc. etc. I have tried to find different places for statistics of this sort but have not had much luck so far.

Can you help by furnishing some statistics as to what types of relative risks there are for someone negative having sex with someone positive - when that positive person is undetectable, they use condoms all the time, etc....versus other types of risk in the world ? i.e. risk of hepatitis, herpes ( even when using condoms ). Risk of getting killed by drunk driver, motorcyles..etc. etc. Just a good solid overview of how anyone should assess the risk they take in everyday life versus how they might be taking a risk having protected sex with a HIV positive person that is undetectable and using condoms all of the time ? I know you have indicated many times how you and your partner have a super sexual relationship of many years although you are of mixed status. Not that you would be trying to convince someone they are being totally irrational about their fear ( which I know is real ), but what types of information of thought provoking data could you provide to someone if you were in my shoes and trying to keep a wonderful love for both of us from just totally being destroyed forever ?

God Bless you always - Bob

Response from Dr. Frascino

Hello,

I'm sorry to hear your relationship is not working out. Unfortunately I strongly doubt facts and figures related to estimated statistical risk are going to be at all helpful in resolving this problem.

Your young buck has a lot to deal with at the moment. He's not out to friends and family; he has ADD, OCD, panic attacks and stress; and he's on Lexapro, which has resulted in "serious sexual side effects." Despite his obvious affection for you, it's not difficult to understand that his irrational HIV fears are at this point just too much for him to handle. My advice would be that rather than overloading him with facts, figures and logic, you step back and give the guy some space to sort things out. I realize it may be difficult for you just to be a supportive friend, but that's what your buddy needs at the moment. He's not rejecting you; he's rejecting the virus! Sure, he may make some mistakes along the way as he navigates the coming-out process and meets some less-than-honorable characters along the way. But you can't come out for him any more than you can protect him from every mistake. He needs to work with his therapist on many issues and find his own way. Only then will his irrational and largely unwarranted fears come into better perspective. If you remain a steadfast and trusted friend, there is a chance that when he's ready, your relationship may once again be rekindled. But to try to force this issue before he's ready will mostly only cause him to resist and perhaps even run for the hills.

As it turns out, he's not the only one in your relationship who could benefit from counseling. You report you are experiencing "huge depression and other emotional issues . . . and have thought many times about suicide . . . ." These are clear indications you should see a psychologist or psychiatrist for evaluation and management of your clinical depression as well as for help in dealing with the emotions resulting from your breakup. Bring a copy of your post and my response to your first visit with your therapist. It will help focus your treatment. In the long run, gaining better perspective on your entire situation may help you transition into the friendship role with your buddy without driving him away. Remember, many long-term successful relationships evolve from strong supportive friendships.

As for the facts and figures you request, they are indeed in the archives of this forum (search for "Swiss Report", an example is reprinted below); however, as mentioned above, I wouldn't use them at this time in an attempt to change your partner's mind. At best, I would suggest you point out that many times our worries are way out of proportion to actual risk. For instance, most people worry more about being murdered than committing suicide. Yet twice as many Americans commit suicide each year than are murdered. Similarly, folks worry more about being struck dead by lightening bolts than falling out of bed. Yet 10 times as many Americans die from falling out of bed as from lightening strikes.

Good luck to you and your buddy. You both have work to do in confronting psychological issues. I urge you to focus on that and on forging a strong supportive nonthreatening friendship for now.

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).



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