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Can me and my neg girlfriend have unprotected vaginal sex . . .
Oct 7, 2009

Can me and my neg girlfriend and I have unprotected vaginal sex? I am pos healthy undetectable Viral load and cd4 708. Over the past 2.5 years we have had well . . . a lot of unprotected sex. She was still neg as of last test. I'm trying to trying to be responsible and say no or lets use a condom but she is voracious and likes sex no rubber between us. We've both seen the Swiss study and its a risk she says she wants to take.

Response from Dr. Frascino

Hello,

Your girlfriend may be willing to take the risk; however, it takes two to do the unsafe horizontal mattress-mambo. Despite her voraciousness, are you still willing to put her at risk by playing sexual Russian roulette now that you definitively know there is a very real risk to her health and wellbeing? Certainly being on combination antiretroviral therapy, which drives the HIV plasma viral load to undetectable levels, significantly decreases the risk of HIV transmission; however, it does not completely eliminate the risk. There are many reasons for this. You could have a transient rise ("blip") in your viral load; you could develop resistance to one or more of your HIV drugs and your viral load could spike without your knowing it; the viral load in the semen also may not be the same as the measured viral load in the plasma, etc. I'd strongly recommend you insist on playing safe by using latex condoms for all penetrative sex. (See below.) Your nymphet gal-pal may dislike the feel of rubber between you, but I guarantee she'll dislike having HIV (AIDS) even more.

Good luck. Be well.

Dr. Bob

Barebacking as a bottom (FINDINGS SUGGEST HIV CAN BE TRANSMITTED FROM MSM WITH UNDETECTABLE VIRAL LOAD 2009) (SUPERINFECTION, 2009) Mar 28, 2009

recently alot of bareback videos have come on the market which i love watching. i am poz and was always told dont bareback you can change your strain and become resistance to your current meds, "atripla" by the way and undetectable. but how can porn stars and even close friends of mine that are poz continue to bareback as a bottom and have the top ejaculate in them and have for years and my friends say it has never interferred with there viral loads and they have stayed undetectable and some of my friends have multiple partners at bathouses and they are still fine this perplexes me i read the recent article following poz couples that are undetectable and how they did not get a super infection, so what is your take on all this? now keep in mind yes a couple of my close friends bareback but not without have gotten other std's but never a increase in viral load or med failure. recently i was in L.A and went to a bathouse and it seemed everybody was barebacking and not only did this place offer hiv testing but also viral load testing and it said to see if you have been recently re-infected again. huh? whats the deal? keep in mind i am 37 and only been poz for 16months so a little naive to it all.. thanks love, love, love you and all your words of wisdom and knowledge of the matter...

Response from Dr. Frascino

Hi,

Your friends are playing sexual Russian roulette. I'm sure they are happy to share their experiences of playing Brokeback Mountain with HIV-positive cowboys riding their rawhides (so to speak) without any negative consequences. However, do you really think they would tell you (or anyone) if their viral load shot up and suddenly they had to switch regimens? Probably not, or at least they'd be much less likely to broadcast such news. Perhaps that's why you haven't heard about it but HIV specialists have.

The possibility of contracting a different and perhaps more virulent strain of HIV is true. Exactly how often this occurs is difficult to tell. (See below.) As for positive couples with undetectable viral loads barebacking and not acquiring a superinfection, see the article below that suggests HIV transmission can occur despite having an undetectable HIV plasma viral load.

The level of risk you want to take is always up to you; however, I can advise you the risk of superinfection is a risk I certainly would not advise or be willing to take. Even though you are a relative newbie to the virally enhanced world, perhaps you could do your friends a favor by passing this information on to them.

Good luck.

Dr. Bob

arv and contagion(FINDINGS SUGGEST HIV CAN BE TRANSMITTED FROM MSM WITH UNDETECTABLE VIRAL LOAD 2008) Jan 1, 2009

friend on arv for 2 years says he is no longer contagious is this possible

Response from Dr. Frascino

Hello,

No. If he's HIV positive, he's capable of transmitting the virus. He may be confused about the terminology of his laboratory tests. On antiretroviral drugs, it is possible (and desirable) to drive his HIV plasma viral load to "undetectable" levels. However, this does not mean he is noninfectious or unable to transmit the virus to others. See below.

Dr. Bob

Unprotected Sex (FINDINGS SUGGEST HIV CAN BE TRANSMITTED FROM MSM WITH UNDETECTABLE VIRAL LOAD 2008) (SUPERINFECTION) Dec 17, 2008

Hi --

I am an HIV+ man who seroconverted within the last year. I recently started dating another HIV+ man who has been positive for 22 years. I'm currently not on meds with a viral load under 400 and CD4 over 600. His viral load is undetectable and CD4 is 400+. At this point we are having unprotected oral sex and protected anal sex. In the future, we have discussed having unprotected anal sex when we both feel comfortable with our monogamous status. I know there is a risk of other STDs. However, if we've been monogamous and clear of STDs and decide to have unprotected anal sex, am I at any risk of acquiring a resistant strain of the virus if he is on meds and undetectable and I am not on meds? What about if I am on meds? Resistance tests reveal that I have no resistances to treatment.

Thanks so much for your time. This forum is a wonderful resource for the community.

Response from Dr. Frascino

Hello,

This issue comes up frequently. (See below.) I have no new information to report. I would still advise against Brokeback Mountain barebacking no matter how hot your cowboy may be in the saddle.

Dr. Bob

??? (Findings Suggest HIV Can Be Transmitted From MSM With Undetectable Viral Load, 2008) Oct 23, 2008

Hi I'm 25 and HIV positive Ive been doing fine on atripla once a day and vitamins Ive been poz for 4 years now.The question that i have is that Ive been dating someone that is also positive But only dated since 07 my levels are undetectable i go to the doctor's every 3 months or as needed ,but I'm not sure what my partners levels are and we have been having unprotected sex together hes not on meds, but is always getting colds and just recently told me that he had a UTI hes had other partners but thinks its me because i take meds ,i haven't had any problems so far and i wanted to know if its anyway that I'm making him sick because I'm taking atripla ? .thank u

Response from Dr. Frascino

Hello,

You are wondering if you are making your bareback-Brokeback-Mountain sex buddy sick, because you are taking Atripla??? WHAT???? No, of course not. However, you are both taking considerable risk by deciding to go commando-Rambo between the sheets. Not only are you both at risk for a wide variety of STDs, but you could also acquire each other's strain of HIV, which could have a very deleterious effect on your health. It is true that driving your HIV plasma viral load to undetectable levels with antiretroviral drugs decreases the risk you would transmit HIV to your partners, but it does not completely eliminate the risk. (See below) I urge you both to reconsider your decision to have unsafe sex, even if you are "serosorting." (See below.)

Dr. Bob

Findings Suggest HIV Can Be Transmitted From MSM With Undetectable Viral Load

Infectiousness and antiretroviral therapy: reports look set to further fuel the debate

Michael Carter, Wednesday, August 27, 2008

A man transmitted HIV to his regular male partner despite taking antiretroviral treatment and having an undetectable viral load in his blood, German doctors report in the journal Antiviral Therapy. The authors believe that this is the first recorded instance of an individual with an undetectable viral load infecting a sexual partner with HIV.

In an editorial accompanying the case report, two of the authors of what has come to be known as the "Swiss Statement", whilst acknowledging a "very low" risk of transmission from individuals taking antiretroviral therapy with an undetectable viral load, highlight what they believe to be some weaknesses in the documentation of this case. Furthermore, they point out that in their own experience "all suspected cases of transmission during antiretroviral therapy turned out to have another source."

And a separately published study looks likely to further fuel the already fierce debate about the infectiousness (or otherwise) of patients being treated with antiretroviral drugs. French investigators report in the August 20th edition of AIDS that 5% of antiretroviral-treated men with an undetectable viral load in their blood had detectable HIV in their semen. None of these men had a sexually transmitted infection.

In January this year, senior HIV doctors in Switzerland issued a statement saying that HIV-positive patients treated with antiretroviral drugs with good adherence to their treatment, a viral load below 40 copies/ml for at least six months, and no sexually transmitted infections should not be considered capable of transmitting HIV sexually. The statement has proved controversial and there was a lively debate about the infectiousness of patients taking successful antiretroviral therapy at the recent International AIDS Conference in Mexico City.

The conference was also told that the lowest blood viral load in a documented case of HIV transmission was approximately 300 copies/ml. But now doctors in Germany have reported a case of transmission when a patient taking antiretroviral therapy had a sustained undetectable viral load in his blood.

The case involved a 39 year-old gay man who first started HIV treatment in 1999. Since 2000 he had been taking a combination of anti-HIV drugs including AZT, 3TC and nevirapine and had maintained an undetectable viral load. Since 2000 this patient had been in a reportedly monogamous relationship with a man of the same age.

The patient's partner reported having had had an anonymous HIV test in 2002, and a search of the records of anonymous tests conducted at the facility the patient attended showed that only one anonymous test was performed on a man at this time, the result being negative . The couple reported unprotected anal intercourse on a number of occasions since May 2003. There is no information in the case report about whether the patient and his partner were insertive, receptive, or both, and the authors failed to clarify this issue when contacted by aidsmap.com e-mail.

In July 2004, the patient's partner was diagnosed with HIV, and tests conducted shortly after showed that his CD4 cell count was 338 cells/mm3 and his viral load 21,800 copies/ml. Such a viral load would have been modest for an individual experiencing HIV seroconversion.

The investigators performed phylogenetic analysis which suggested a close relationship between the virus in the patient and his partner. Neither partner reported a sexually transmitted infection.

"We feel confident", write the report's authors, "that the present case report suggests that transmission can occur despite undetectable plasma viral load. Therefore, we cannot support any recommendations that abandon the use of safer-sex practices in this context without mentioning the possibility of HIV transmission."

But the authors of the editorial accompanying the case report highlight what they believe are some weaknesses with the reporting of the case. Although they acknowledge that the phylogenetic analysis indicated a linkage between the virus in the two individuals, they write "an infection by an epidemiologically linked third individual is only ruled out by sexual history, which is notoriously unreliable". They also suggest that "the recollection of a non-documented HIV antibody test more than 5 years earlier is a considerable weakness of this report."

However, the editorial's authors also believe that even a well-documented case report of sexual transmission of HIV involving a patient taking anti-HIV drugs with an undetectable viral load would "not indicate that this practice is associated with a risk of sufficient magnitude to have public health implications." They draw an analogy with oral sex, where individual cases of HIV transmission have been reported.

Detectable viral load in semen when viral load is undetectable in blood

A separate French study has found that 5% of 145 HIV-positive men enrolled in an assisted conception study had detectable viral load in their semen, despite having an undetectable viral load in their blood.

The men provided paired blood and semen samples between 2002 and January 2008. The lower limit of detection for HIV in blood was 40 copies/ml and 200 copies/ml for semen. In the vast majority of samples (85%), HIV was undetectable in both blood and semen.

But in 3% of samples HIV was detectable in both body fluids, and in 6% viral load was undetectable in semen, but detectable in blood. The remaining 5% of paired samples showed that HIV was undetectable in blood, but detectable in semen.

The investigators note that the patients in this 5% had all been taking antiretroviral therapy for at least six months and had maintained a blood viral load below 40 copies/ml. Furthermore none of these patients had a documented sexually transmitted infection.

On the basis of these findings the investigators conclude, "for serodiscordant couples with a desire to have a child, assisted reproduction technology remains a preferred method, when accessible to avoid HIV transmission".

Reference

Sturmer M et al. Is transmission of HIV-1 in non-viraemic serodiscordant couples possible? Antiviral Therapy 13: 729 732, 2008.

Vernazza P et al. HIV transmission hunting the chase for low risk events. Antiviral Therapy 13: 641 - 642, 2008.

Marcelin A-G et al. Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma. AIDS 22: 1677 79, 2008.

"Dealing with HIV+ Fiance' when I have OCD (HARM REDUCTION STRATEGIES FOR MAGNETIC COUPLES, 2009) Aug 1, 2009 Dear Dr. Fascino: I've never seen this ? before but is there any advice on the day-to-day dealing w/magnetic couple issues? (i.e. my fiance' is 15 yrs w/HIV. Still undetectable viral load). Each and every day I don't know if I can deal with this. I suffer from OCD and have spend many visits w/his ID specialist asking ?. He has assured me that since we follow ALL safe sex practices everything should be fine. I also test every 6 months. I'm still -neg but with the OCD I am having a hard time coping. Any books suggested to read? Is there anyone else that has such concerns? Am I incapable long term of dealing with this? He's a wonderful man and I do love him. Maybe this is why I haven't settled on a wedding date? Signed - Living with daily panic.

Advertisement Response from Dr. Frascino

Hello,

This is much more of an OCD than HIV problem! You've already spent "many visits with your partner's ID specialist asking questions." He has assured you that since you follow safer sex practices you should be OK. I doubt reading the same advice in a book will help your problem. I'd suggest both you and your positively charged fiancé read through the archives of this forum. We have entire chapters devoted to magnetic couples, safer sexual techniques, HIV sexual prevention, HIV non-sexual prevention and related topics. I'll repost below some information from the archives concerning harm-reduction strategies for magnetic couples. In addition I strongly recommend you seek professional help for your OCD problem. Psychotherapy (counseling) can be extremely helpful in confronting and conquering irrational fears and anxiety. Hopefully your OCD won't cause you to be singing "The One That Got Away Blues!"

You may or may not know that I and my legally married spouse Steve (Dr. Steve, the expert in The Body's Tratamientos forum) are a magnetic couple. We've been together for 16 years in a union that most people only dream about. Consequently I can advise you from personal experience that "happily ever after" can come true for magnetic couples.

Good luck.

Dr. Bob

In love with + man, NOW worried about myself Jun 19, 2009

Hello Dr. Bob. I've been reading your responses for about 2 weeks now and you are a great man for giving us your vauable time. So long story short: Met a guy in Aug 08. we had protected and unprotected sex. He got deployed but came back early because he was told he was +. I got tested at 8 weeks and was -. He came back and to his surprise I still wanted to be with him. From then on we always had sex with a condom. Around March 29,during sex, the condom broke. He didnt realize and he ejaculated inside me. Today I went to get tested and got the ClearView hiv 1/2 stat-pak (15 minute results). The test came out negative. I didn't get tested exactly at 3 months (about at 12 weeks). So I'm wondering how accurate is the ClearView and should I go back to get tested again?

Response from Dr. Frascino

Hi,

Your 12-week negative HIV-antibody test is very encouraging. However, because you had a significant exposure to someone who is confirmed to be HIV infected, the CDC recommends HIV tests at both three and six months to assure you are not infected. The odds at this point are dramatically in your favor that you did not contract the virus.

I would suggest you and your positively charged mate read through the chapter in the archives of this forum devoted to magnetic couples. I'll reprint below a sample of what can be found there pertaining to harm-reduction measures for magnetic couples (one poz and one neggie).

Good luck.

Dr. Bob

condom failed (HARM REDUCTION STRATEGIES FOR MAGNETIC COUPLES, 2009) May 27, 2009

I am an hiv neg. female, my boyfriend has been hiv pos. for 20 years.and his viral load has always been undetectable.3 nights ago,after sex, we realized the condom had come off and was still inside me,it took some digging, but he got it out.and it was evident that he had come inside me.. afterwards, i started spotting, and started my period the next day. wich has me concerned.i get tested every 4 to 6 months, and had just been tested a week before..i am not going to get all stressed out about it,i know nothing is ever 100% safe,and it can only make things harder. but, the fact that i was bleeding a little has me worried.. how likely is it i've been infected ?, and how long should i wait to get tested again?.this is the first, and hopefuly the last accident we have had.!!

Response from Dr. Frascino

Hi,

Condom failure does place you at some degree of risk for HIV. That your positive boyfriend has an undetectable HIV plasma viral load would significantly decrease the risk of HIV transmission. However, your spotting may increase the HIV-transmission risk. In situations where there has been a significant HIV exposure, post-exposure prophylaxis (PEP) would be warranted if it can be started soon and no later than 72 hours after the exposure. Your exposure was three nights ago; consequently, this is no longer an option for you. But I would encourage you and your boyfriend to review the information about harm-reduction strategies for magnetic couples in the archives of this forum. We have an entire chapter devoted to magnetic couples. I'll reprint below a sample of what can be found there. At this point we would recommend you have an HIV-antibody test at the three- and six-month marks. The six-month test is recommended by the CDC because you had a significant HIV exposure from a partner confirmed to be HIV positive.

Good luck. I agree getting all stressed out won't help!

Dr. Bob

Undetectable Viral Load in Semen MAGNETIC COUPLE SEXUAL RISK 2009) May 26, 2009

A "big G'day" from Australia to you, Doctor Bob!

I am an HIV positive male involved in a relationship with an HIV negative female.

I have been on Atripla (or the Aussie equivalent) for a year now, and for 10 of those months been undetectable.

My girlfriend and I always practice safe sex - I wouldn't put her at risk for anything!

However, during sex last night, the condom broke. We were unaware that it broke and probably had vaginal intercourse for about 15 minutes before realising it had snapped.

I did not ejaculate inside her, but (obviously), can't tell you how much pre-cum would have "leaked" during this 10 minute period.

What are the chances she would have contracted HIV from me?

We are both frantically worried about it and it is putting a strain on our (otherwise wonderful) relationship.

I have read that a recent Swiss study found that a consistent undetectable viral load in the blood correlated with the semen, but I have read other reports that say this might now be the case.

I am hoping that being undetectable and not cumming inside her stacks the odds well and truly in her favour. What would be the chances of her contracting something from this one-off incident?

Thanks if you can shed any light on the matter, and good luck to you and your partner in your own magnetic relationship - opposites attract!!

All the best, Oz Boy. xx

Response from Dr. Frascino

Hello Boy from Oz,

Here's what we know:

1. The HIV plasma viral load usually, but not always, correlates with the HIV viral load in semen (or cervical secretions).

2. Having an undetectable HIV plasma viral load significantly decreases the chances of HIV transmission.

3. Not ejaculating in the love canal significantly decreases the chance of HIV transmission.

4. PEP (post-exposure prophylaxis) taken as soon as possible and no later than 72 hours after an exposure can decrease the chance of HIV transmission. (You can read much more about PEP in the archives.)

To specifically answer your question, the odds are very much in your girlfriend's favor. However, HIV testing is still warranted. I would also recommend you and your gal-pal review the harm-reduction strategies available for magnetic couples (PEP, PrEP, proper condom use, etc.). I'll reprint below some information from the archives. Please note we have an entire chapter devoted to magnetic couples.

Good luck from one magnetic couple to another! Magnetic couples rock!

Dr. Bob

Hiv infection? Magnet couple stress and fear (MAGNETIC COUPLE SEXUAL RISK 2008) Oct 8, 2008

I am negative at the moment and my boyfreind is HIV positive. he is an HIV educator actually.

After I accepted his status, we finally became intimate with each other. I did oral sex on him 3 times that night. Twice on his penis and once with his ass. He precums almost instantly (I don't know if its just with me lol), but I feel like despite the wealth of knowledge about the risk of unprotected oral sex I feel like I may have exposed myself. I didnt not swallow much if any precum. I had a little after taste and I mouthwashed mid session. I only have minor gum bleed after toothbrushing. I am a little concerned about anal oral intercourse too even thought I saw no possible way i could get infected. He penetrated me with a condom and i am not concerned about infection there.

I just want to feel a little assured about my chances for infection here. I love him so much and I find it hard to be intimate with him without thinking about his status. It's a reason why I can't put myself in a condition to penetrate him. And I feel horrible even thinking about talking to him about it because he is an HIV educator and probably know more than most about safe sex practices. Gawd, Just thinking about it and letting my mind run amok about possible infection makes me want to cry becasue I dont want to hurt nor loose him, but I want to trust him with us and our intimacy. And I want to be able to give him my all when we make love without holding myself back.

Given what I said, what were my exposure risks. And what advise do you have for me and the relationship with the one i can see myself with forever?

Response from Dr. Frascino

Hello,

Your HIV-acquisition risk is extremely low. There have been no documented cases of HIV transmission due to rimming or getting rimmed. Oral sex carries only a very slight risk for HIV acquisition/transmission. You can read much more about this in the archives of this forum. We have entire chapters devoted to oral sex and sexual-HIV transmission risk.

Regarding your concerns about sexual activity within a magnetic relationship, as you might imagine, you are not alone. It's something all magnetic couples must come to terms with. Communication is key and that is what is lacking in your current relationship! That your Mr. Right is an HIV educator should make communication easier, not more difficult! Chances are he's as worried about infecting you as you are about acquiring the virus. The two of you are overdue for a heart-to-heart (note that's heart-to-heart, not hard-to-hard) talk! You need to openly discuss your concerns and together the two of you need to develop sexual rituals based on what is known scientifically about the HIV-transmission risk and on your individual levels of comfort. I suggest both you and your Mr. Wonderful read through the chapter in the archives devoted to magnetic couples. You'll soon see your concerns are shared by many of us in serodiscordant relationships. In addition to taking equal responsibility to make sure HIV is not transmitted, there are a number of other measures the two of you might want to consider to further reduce transmission risk:

1. Have your poz-partner take antiretrovirals to drive his HIV plasma viral load down to undetectable levels. This will significantly decrease transmission risk.

2. Get a starter dose of PEP (post-exposure prophylaxis) to have on hand just in case there is an accidental exposure (condom break).

3. Consider PrEP (pre-exposure prophylaxis). This involves the negative partner taking antiretroviral medication prophylactically on a routine basis. We still don't know if this approach is effective. Clinical trials are underway. Some magnetic couples aren't waiting for the results of the trials, but rather are instituting PrEP as a harm-reduction strategy now.

You can read much more about PEP, PrEP and other risk-reduction strategies in the archives.

Finally, I want to assure you from personal experience that opposites attract and that happily-ever-after can indeed become a reality for magnetic couples. Steve (Dr. Steve, the expert in The Body's Tratamientos forum) is HIV negative. I'm "virally enhanced." We've been happily-ever-aftering for 15 years and yes, that includes toe-curling, wake-the-neighbor, own-name-forgetting fusion sex. My advice to you is to make sure Mr. Right doesn't get away for all the wrong reasons.

Good luck to you both!

Dr. Bob



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