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HIV Transmission Risk
Jun 27, 2012

I am a 50 year old HIV negative gay man, and my boyfriend is a 51 year old HIV positive gay man. We have been together for many years. He has high t-cells and an undetectable viral load thanks to daily HAART. In the past we had low risk sex but recently that has changed. For the past few years I have been swallowing his cum and I never converted. Recently, we started having anal sex without condoms. I usually ejaculate inside of him and he always pulls out before ejaculating. I need need a lesson on safe sex. We have been practicing it since 1986, but I would love to feel him cum inside of me and am hoping that in this new epoch of HIV and AIDS, that I will be able to freely allow him to cum inside of me without a condom. I know you will advise condom use (and I have been using them for years and years), but I would like to know the TRUE degree of risk I would be taking if he were to cum inside of me. I love him very much and would love to one day finally feel him cum up inside of me freely and without dread of infection. ALSO, and I think this is important ... if I were to take HAART prophylactically, would my risk of infection be reduced even further? If so, to what degree? Would that lower or further eliminate the risk of viral transmission. I want to freely make love, as does he, but we really need to do this the right way should we decide to start having sex without barrier protection since he has been undetectable for many many years. MANY THANKS

Response from Dr. Wohl

Since you are both grown-ups you can make a grown up decision based on the facts.

Fact 1: People with undetectable viral load in the blood have a much lower chance of transmitting HIV to others. Much of these data come from heterosexual couples. Is it totally impossible for such people to transmit the virus? Probably not and some of this may have to do with breaks in HIV therapy and possibly transient increases in the amount of shed virus, like during another sexually transmitted infection (this is theoretical).

Fact 2: Taking Truvada daily was associated with over 40% reduced risk of acquiring HIV among very sexually active men who have sex with men in an recent study. That is not a great result but shows there is an effect. According to one analysis, those who were better at adhering to the Truvada may have had higher levels of protection. The drug costs money, has some side effects (nausea and bone loss) and for many it is unclear how long they will really take this day after day.

Fact 3: Being the bottom is riskier than being a top. When he ejaculates inside you, he delivers more than sperm and if he had detectable HIV in his semen it would enter you and possibly cause infection. With you on top, there is somewhat less of a risk of his virus entering you.

So, you have to determine with your partner what makes sense and feels right for you and for him. If any risk is too much risk, or if his worry about your getting infected puts a damper on his wanting to have sex, this would lead you toward sticking with condoms. But, if you interpret the facts to mean there is some but very low risk of infection in this monogamous partnership where the infected partner has reliably undetectable virus, this may trump all else in your eyes.

DW



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