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Feb 19, 1998

What are the risks involved with an HIV-positive husband and wife continuing their sexual relationship? Should sexual relationships continue?

Response from Mr. Sowadsky

Hi. Thank you for your question. First of all, the decision on whether to continue to have sex or not is a deeply personal one. Nobody can tell you whether you should have sex or not. Only the two of you can make that decision. But, if you do decide to have sex, practicing safer sex is in your best clinical interest, as I will describe below.

The issue of positive persons having unprotected sex with other positive persons has been extremely confusing for many people, and also very controversial. The following is a general review about the issues of reinfection with HIV, and also about the risks of STDs and opportunistic infections. Ultimately, the decision of how much risk you are willing to take, is up to you.

Let me first review the risks of HIV reinfection and STDs, then the risks of opportunistic diseases being transmitted from one positive person to another.

Reinfection can pose a risk for several reasons.

1. If you become infected with another strain of HIV that is drug resistant, you can become resistant to that drug yourself. For example, if you presently have a predominant strain that is sensitive to a protease inhibitor, if you become reinfected with another strain that is resistant to a protease inhibitor, you yourself can become resistant to the protease inhibitor. When you are taking a certain antiviral drug, when a new virus "comes along" with resistance to that drug, there is selective pressure for that new strain of virus to become the most common (dominant) strain over time (this is from the basics of Darwinian Evolution). With only a limited number of antiviral drugs out there, you want to avoid as much as possible acquiring a drug resistant strain. We already know that there are strains of HIV that are resistant to the protease inhibitors, AZT, and other antiviral drugs. In fact, we even know the exact genetic mutations that lead to drug resistance, and in some cases, multi-drug resistance from a single set of mutations. When a virus enters another persons body, it brings with it its characteristics (like drug resistance) that are genetically encoded. The issue of HIV drug resistance closely follows that of TB drug resistance. If a person has a drug resistant strain of TB, and they infect another person, that new person is already drug resistant. The same principals of drug resistant TB, can apply to HIV as well. And for both of these infections, we are now dealing with problems of multi-drug resistant strains.

2. STDs are an important consideration in persons infected with HIV. If you are putting yourself at risk for HIV, you are also putting yourself at risk for other Sexually Transmitted Diseases (STDs), which can put a further strain on the immune system. STDs in persons with HIV (and especially in persons with AIDS) can be much harder to treat and can be much more severe, than what is normally seen.

In addition, new studies are now showing that people who have HIV, and also Chlamydia or Gonorrhea at the same time, are more likely to transmit HIV to their partners (in addition to the risks for transmitting Chlamydia or Gonorrhea). In other words, persons with HIV who also have Chlamydia or Gonorrhea, are more infectious for HIV. In addition, persons with certain STDs (like Herpes, Syphilis, Chancroid, Chlamydia, and Gonorrhea) are more susceptible to becoming infected with HIV. This is because these infections make it easier for HIV to enter the bloodstream, thus leading to a greater risk of infection (or reinfection).

Kaposi's Sarcoma, an opportunistic infection sometimes seen in persons with AIDS, now appears to be due to a sexually transmitted virus called HHV-8. If an HIV positive person becomes infected with HHV-8, and their immune system becomes severely damaged, they run the risk of getting Kaposi's Sarcoma. For more information about HHV-8, go to the posting, KS (HHV-8).

3. We are finding that some strains of HIV may be more virulent than other strains. If you get a more virulent strain than the one you already have, this may allow the disease to progress more rapidly. This is just one of the many reasons why some people may progress faster to AIDS than others.

4. If you get more of the virus in you, this could theoretically increase viral load. The more virus that gets in you, the more virus that is there to reproduce, hence a higher viral load. The higher the viral load, the more damage to the immune system, and the poorer the prognosis. Although this is still theoretical, since we already clinically know that high viral loads lead to a poor prognosis, it is best to do whatever you can to keep your viral load as low as possible.

Now, in regard to the transmission of opportunistic infections:

There are over 20 diseases associated with AIDS. Each of these can be quite severe, and each is transmitted in different ways.

Some are transmitted through airborne contact, for example, Pulmonary Tuberculosis (TB). However, if your partner had active infectious TB, they should be in an isolation room in a hospital. But remember a person with TB is not always contagious. If they do not have active TB, and they are not infectious, you would not be at risk of this infection.

Other AIDS related diseases can be transmitted by direct contact with various body fluids (like CMV), or through sexual contact (like Herpes infection). And remember, Kaposi's Sarcoma, a cancer sometimes seen in AIDS patients, now appears to be due to a sexually transmitted virus (see above).

Some opportunistic infections are acquired through oral-anal sex/rimming, or by food or water (Cryptosporidium, Isospora, and Microsporidium are examples).

Other opportunistic infections are naturally found all around us (Pneumocystis Pneumonia is a good example), and are not usually transmitted person-to-person. Some infections are transmitted through animals. For example, Toxoplasmosis is transmitted through cat feces (but not the cat itself--just it's feces!).

The key here is that since AIDS is actually a group of diseases, some can be transmitted person-to-person, and not so for others. The best way to avoid exposing each other to opportunistic diseases is to talk with each of your doctors. If one of you were to get an opportunistic disease, talk to the doctor and ask him/her if that opportunistic disease is transmitted from person-to-person. Some can be, others not. So take this issue on a disease-by-disease basis.

In summary:

Our biggest concerns are primarily those of drug resistant strains of HIV, STDs, and exposure to opportunistic infections. If a person does not want to practice safer sex because they do not believe in reinfection, then by all means, they should at least practice safer sex because of the concerns of other STDs, and opportunistic infections. Ultimately, the choice to practice safer sex is a personal one.

If you have any further questions, please feel free to call the Centers for Disease Control at 1.800.232.4636 (Nationwide).

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