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Viral Load and Risk Assessment
Apr 9, 1997

In the 1 1/2 years I have known I am hiv-positive I have been fairly sexually active, including being the penetrator in both vaginal and anal intercourse (with informed and willing partners). I always use a well-lubricated latex condom and, with negative lovers, also pull out before ejaculating to further reduce risk. Since I do not ever produce any pre-cum fluid I have believed this practice to reduce the risk of a very risky practice to acceptable levels (to me). All my lovers have continued to test negative. I have a relatively new hiv-negative male lover who, since the outbreak of aids, has never been the receptor in anal sex. Even under the conditions above he is not comfortable doing so with me. Obviously he is cautious, which is just fine with me. Although I do not believe he thinks sex with me is without any risk, he is obviously, in general, shooting for the safer end of the safer sex continuum. However, we are wondering about viral load and risk levels. Over the last several months while I have been on triple combination therapy I have tested at as low as 120 copies/ml (six weeks after initiating the tri-combination), and otherwise at undetectable levels

Response from Mr. Sowadsky

Hi. Thank you for your question. The Quantitative PCR test, also known as a viral load test, can find HIV at levels as low as 400 copies/ml of blood. If levels of HIV are lower than this (which is certainly possible), the test may not be able to detect HIV infection. This test only measures the amount of HIV in the blood, not other parts of the body. Therefore, if a person has a viral load "below detectable levels", this does NOT mean they are cured or non-infectious to others. It does mean that the levels in the blood are too low for the test to find it. Because HIV can be found in various tissues of the body (including the lymph glands and the brain), and because HIV can be found in body fluids other than blood (semen, vaginal secretions etc.), having a viral load below detectable levels does not mean that the person is cured or non-infectious. All the medical data currently indicates that a person is still infectious to others, even with a blood viral load that is below detectable levels. Research studies are currently underway to see if a person with a low viral load may be less infectious to others. But at this point in time, we have to assume a person is still highly infectious to others while engaging in high risk activities, regardless of the viral load in the blood. When you mention that you "do not ever produce any pre-cum fluid", this would be very unusual. It is a normal function of the man to produce pre-cum, although the quantities of this can vary from man to man, and the quantities are usually small. When you mentioned that you use the withdrawl method to reduce your partners risk ("pull out before ejaculating to further reduce risk"), keep in mind that, by itself, this is not a foolproof method of infection control (or birth control for that matter). However, if the withdrawl method is used along with a condom (as you have done), then the risks to the partner would be very low.

So at this point, what I can say is, based on currently available data, you are not putting other people at significant risk, primarily because you have been using condoms with your partners (and your use of the withdrawl method reduced the risk further). Please do not stop using condoms because of your low viral load. You are still considered infectious to others. Also, if you were to start having unprotected sex with another positive person, you risk the problems associated with reinfection. See the question, " possible cross-infection btwn HIV+ couple"for more information about this particular issue. So in summary, continue to practice safer sex as you have, regardless of your viral load. This will protect you from other STD's, and will protect your partners against possible HIV infection. I hope that your viral load continues to remain at low levels.

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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