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Sexual Encounters With Undetectable HIV-Positive Men

A Controversy About HIV Transmission

November/December 2008

Daniel S. Berger, M.D.
Many HIV experts have recently become embroiled in a new controversy: Does an undetectable viral load translate to significant reduction in HIV transmission during sex? If so, are condoms necessary? What message should be imparted by physicians to their patients who confront this situation in their daily lives?

In January 2008, an important and prestigious panel of experts from the Swiss Federal Commission for HIV/AIDS boldly produced the first-ever consensus statement saying that HIV-positive individuals on effective antiretroviral therapy and without sexually transmitted infections (STIs) are sexually non-infectious. This opinion was also published in the Bulletin of Swiss Medicine (Bulletin des médecins suisses). Hotly discussed at the International AIDS conference in Mexico City this summer, it was soon followed by a rejection statement by a joint Australasian group of experts.

The members and authors of the Swiss Federal Commission for HIV/AIDS are made up of the most reputable Swiss HIV experts, including professor Pietro Vernazza, of the Cantonal Hospital in St. Gallen, and President of the Swiss Federal Commission for HIV/AIDS, and professor Bernard Hirschel from Geneva University. Their opinion was based on a review of the medical literature and extensive discussion. They concluded with this statement: "An HIV-infected person on antiretroviral therapy with completely suppressed viremia ('effective ART') is not sexually infectious, i.e. cannot transmit HIV through sexual contact." The Swiss also considered study data from Rakai, Uganda, where no transmission event occurred in individuals who had viral loads lower than 1,500 copies/ml, although this was a relatively small study.

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In laymen's terms, this means that barebacking among HIV-infected persons who are on the cocktail who have undetectable viral load, would not transmit HIV to their partners.

However, the Australasian group soon rejected the Swiss expert consensus and responded that condom use and effective treatment of STIs is the only way to prevent HIV spread. They went further to suggest that there could be a fourfold rise in transmission if condom use is left awry. They based this on a mathematical model that utilized published data estimating relationships between viral load and HIV transmission risks; they also assumed that transmission does occur at all viral load levels, regardless of how low they may be. Without true data, many question the utility of using mathematical models to form factual declarations. One doesn't forget the mathematical model that was used by Dr. David Ho to regrettably forecast HIV eradication in patients who were at undetectable levels of HIV on treatment. HIV latency was not well understood at that time.

With these two differing opinions at hand, a more balanced editorial commentary which was more practical emerged from the UK. Drs. Geoffrey P. Garnett and Brian Gazzard state that ignoring the effect of undetectable viral load would be dishonest. They welcomed the Swiss statement for having opened up the discussion to where we can further suggest to patients to consider HIV treatment and urge better adherence. This may promote a reduction in the risks for HIV transmissions and other infections.


Past and Present

Sexual behavior has been an evolution throughout the AIDS epidemic. During the first years of the HIV epidemic, without the knowledge of how HIV transmission occurred, most gay men continued to have unprotected sex. Without a clear dissemination of information, there was little caution during sex. Places such as bathhouses were a booming business. Eventually, as the AIDS epidemic progressed, individuals were in fear of contracting the virus and practiced safe or safer sex. "Safe sex" became a household term. HIV was at that time an incurable, progressive disease. Thus bathhouses were closed in various cities such as New York and San Francisco, and clientele dropped sharply since bathhouses were felt to be a reservoir for HIV transmission.

Real progress finally occurred in the field of HIV treatment with the arrival of the "cocktail" and soon coincided with many patients achieving undetectable levels of virus. The practice of safe sex was still heavily promoted. But this eventually led to a "safe sex fatigue," especially since HIV infection was no longer viewed as a "death sentence." Not safe sex but safe sex fatigue (which I am coining here) has become the pervasive attitude. In the real world, many patients admit that condoms hamper spontaneity during sex and have become too much of an inconvenience, not to mention the resulting reduction or loss in pleasurable sensations during anal intercourse, for some individuals. Not uncommonly, condoms are also a "turn off" and cause some individuals to lose their erections.

Not confronting safe sex, too many HIV-positive individuals avoid having the "conversation" about their HIV status. They've grown tired of feeling the need to re-assure their negative partners about reduced transmission. There's already been the consensus in the men-having-sex-with-men (MSM) community that undetectable patients only remotely pose risk for HIV seroconversion. Also, oral sex has never been considered to be of significant HIV risk nor has it ever been adequately proven to cause HIV seroconversion. However, a common solution for HIV-positive men had been to act as the receptor of anal intercourse or "bottom" for someone HIV-negative, thereby further limiting exposure to their partner.

It is unfortunate that MSMs avoid discussing HIV status during first sexual encounters. One would expect that encountering HIV-positive men within the gay community is not uncommon. It should be a positive experience for a partner to disclose their status and have a reasonable discussion. In particular situations, it's usually a relief to both partners when discovering what they're each dealing with. If it is revealed that both partners are HIV-positive, it's a tremendous relief and stress reducer for both. Alternatively, if only one partner is positive, it opens a conversation about harm reduction during sex. The absolute worst that can happen is that a negative person does not want to proceed with the situation and thus neither need waste the other's time. HIV status is a personal issue, but individuals should all act responsibly without being inhibited about disclosure from the start.


Undetectable Viral Loads and Transmission

The Swiss expert statement had been originally downplayed in the media for fear of encouraging more unsafe sex. One applauds the Swiss for encouraging individuals to get tested and begin effective treatment, thereby slowing the transmission of the virus within the community. The Swiss statement and referenced studies, however, were also criticized due to being heterosexually based and debated as to its application to the MSM population or gay community. But it also generated irrational fear that HIV transmission would get out of control.

Hence the Australasian rejection and conclusion of only the strict use of condoms plus early treatment of STIs being the only means to reduce transmission of HIV. However this continues to beg for further debate. It is fruitless to ignore that effective antiretroviral therapy eliminates HIV from genital secretions, and that HIV RNA, measured in sperm, declines below the limits of detection on antiretroviral therapy. HIV RNA also falls below the detection limits in female genital secretions during effective antiretroviral therapy. Moreover, usually sperm cell viral particles rise only after an increase in viral load from the blood. The cell-associated viral gene particles, present in genital secretions during effective antiretroviral therapy, are actually non-infectious virions; HIV-containing cells in sperm lack markers of viral proliferations such as circular LTR-DNA.

Thus it's logical to abstract that less virus (undetectable) translates to less ability to transmit HIV to others. There can never be a prospectively conducted ethical study since one can't ask HIV-negative individuals to participate in having unprotected sex with undetectable positives. However, patients infected with hep C are usually not undetectable and can also transmit hepatitis C sexually. Thus, unsafe sex, although protective for HIV if the partners are undetectable, does not protect against hepatitis C or syphilis.


Harm Reduction

Let us reconcile ourselves to the widespread existence of safe sex fatigue. While many HIV-positive men abandon safe sex, some do this while engaging themselves primarily with other HIV-positive men. Incomprehensibly, many HIV-negative gay men have accepted the idea that they'll eventually seroconvert to HIV and thus avoid safe sex.

Addiction has also had a major impact on behavior. Methamphetamine addiction often results in irrational and relentless search for lust and sex with multiple partners by means of higher risk behavior. It is also associated with HIV seroconversions; other STIs while using is also associated with non-adherence to antiviral treatment. As a physician engaged in the research and treatment of HIV infection within the MSM community, I have observed a burgeoning epidemic of increasing HIV, hepatitis C, syphilis, and MRSA (resistant staphylococcal) infections.

Individuals who take extra precautions are always better off. Once becoming HIV and/or hepatitis C infected, there are tough consequences to face. Sexually active men should be responsible and have frequent HIV, hepatitis, and STI testing. Anal warts should be treated quickly to discourage the transmission of HPV. Anal Pap smears should be done when indicated. Finally, vaccination for HPV in gay men as a preventative step against development of anal cancer should be studied. At Northstar Healthcare in Chicago, Gardasil, the HPV vaccine, is currently offered to patients for this reason but is pending further study. HPV is the cause of anal cancer (and anal warts) and is a quickly rising problem among HIV-infected individuals.


Conclusion

Sexually active HIV-positive individuals are better off knowing their status and undergoing effective treatment and therefore reducing HIV transmission. Although HIV transmission has been curtailed among individuals who are undetectable and barebacking may be considered safe in some situations, there is still the prevalence of hepatitis C, syphilis, and resistant staph infection. On the other hand, HIV-positive persons in stable relationships with HIV-negatives, or individuals who understand the importance of adherence to HIV treatment while getting frequent STD (sexually transmitted disease) screening may provide effective harm reduction. Still, condoms should always be considered when sexually interacting with unknown partners.

Dr. Daniel Berger is a leading HIV specialist in the U.S. and is Clinical Associate Professor of Medicine at the University of Illinois at Chicago. He is the founder and medical director of Northstar Medical Center, the largest private HIV treatment and research center in the Greater Chicago area. Dr. Berger has published extensively in such prestigious journals as The Lancet and the New England Journal of Medicine and serves on the Medical Issues Committee for the Illinois AIDS Drug Assistance Program and the AIDS Foundation of Chicago. Dr. Berger has been honored by Test Positive Aware Network with the Charles E Clifton Leadership Award. Dr. Berger can be reached at DSBergerMD@aol.com.


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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
 
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More on Safer Sex for the HIV Positive

Reader Comments:

Comment by: Ricky (Southgate, Mi) Fri., Oct. 18, 2013 at 3:09 pm EDT
So is barebacking safe, or unsafe with1 pos, and 1 neg partner?
Reply to this comment


Comment by: Retlaw (Whk) Wed., Sep. 18, 2013 at 5:35 pm EDT
Safer sex,saves lives
Reply to this comment


Comment by: michlo (kansas city) Fri., Mar. 22, 2013 at 3:43 pm EDT
can i receive oral sex from a negative women and im undetected and can i give oral
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Comment by: Adel (United Kingdom) Wed., Aug. 22, 2012 at 5:23 am EDT
I have been living with hiv for 10yrs now and been on meds for 5yrs. I have to say I am more confident now with regards to my status in relation to my partners. I certainly do concur with the Swiss team's statement about the non transmission of the virus to an hiv negative partner through the practice of unsafe sex. I have been lucky to have had partners who are hiv negative and who didn't consider me a threat to themselves at all because my viral load was undetectable. While i don't go around having unprotected sex with random strangers because of the risks of contracting hep c or something equally as hideous,experience has taught me that I cannot transmit the virus to my steady partner even when I 'top' him. I am a bottom, but have topped my last partner loads of times, he has had tests done and he is still negative. So, I think rather than hide this fact away from the public, researchers should come clean about it. The important thing in my opinion is the fidelity between two people. As long as this is in the equation, there would be no risk of catching other STIs and thereby posing a risk to both parties concerned. Hiv patients who are on treatment have to recognize that this is an important element in reducing the transmission of hiv if they are going to bareback. Similarly, if researchers come clean about this fact, and make the public aware that people on hiv treatment are not 'risky' it would help remove the stigma that is attached to someone who is hiv positive and also many people would come forward and get themselves tested, which would lead to a more balanced and well informed approach in the management, treatment and prevention of the spread of the virus. By adopting the current approach in the UK and Australasia, which is ruled by fear, information about the virus and people living with it, continues to be shrouded in mystery thereby instilling a culture of fear and stigmatization.
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Comment by: John H. (Kansas City, KS) Mon., Mar. 26, 2012 at 3:01 pm EDT
From what I've read, it appears that people who are HIV- and with a non-detectible viral load can very well be contagious through unprotected sex. My most recent partner told me that he was HIV- and we had unprotected sex. He was the top, but I thought he was been monogamous.

I later learned that he had been in a relationship with a HIV+ partner the entire time. And I think that he still is. And they had nunerous profiles on line advertising bareback group sex. He said that he was neg and his partner was saying that he was pos.

I confronted him by email and said that I found his and his parnters adds soliciting group bareback sex and questioned his HIV- status. I told him that I hope he isn't lying aobut his status. His only response was "poor John".

Almost immediately after that, I noticed that he is changing those profiles to say HIV+ and non-detectible. And I found out that nearly everything this many said has been unreliable.

I've since been tested and remain HIV-. Since I can't even believe that this man is non-detectible, I suppose this question is a bit stupid to ask. But, how likely is it that I could contract HIV from his if he does have a non-detectible viral load?

I think the the assumption is that one could never totally trust anyone about their HIV satus. So, why even trust them about their viral load status.



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Comment by: high time (Ontario, CA) Tue., Nov. 29, 2011 at 7:01 am EST
No way, come on people. No glove No Love! Simple as that.
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Comment by: Khalid W. (Ottawa, Ontario) Tue., Nov. 29, 2011 at 6:55 am EST
" Always assume, the person you're about to have sexual intercourse might be positive" unless otherwise proven! So, this just always comes down to "No Glove No Love"
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Comment by: dave (dallas) Thu., May. 12, 2011 at 10:18 pm EDT
Thank you for posting this informative information. I'm always honest about my status, but it's good to know though undetectable the best choice is to always use condoms and practice safe sex. I would never want to be responsible for someone else's life, but I fear most people - either don't ask, don't want to know, or are just in denial about their own status. When I'm with other positive men I don't always practice safe sex, but we are both aware and realize the risk involved. Sadly, when a positive man, like myself, is honest about their status and aware of the importance of being safe, many men choose to sleep with someone who doesn't know their own status. These are the folks who will become positive out of fear and ignorance. What to do?

Thanks for putting great information out there for those who don't take the time to really understand HIV.

Warm regards, Dave
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Comment by: Russ (Milwaukee) Mon., Feb. 21, 2011 at 9:57 am EST
Dr. Berger really needs to go out to a gay bar sometime and just see how people react when you tell them you are positive. It is not a positive experience, it is filled with anxiety and fear for the positive individual. It is horrible because you never know how the other is going to react. come out of your lab, good doctor and join reality.
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Comment by: JR (San Antonio, TX) Thu., Dec. 30, 2010 at 3:07 pm EST
Great article. Too bad that sex sites don't have a shortened version of this everytime someone logs in. Heck, even craigslist has a little warning but could always use more.
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Comment by: James (Chicago) Tue., Jan. 19, 2010 at 7:08 pm EST
Great article. I think it is indeed important to distinquish that "barebacking may be considered safe in some situations" because all situations are not equal. I am in a long-term relationship. I am HIV+ and my partner is negative. I have 100% aherence and I am undetectable. I do allow my parter to top me without a condom but I do not top him without one. He is tested regularly and remains negative.
Reply to this comment
Replies to this comment:
Comment by: jim (phoenix, arizona) Tue., Jul. 16, 2013 at 1:24 am EDT
so it is safe to top someone who is hiv pos undetectable without a condom?


Comment by: James (Chicago) Mon., Jan. 18, 2010 at 2:03 pm EST
Great article. I think it is indeed important to distinquish that "barebacking may be considered safe in some situations" because all situations are not equal. I am in a long-term relationship. I am HIV+ and my partner is negative. I have 100% aherence and I am undetectable. I do allow my parter to top me wihtout a condom but I do not top him without one. He is tested regularly and remains negative.
Reply to this comment


Comment by: Ernest (Chicago, IL) Wed., Jan. 13, 2010 at 11:04 pm EST
It's amazing the things people say on here. Poz individuals are not the enemy, but certain behaviors are. Doing everything one can do to prevent transmission should be the ultimate goal; including HAART. If we really wanted to see a decrease in transmission, doctors would have the ability to provide treatment of HAART to any individual in a high risk category as well as treating those that already carry the disease. However, insurance and drug companies would never agree to affordable prices so prophylaxis treatment will most certainly never happen. So while we debate about the science all day, the bottom line is that HIV transmission and viral load are proportionally correlated. I personally like the odds of using HAART as an effective method to reduce transmission. Anyone that shares a similar interest in that goal should agree.
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Comment by: Doug (South Africa) Thu., Jan. 7, 2010 at 10:08 am EST
I think it is irresponsible to engage in a sexual act with someone you know is HIV+, I first heard about HIV when I was in standard 1, I have spent my life protecting myself against it and as a gay man I have see that people (particularly gay men) have a no care attitude. I just wish we could eradicate this virus, I have already lost a brother to HIV and seeing him in his last weeks of life has reinforced my will to protect myself.

No Glove, No Love.
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Comment by: Alan (Northampton, Ma.) Sat., Nov. 21, 2009 at 11:50 am EST
This information gives me hope. I have not had sex since I was diagnosed 5 years ago! I am Frustrated and lonely, in need of a loving woman's touch. I am undetectable and healthy but have been afraid to date due to stigma and fear. Some of it my own. Now perhaps I will build up the courage to get back out there. God knows I need the lovin.
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Comment by: Abie (New york, ny) Mon., Oct. 12, 2009 at 7:24 am EDT
Hi AlstonIz
Just wanted to tell you that it's great that you are so supportive of your partner...one thing is that you SHOULD NOT use SPERMICIDE! it increases HIV risk. Read about it here
http://www.thebody.com/index/treat/nonoxynol-9.html
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Comment by: AlstonIz (Texas) Fri., Oct. 9, 2009 at 12:52 pm EDT
I found the article very interesting. Seeing that I am currently in a monogamous relationship going on two yrs. My fiance is HIV-1 positive but undetected due to his compliance with his "cocktail" therapy. I am neg. for any STD's including HIV and I know this because I am tested every 6 mo. We have unprotected sex and he does not ejaculate inside of me and we use a spermiside gel for any pre-ejaculation. When it is time he pulls out. We do not engage in anal sex either. We do have oral sex and no there is no drinking of any specimens on my part. I agree that it is safe because it has proven so thus far. The point of the article was based on studies done on heterosexuals in a monogamous retationship where one partner is positive but undetected and the other is negative. I can only comment on my experience. I love this man & I stay with him because I know his condition. I feel that this is safer than being single again looking for a mate. The average person stops using condoms in a relationship when they feel like its monogamous and you dont ask your partner to take a test when you do. (Point Proven)
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Comment by: youkno_watsn_dapuddn (Pasadena, Ca) Wed., May. 27, 2009 at 3:34 am EDT
An HIV 1 virus Test searches for specific enzymes that is carried in the blood stream genital, and Anal secretions.
The term "Undetectable" implies
That the HIV 1 virus is dormant, And Not able to be detected. which means the enzymes (HIV 1 Virus) in
the body is so low it is not able to be detected! Free virus in your blood and genital secretions increases the chances of transmission. This is because of the amount of free virus in your body! If your Undetectable the enzymes in your body decrease dramatically and lower your HIV 1 Virus count (Viral Load)! Which means the chances of transmission of HIV 1 virus decreases. Think of it as such! If you pick up an apple off the dirty ground and bite into it without washing it, chances are great you will get some dirt along with that bite! But if you wash the apple and then bite it, your decreasing your chances of getting any dirt in your mouth! An HIV 1 Undetectable Viral Load decreases your chances of transmission of HIV 1, Because there is almost nothing in you body to transmit! Thank you!
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Comment by: mike (florida ) Mon., Apr. 6, 2009 at 4:29 pm EDT
Since it isn't 100% proven that at an undetectable level HIV cannot be contracted through barebacking, then we should all bite the the bullet and wrap it up. Because the last thing we need is a massive outbreak because of something that isn't proven. As they say the levels are undetectable that doesn't mean that they aren't there. The infected person is already on the meds so its suppressed but the other person isn't. So once ejaculated the virus is still carried on to the next person. That person isn't on the cocktail and there for that person will get sick that is my opinion on it and i am in the medical field. Until it is 100 percent certain that is won't be passed on I'm goin to wrap that sucker up no matter what.
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Comment by: Paul (Salt Lake City) Sun., Jan. 11, 2009 at 5:30 pm EST
It seems absurd that there is such a hysterical over-reaction of the anti-barebacking people to the simple proposition that if there is no "free virus" existing, which is the implication of undetectable, that there is nothing to transmit as only "free virus" can be transmitted. This insistence that condoms are the ONLY way to ahve sex just seems fear and hiv bigotry inspired not fact (bigotry original meaning attributing to a group an attribute that may not be universally true of a particular individual in the group). The possibility that non-protected sex with a known undetectable viral load on effective HAART regimen person might be safer than sex with an assumed but never know for sure negative person seems to elude these people in their diatribe. Sure there are always ways to be safer but get off the kick that only condoms are safe, maybe sex with an undetectable viral load effective HAART person is safe sex!
Reply to this comment


Comment by: Mando (California) Wed., Dec. 24, 2008 at 12:37 am EST
found this on another site the comment author mayy have commented here before so sorry id repeat:
Shawn, Troy, NY, 2008-10-29 18:21:45
A fairly recent article on a study in Africa of mixed couples, reported that when the positive partner had viral load less than 1500, that no transmissions occurred over 2 years. Dr. Bruce Walker's Elite Controllers Study website also claimed that HIV transmission was virtually impossible with viral loads below 1500. I'd love to see these sources and the studies behind them included in this important discussion!
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Comment by: Peter Grueber (San Francisco. CA) Sun., Dec. 21, 2008 at 6:40 pm EST
I find that the statement, "Although HIV transmission has been curtailed among individuals who are undetectable and barebacking may be considered safe in some situations, there is still the prevalence of hepatitis C, syphilis, and resistant staph infection" is weak and lacking in prudent emphasis. It is known that HIV+ men are about 50 percent more likely to be infected with various STD's, other infectious agents - such as MERSA, warts, and various cancers - which are even being hypothesized to be infectious - than HIV-negative men and women. This should have been stated clearly and emphatically -- "there is about 50 percent MORE risk of various infections, such as................ when having sex with HIV+ men," rather than there being only a short notation in reference to this. This is not good, ethical medicine and will result in people being less careful -- which equals more HIV and other infections. We owe it to our brothers and sisters not to spread our infections. My infection stays with me.

Peter Grueber
San Francisco
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Comment by: Craig (Toledo) Mon., Dec. 8, 2008 at 4:33 pm EST
Tops not contracting HIV is a myth. Undetectable viral loads or not condoms need to be worn to protect your body from all forms of infection. I think it is risky in heterosexual and homosexual relationships to forgo the condom use. I think this was a great article that will most benefit people positive and negative who are in committed relationships. Something that was not discussed in the article is an undetectable positive individual having unprotected sex with a positive person who does not know thier status. This can disrupt resistance and change the viral load. Harm reduction is a viable methodology for changing behaviors. Most people cannot change thier behavior overnight, harm reduction asks that you lessen your risk increasingly. It is a very good tool in clinics and drug treatment programs.
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Comment by: Newfie (Newfoundland, Canada) Mon., Dec. 8, 2008 at 2:22 pm EST
Why is there always this us and them mentality??
Negative MSMs need to educate themselves and use appropiate protection! If not, it is your choice to put yourself at risk!
Remember it takes 2 to tango!
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Comment by: Harvett Ellington (East Cleveland, OH) Sat., Dec. 6, 2008 at 10:51 am EST

I believe that people today are so out of touch with reality that people actually think that they can have sex with someone with undetectable HIV loads. That is suicide for any disease (Hep A/B/C, syphilis, gonorrhea, herpes, etc.)
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Comment by: Jim (Columbus, OH) Fri., Dec. 5, 2008 at 1:36 pm EST
Where you said: "In laymen's terms, this means that barebacking among HIV-infected persons who are on the cocktail who have undetectable viral load, would not transmit HIV to their partners."

Would have been better said: "In laymen's terms, what they inferred was that barebacking among HIV-infected persons who are on the cocktail who have undetectable viral load, would not transmit HIV to their partners."

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Comment by: Mary (Kenya) Thu., Dec. 4, 2008 at 11:55 pm EST
Thanks so much for this update, however i feel that despite all the information that i have been able to gather we still have so many sexually transmitted infections and so CONDOMS should be used always during sexually intercourse.

Regards

Mary
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Comment by: Kirk (Dallas) Thu., Dec. 4, 2008 at 6:18 pm EST
Very informative and responsible article. HIV is not the only thing condoms help protect us from. Besides, barebacking, and any other form of "exciting sex" has not preserved a relationship. It is things like trust, respect, humility, considering the other, etc. that make relationships work. If ridding myself of condom sex was "it", then why am I not recommending others to aquire HIV like me. Thanks again for the article.
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Comment by: snippy (detroit) Thu., Dec. 4, 2008 at 1:08 pm EST
I have been poz for 22 years. I have had a couple ltrs and many bfs that are neg. It has been known that the risk is for the bottom. when the crisis first hit, I noticed that couples where one was a top, the other a bottom, the top was always neg. It is true that in a non monogomous relationship you are at risk of stds in which hiv can hitched a ride on. So caution is still advised outside a monogomous relationship. For God's sake guys give up meth! Tina is not your friend.
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Comment by: Ralph Chartier (Philadelphia, PA) Thu., Dec. 4, 2008 at 8:52 am EST
After reviewing the complete Swiss study, isn't it true that their conclusion came from analysis of primarily heterosexual vaginal sex? This is an extremely different transmission mode than anal sex, with different implications for the sex sites and trauma experienced in those sites during intercourse. I think this needs to be mentioned, and the implications discussed.
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Comment by: Eddy (United Kingdom) Thu., Dec. 4, 2008 at 5:54 am EST
Daniel, thanks for helping to clarify this situation.

Two of your sentences bring information to me that I have not read elsewhere. The first is:

"It is fruitless to ignore that effective antiretroviral therapy eliminates HIV from genital secretions, and that HIV RNA, measured in sperm, declines below the limits of detection on antiretroviral therapy."

I find this amazing to learn because everything I have been reading over the last 10 years or so has insisted that while HIV may be undetectable in the blood it thrives in the "reservoirs" -- the reservoirs being the testes, lymph nodes, & the brain, amongst others. So I have to gasp, and ask, "Is this REALLY true? Because I am 'undetectable' is my sperm basically 'clean & pure'?"

The other important information you provide is that "unsafe sex, although protective for HIV if the partners are undetectable, does not protect against hepatitis C or syphilis." Indeed! There's a whole raft of other STDs out there which may well "get in" if condoms are not used. (And some of them may well be contracted just through oral sex, even if condoms are used for the 'anal' part of sex.)

The last thing I would like to say is that your conclusion does not seem to dare to go all the way. You suggest that if one partner's HIV level is undetectable and both partners are monogamous then there will be "effective harm reduction". But "reduction" is not good enough, is it! There has to be absolutely NO POSSIBILITY of the HIV-negative partner becoming infected! And what if one partner's viral load had become "detectable" between clinic visits, despite good adherence and due simply to the onset of resistance in the long-term? As a person having to deal with the trauma of having HIV, I say that the risk of infecting a partner and saddling them with this burden is just not worth it.
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Comment by: Thomas Crandall (Maryland) Wed., Dec. 3, 2008 at 8:13 pm EST
There is no mention whether there is a risk of HIV transmission if the person who is HIV + is the receiver in the sexual act. Does the risk factor remain the same or less or completely no risk factor in that case? Some M4M are total tops and total bottoms and this is something I have not seen addressed in any article.
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