HIV+ boyfriend wants unprotected anal sex


Dear Sir,

I am a 25 yo guy and have been dating my boyfriend for two months. He is positive and I am negative. He is 42 yo and has been positive for 12 years and is in good health. Recently our sex lives elevated to anal sex. I readily admit that I am not as informed on HIV as I should be, but I have always heard that protection should be used during anal sex. My BF insists that if I, as the negative one, am the top then there is low risk of infection for me. He says hes been through all the classes and such and I should trust him. He has been honest about his status from the get go, but I wonder if I should trust him in this instance. Am I less at risk since I am the top in the relationship?



"Less at risk" is true, but "not at risk" is not true! The insertive partner is always at less risk than the receptive partner in all types of sex. However, being "top gun" doesn't mean you would not be at significant risk of becoming HIV infected if you choose to go commando. It's a risk I strongly advise you do not take! The consequences could be catastrophic and are so easily preventable. I suggest both you and your not-so-well-informed boyfriend read through the information in the archives on magnetic couples and also the questions reposted below.

Get informed. Stay safe to stay well.

Dr. Bob

Risk of unprotected anal intercourse for top Jan 20, 2007

I just want to say what a great site this is and how wonderful you all are. i am hiv positive and recently began seeing a man who is negative. he wants to have unprotected anal intercourse with me and says that he believes that he is safe since he is the "top". He says he thinks the risk would only be in the reverse situation for the "bottom". is this true? i have looked and looked for an answer about this but they seem to lump all anal intercourse together with no difference in risk mentioned between being the recipient or the giver. i hope this question is not too blunt for your forum. but i really would like to know what your thoughts are. thanks again very much.

Response from Dr. Frascino


Too blunt for this forum? No way! No how! In fact, this question comes up so frequently it qualifies as a QTND (question that never dies). See below.

Dr. Bob

Im a poz bttm and partner is a neg (POSITIVE BOTTOM AND NEGATIVE TOP RISK) Oct 21, 2006

Im a poz bttm homosexual male (Taker only) and partner is a neg top (Giver only), since the anas has no bodily fluids, what are the real risks of unprotected sex for him??? Reason i ask is we want to be close to one another without that barrier since we have been together a while. Also, Ive been told since im undetectable that his risk of contracting hiv is almost impossible with unprotected sex... Please give me a real answer on this and not just a typical medical answer...

Response from Dr. Frascino


This question comes up frequently and I've addressed it numerous times before. Check the archives! In this case, as in many others, the "real answer" and the "medical answer" are one and the same. See below.

Dr. Bob

Risky BTTM GUY Oct 12, 2006

Ok, hello how are you? I'm concern on something I'm a hiv+ male who is having unprotected sex with my neg top partnerfor 6months now and he was tested two months ago and was neg, but I wanted to know was since he is a top and I am a bttm is the odds of him contracting hiv from me, would be just as high? Could you give me your feed back on that please


Response from Dr. Frascino


Sure. However, since I've discussed this multiple times in the past (check the archives!), I'll be brief, OK?

The estimated per-act risk for acquiring HIV from unprotected insertive anal intercourse with a positive partner is 6.5 per 10,000 exposures.

Now, I have a question for you. Why are you putting your partner at risk for HIV and yourself at risk for STDs and potentially an HIV superinfection by having commando nookie???

I suggest you spend some time perusing the information in the archives related to magnetic couples, HIV transmission, STDs, and safer sexual practices, OK?

I also strongly advise you stock up on latex condoms and water-based lube and to stop playing sexual Russian roulette.

Dr. Bob

undetectable VL. Risks of unprotected sex with neg partner. May 15, 2006

I have been poz for 3 yrs and on meds the whole time. I have an undetectable viral load and high CD-4's. I never miss a dose of my meds. I am with a neg partner. He likes to have unprotected anal sex (insertive and receptive) with me without ejaculation into him on my part. We know there is some risk involved with this but are comfortable with it. I know there are small amounts of HIV in my semen even with an undetectable VL in my bloodstream. Are there any hard statistics on transmission risks in this situation, with undetectable viral load and no ejaculation into the neg partner? Is there really enough HIV in my pre-ejaculate/semen to put him at a great risk for infection, or can we be reasonably sure that there is an acceptable low risk of infection?

Response from Dr. Frascino


Your facts are correct:

  1. There is risk involved in magnetic couples having unprotected anal sex, even with an undetectable viral load.

  2. Yes, your semen may have a different viral load (VL) than the VL measured in your blood.

Now to your questions:

  1. No, there are no hard statistics on your particular situation, because there are too many variables to control for. Also, because we know this type of exposure does carry some degree of risk, it would be unethical to conduct a clinical trial to determine exactly how risky. We can say the risk is real.
  1. Can you be reasonably sure there is an acceptable low risk of infection? Although ultimately that would depend on how you define "acceptable low risk," the general answer to your question is no.

Your basic premise that an undetectable plasma viral load decreases the risk of HIV transmission is true. In addition, pulling out before ejaculating also decreased the overall risk of transmission. The important question, however, is that taking these "harm reduction" measures into account, is unprotected anal sex safe enough? Based on our current knowledge, the answer would have to be no.

If despite this information, you and your partner remain comfortable with the risks associated with unprotected anal sex, I would suggest you consider enrolling in a PrEP study. These are clinical trials designed to investigate where pre-exposure prophylaxis (PrEP) is effective in reducing the risk of HIV transmission. You can read about these clinical trials in the archives. They involve the negative partner taking Truvada (Viread plus Emtriva) on a chronic basis. I must emphasize we do not know if this is an effective strategy or not. However, it may afford your negative partner some degree of protection.

Good luck.

Dr. Bob

Hiv risk for a top? Jun 22, 2005

My boyfriend is negative, and I'm positive. He's mostly a top, and I'm mostly a bottom.

He says he is comfortable having unprotected anal sex only when he is the top, but I am not sure I am comfortable with it. He says that there is little or no risk to him if he's the top. I love him and I am scared of infecting him.

I plan on talking to my doctor about this... but I want to get as much information as possible. How risky is unprotected anal sex, if he is the top?

I have been poz for 3 years, I am also on meds and undectable, and otherwise very healthy.

Response from Dr. Frascino


I don't know whether to label this a QTND (Question That Never Dies) or a MTCKY (Myth That Could Kill You). Either way, I've addressed this "dangerous liaison" multiple times in this forum over the years. But there is an old proverb that says "repetition is the mother of learning," so the message bears repeating. There is a significant risk a negative top could contract HIV by having unprotected anal (or vaginal) sex with a positive bottom. The estimated per-act risk for acquiring HIV form unprotected insertive anal sex with an infected partner is 6.5 per 10,000 exposures. I'm confident your HIV specialist will corroborate this risk. It is true that having an undetectable viral load may decrease the risk somewhat, but not to the "little or no risk" category your boyfriend claims to be comfortable with. Your fears are justified; his nonchalance is not.

Stay well. Good luck to you both.

Dr. Bob