I’ve heard people with HIV, who have undetectable viral loads, ask whether they still have to practice safer sex.
At first glance, the logical answer would seem to be “No.” No virus
present, so no chance of infecting someone else, right? So why wear a
condom?
But let’s think about that a little.
In 2008, the Swiss Federal Commission for HIV/AIDS stated that “after
review of the medical literature and extensive discussion, [we] resolve
that 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.”
Their conclusion was based on just a few research studies in
heterosexual couples. Each study following about 400 couples for about
two years. These studies were conducted in Europe and Africa. In most
circumstances, the male partner was HIV positive and the female was HIV
negative. The studies mention that the couples engaged in vaginal
intercourse. No mention was made of whether the couples had anal
intercourse. These couples did not practice safer sex. The HIV positive
partner was on antiretroviral medications and had reached an
undetectable viral load level. In these studies, the HIV negative
partner remained HIV negative.
Note that these are relatively small studies in which the couples
were followed for a short time. The Swiss physicians generalized from
these results that safer-sex doesn’t seem to be necessary in
adequately-treated HIV positive patients.
A few points to consider about that conclusion. We don’t know how
sexually-active the couples were. A couple having sex three times per
month would have a lower risk of transmitting HIV than a couple having
sex twice a day. We also don’t know if there were any instances of anal
intercourse. There may be a different degree of risk if anal intercourse
occurred vs. vaginal intercourse. The couples were monogamous. If they
had not been, there would be a risk of developing another STI, which
could increase the viral load and increase the risk of infecting the
uninfected partner (more on that below).
Let’s also take a look at a few other factors.
Does “undetectable” viral load equal “no virus”? Not really. It just
means that the virus, if present, was there in numbers too small to be
found by current methods of testing. So there may be a few particles or
none in the tiny volume of blood tested. Both would give a result of
“undetectable.” But, let’s say that, indeed, there is no virus present
when the test is done. In that case, is it safe to go condom-free? Well,
think about that. The test measures HIV at one point in time. Someone
who has an undetectable viral load on Wednesday at 2 PM (when the
specimen was drawn) may have a viral load of 600 three weeks later.
Viral load measurements can vary in a patient on antiretrovirals from
test to test. A concomitant infection with some other organism, might
cause a temporary spike in HIV particle numbers.
Also, the test is searching for HIV particles in blood. It’s not
telling us if virus is present in seminal fluid, and, if present, how
much is there.
Additionally, the World Health Organization and the Centers for
Disease Control, after looking at the same data and the statement by the
Swiss Federal Commission for HIV/AIDS, both reiterated that safer sex
techniques should be continued by persons who are HIV positive,
regardless of level of viral load. And, of course, condoms can also help
prevent the transmission of other STIs like gonorrhea and syphilis.
One more thing to consider: Even if the risk is extremely low, HIV is still not curable, and still significantly decreases the lifespans of most of the people affected.
So, based on the data, the statement from the Swiss might be correct
for certain scenarios. But I think that there are several unanswered
questions that need to be investigated before making a blanket statement
supporting unprotected sex in HIV positive patients with undetectable
viral loads.
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