HIV, viral load and (un)protected sex

Information for professionals
 
This information sheet describes the current (May 2011) state of research regarding the relation between HIV viral load, combination therapy and the chance of HIV transmission through (un)protected sexual contact. Professionals who deal with persons with HIV and/or their partners can use this information to give their clients customised advice, thereby enabling them to make informed decisions.

Background
In 2008, the Swiss Federal Commission for HIV/AIDS adopted the stance that HIV-positive individuals who have  had an undetectable viral load for six months or longer as a result of a combination therapy, who adhere to their  therapy, and who have no other STI are practically speaking no longer sexually infectious. In the Commission’s  view, this means that, under those conditions, steady partners in a serodiscordant relationship (where one partner  has HIV and the other does not) can consider not (or no longer) using condoms. In case of multiple sexual  contacts, however, one should nevertheless continue to use condoms. 

This standpoint has led to a worldwide debate among people who have HIV and those who do not, as well as among prevention workers and physicians who treat HIV. The vast majority of experts concur with the findings of recent studies that have shown that the proper use of HIV medications reduces the patient’s viral load and, along  with that, the chances of HIV transmission. Nevertheless, there is still no consensus regarding the significance of this scientific knowledge in practice and how that should be dealt with in terms of the information provided to the public. 

The organisations listed below consider it important to provide the public with unambiguous information. This information sheet is intended to help everyone understand the latest state of affairs (May 2011). It also serves as a positive (reassuring) signal to people with HIV and their partners, namely that the HIV-positive partners run considerably less risk of transmitting HIV to their steady partner if they meet the conditions described in this information. Such information will also help to counter the stigma that people with HIV face. 

Information
The general advice is still to use condoms.
When taken consistently, HIV medications reduce the viral load in people with HIV. A reduced viral load means a lower risk of HIV transmission through sexual contact. With the successful treatment of an HIV infection, the chance that the person will transmit HIV through unprotected sexual contact is (very) slight if that person meets  specific conditions:

  • Successful treatment: The HIV-positive person must have had an undetectable viral load (i.e. fewer than 50 copies of the virus per ml of blood) for at least six months; the most recent blood test results must be no more than half a year old; he or she must adhere properly to his or her therapy and get checked on a regular basis.

  • Specific conditions: Both the partner with HIV and his or her HIV-negative steady partner must not have any damaged mucous membrane (anus, penis or vagina) resulting from a recent STI or from rough sex, for example. Both partners must also not have run any risk of contracting an STI in the period since their most recent STI check-up.

It can be difficult to determine whether someone meets the specific conditions and the criterion of ‘successful’  treatment. It is better to determine that in consultation with the physician who is treating the HIV-positive partner’s  HIV or with that partner’s HIV consultant. Since the HIV-negative partner is the one who potentially runs the risk, it is necessary that he or she is also present during that consultation.

For HIV-serodiscordant monogamous couples who meet the above-mentioned conditions and who – after having  consulted with the physician who is treating the partner with HIV – choose not to use condoms in their sexual contact with each other, the chance of HIV transmission is (very) slight. They should be explicitly informed of the following: 

  • They still run a (very) slight risk of HIV transmission, because:
    • studies show that someone with an undetectable amount of virus in his or her blood can nevertheless have a detectable amount of virus in his sperm, her vaginal fluid or his or her anal fluid. o  damages to the mucous membranes are difficult to notice and cannot be ruled out completely. It is  possible to reduce the chances of having damaged mucous membranes by exercising caution with rougher forms of sex such as fist-fucking or the forced penetration of the anus or vagina.
    • one’s viral load might have risen since his or her most recent test, even though the chance of that is very slight under the specific conditions.
  • The chances of HIV transmission through anal sex are expected to be small under the conditions mentioned above but are probably still higher than in the case of vaginal sex. This statement is based on assumptions, not on research. The knowledge about the chance of HIV transmission is based primarily on studies involving heterosexual couples.

  • The literature to date (May 2011) describes just one possible case of HIV transmission under the specific conditions (through anal sex). While studies have described multiple cases of HIV transmission during  the use of combination therapy, the HIV-positive partner in those cases did not meet the specific conditions or it remains unknown whether he met those.

  • The chance of HIV transmission only remains (very) slight if the risk of contracting STI has been truly excluded. That is only possible if neither partner has sex with others. Even protected sex with others is not allowed. In specific cases it can be difficult to determine whether someone has run a risk of contracting an STI or actually has one. An STI test is no more than a ‘snapshot’.

  • The decision not to use condoms is to be made by both of the partners involved, and they will be jointly responsible for any consequences resulting from the (very) slight risk. The HIV-negative partner must realise the possible consequences and make his or her own choice in that regard.

Other relevant considerations

  • In the event of exposure to HIV, for example as a result of condom failure, one can consider not using  Post Exposure Prophylaxis if the HIV-positive person meets the conditions mentioned above (in Switzerland, PEP is essentially no longer administered when the viral load of the HIV-positive partner is below 50 copies per ml blood).

  • Serodiscordant couples who wish to have children can potentially decide against using specialised assistance such as insemination after ‘sperm washing’ and are advised to have intercourse without condoms at regular intervals in order to fulfil their wish to have children.

  • The current guidelines prescribe starting the treatment of HIV when one’s CD4 cell count drops below 350 per mm3. To further reduce the chance of HIV transmission, one could consider starting treatment earlier. That also holds specifically in the case of a serodiscordant steady relationship. The choice to start treatment earlier could have potentially detrimental health implications in the long term for the person with HIV, such as a loss of treatment options, a variety of side effects, or comorbidity. This choice should therefore be made without any coercion by all parties concerned and in consultation with the physician who is treating the partner with HIV.

It is essential that persons with HIV and their steady partner who want to have sexual contact with each other without condoms inform themselves together and seek advice from the physician who is treating the HIV-positive partner’s HIV or his HIV nurse with regard to any risks of HIV transmission.

It is crucial that the information presented here be properly communicated to the individuals concerned and properly acted upon by those individuals. Otherwise, there is a danger that people will wrongfully stop using condoms or adhere to the conditions less strictly, which could result in a rise in the number of infections.

The following organisations have endorsed the content of this text:
Aids Fonds, Hiv Vereniging Nederland, Schorer, and STI/AIDS Netherlands

Contact

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020 6 160 160

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