Is safe-sex necessary in an age of undetectable HIV viral loads? Yes.

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.

HIV/AIDS ribbon via Shutterstock

HIV/AIDS ribbon via Shutterstock

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.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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41 Responses to “Is safe-sex necessary in an age of undetectable HIV viral loads? Yes.”

  1. BeccaM says:

    I’ve done plenty of research.

  2. h says:

    HPV vaccine is for four strains of over a hundred, the efficacy rating is overblown and the vaccine coverage for type 16 and 18 may be three years, may be five may be? but has no impact for other strains that also lead to cervical cancer. Get a pap smear every three and catch cervical cancer without the boost to pharmaceutical companies that force their product into political processes. You can skip the HPV vaccine, but please do the rest…including a little more research.

  3. I agree. Thanks for sharing.

  4. Julien Pierre says:

    True. Most people do not use condoms for all sex acts, however, only for the riskiest acts, ie. anal / vaginal sex.

    Very few gay men use condoms for oral sex, even though chlamydia, gonorrhea, herpes and syphilis still transmit easily that way, unlike HIV.

  5. trinu says:

    That depends on the specific STD. For chlamydia, gonorrhea, syphilis, and hepatitis, condoms are about as effective as they are with HIV. For herpes and HPV, they’re less effective but still better than nothing.

  6. sayencrowolf says:

    That article makes no mention of any black or grey market ARVs

  7. docsterx says:

    From the American Academy of Pediatrics :

    Determining the efficacy of condom use in preventing
    transmission of STDs and HIV is much more complicated, because each STD
    must be considered individually. Several articles
    have reviewed the literature on this topic, with additional studies
    the effects of condom use on transmission of HIV
    and specific STDs.49–60 The literature findings can be summarized as follows:

    1. Condom use appears to decrease the
    rate of, but does not fully eliminate, transmission of most, and
    possibly all, STDs to
    males. Protection rates of one half to three
    quarters (ie, relative risk ratios of one half to two thirds) have been
    in several studies ofNeisseria gonorrhoeae and Ureaplasma urealyticumtransmission, with 2 studies demonstrating 100% protection with short-term, consistent use.49 Less clear is the demonstration of protection against Chlamydia trachomatis and Treponema pallidum
    in males, and there are no definitive studies to date on protection
    against herpes simplex and human papillomavirus, 2 organisms
    that can be transmitted by skin-to-skin
    contact for which the condom may offer less protection.49–55

    2. Because a female is more likely to acquire an STD from an infected male partner than a male is from a female partner, condom
    use offers less protection from STD acquisition for females than for males. Studies of gonorrhea and Trichomonas infection demonstrate protection rates with condom use of only one third to one eighth (ie, relative risk ratios of 0.66–0.87).49
    Although some studies show no protection, others demonstrate some
    protection for women against infection with human papillomavirus
    and C trachomatis and bacterial vaginosis and decreased rates of infertility and hospitalizations for pelvic inflammatory disease among those
    who use condoms for contraception compared with those who use no protection.49

    3. Condom use decreases the rate of
    acquisition of HIV by those who engage in high-risk sexual activity or
    whose partners are
    seropositive for HIV, with relative risk
    ratios generally in the range of 0.04 to 0.4 (ie, 60%–96% protective).49,56–60 In 1 study of serodiscordant partners, consistent condom use decreased the rate of HIV conversion by the negative partner
    to 1%, compared with 7% in those who did not use condoms.56 A recent meta-analysis of condom use in HIV-discordant couples yielded a consistent HIV infection incidence of 0.9 per 100
    persons per year in those who always used condoms.61

    In general, the data indicate that condom
    use is less protective against transmission of STDs and HIV than it is
    for pregnancy
    when used correctly and consistently (“theoretical
    effectiveness”) and in real-life use (“actual effectiveness”). The fact
    that any single act of intercourse is more likely
    to result in transmission of disease from an infected partner than in
    may partially account for this difference.49
    From a public health perspective, condoms, especially if used
    consistently and correctly, can be expected to decrease the
    rates of unintended pregnancy and STD and HIV
    acquisition among those who are sexually active, including adolescents.
    the individual, however, condom use, even if
    consistent and correct, does not ensure prevention of unintended
    pregnancy or
    acquisition of an STD or HIV. It is for this reason
    that abstinence remains the major focus of primary prevention in
    to decrease adolescent pregnancy, STDs, and HIV
    infection, whereas condom use is the main focus of secondary prevention
    those who are already sexually active and plan to
    remain so.

    “Natural” (made from lamb intestine) condoms and condoms made in foreign countries may have less efficacy in protecting against STIs.

  8. docsterx says:

    See “International Operation Pangea V” carried out by Interpol and the US Food and Drug Administration. Here’s one URL with some of the information on the crackdown:

  9. docsterx says:

    I’m talking about the internet “pharmacies” that may be run out of someone’s basement or based in a foreign country.

  10. sayencrowolf says:

    Cite your source for this claim please

  11. sayencrowolf says:

    That answer is a slippery slope. It depends on
    who you talk to and the study they cite. I’ve seen the numbers go from 69pct at a low end to 99pct at the high. Common citation from the CDC is 85pct. Usually if I’m giving an HIV talk I’ll stick to the high side of percentages. There are so many variables (condom type, lube type, was the condom used correctly) that it is difficult at best to get to one percentage of effectiveness. Bottom line: should they be used? Of course. But they don’t make anyone bulletproof

  12. Julien Pierre says:

    Of course wearing condoms is still necessary to reduce the risk of transmitting other STDs, though it won’t eliminate it. It doesn’t eliminate the risk of HIV transmission either. Condoms do have a failure rate that is non-zero.

    When it comes to reducing HIV transmission though, I think it’s very much in question whether using condoms or having the HIV patient on medication is the more effective method of preventive transmission. Of course, doing both cannot hurt.

    I don’t think the theory about the rise in viral load at certain times of the day is correct. For most people who are on ARV long-term, the viral load remains undetectable for every test. Some people have viral “blips” where the viral load rises above the threshold of detection, but this is rare. This is very different say, your tcells which are known to very much vary by large amounts throughout the day. There should certainly be a study on people on already on ARV’s viral load test results to disprove this.

    There are reported concerns that presence of other infections such as STDs will increase the viral load and transmission risks. I will say that personally, even when I have had some incidence of other STDs (for example, herpes outbreak, but not only), my HIV viral load has also remained undetectable. I get a full STD panel for each one of my viral load tests, every quarter. Of course, this is only personal and anecdotal data. But it makes me think that the claims of increased HIV viral load when other STDs are present may be exaggerated when the patient is on medication. Hopefully the studies will be in soon and provide the full picture for everybody.

  13. Julien Pierre says:

    The effectiveness of condoms against many of the other STDs is more limited than against HIV though. For example, herpes.

  14. Julien Pierre says:

    Actual brand-name antiretrovirals from a pharmacy cannot be legally purchased in the US without an RX.

  15. Julien Pierre says:

    PEP is post-exposure prohphylaxis. The infection risk was reduced to 80% for occupational exposure. For non-occupational exposure (ie. sex) it is not really known how much the risk reduction is.

    PrEP is different though, as it is pre-exposure.

  16. Julien Pierre says:

    A lot of it depends on how they are used. Condom do tear or slip on occasion. I haven’t heard of a 6% failure rate, though. I think the generally accepted failure rate is closer 2-3%. My personal failure rate is higher than that, though. Perhaps it explains why I’m positive. I’ll never really know.

  17. Julien Pierre says:

    There is definitely a potential problem with the PreP, namely the buildup of drug resistance for those who still get infected and continue to take the PrEP without knowing their status.

  18. Okay now you’ve sufficiently freaked me out. What percent effective are condoms alone in preventing hiv transmission?

  19. docsterx says:

    Just FYI, antiretrovirals can be purchased onlne without an Rx. Though a recent study has shown that 50+% on “medications” sold on the internet may be placebo, contaminated, expired. So, these men may be taking nothing more than sugar pills and thinking that they’re on PrEP.

  20. docsterx says:

    It depends on what research you’re citing. Research drawn from clinic/hospital/PCP records will give different statistics from research done on the general population. And that will differ from research data taken collected globally. The first set of numbers, will show an improved life expectancy, primarily because these individuals are receiving treatment and probably got tested, diagnosed and treated earlier. Additionally, they’re getting their other medical problems treated as well. However, several groups often DON’T get tested, or treated, or continue on treatment. People like IV drug abusers, many teens, Africans and others. Therefore, their CD4 counts are lower and they may have developed other HIV-related diseases. They frequently don’t get treatment, or stay on treatment, aren’t treated for other medical conditions (like hepatitis C) and have a shorter length of survival.

    When you look at data from this group (and data that is taken from both groups, you find that people with HIV still die earlier than their uninfected counterparts. Nakagawa
    and colleagues say that ” . . .7.0 years of life were lost on average
    due to HIV.” And that the later the diagnosis (lower CD4 count) gave a
    life expectancy of ” . . . 71.5 years, implying an average 10.5 years of
    life lost due to HIV.” (2013). Similar information is seen in the results from Stockle and his group from 2012.

    The reason for many of the “ifs” is that there has been NO similar research that I’m aware of that has been conducted on serodiscordant gay couples that fulfill the criteria listed in studies in the OP. Therefore, generalizing that the results from heterosexual couples can be applied to homosexual couples is just an assumption, not proven.

  21. sayencrowolf says:

    Thanks. I tend to be very passionate when it comes to HIV/AIDS and PrEP. I also write so that means I tend to rant and sometimes miss the point where I’ve overstayed my welcome.

  22. BeccaM says:

    In other LGBT-related news: For the second time in as many weeks, a study shows that it is the quality of the parents’ relationship with one another and not their sexual orientation that has an impact on the quality of their kids’ upbringing.

    According to researcher Rachel Farr:

    While actual divisions of childcare tasks such as feeding, dressing and taking time to play with kids were unrelated to children’s adjustment, it was the parents who were most satisfied with their arrangements with each other who had children with fewer behavior problems, such as acting out or showing aggressive behavior. It appears that while children are not affected by how parents divide childcare tasks, it definitely does matter how harmonious the parents’ relationships are with each other.

    There was one difference they found between gay/lesbian headed families and hetero ones: The heteros are more likely to divide tasks unevenly along ‘traditional gender role’ lines, with mothers doing more household work overall, while the gay/lesbian families tend to divide work more evenly and fairly.

  23. sayencrowolf says:

    I stand corrected, PrEP is actually up to 94% effective in preventing transmission, which makes it more effective than condoms. Found it in an old piece I wrote.

  24. sayencrowolf says:

    Not necessarily. Lot of individual PrEP experiences can be found here – One of them is my own

  25. BeccaM says:

    Gents should use condoms. Gals should use dams. Everyone should get the HPV vaccine and educate themselves on safe sex practices. The more sex partners you have, the more important this becomes.

    It’s not just for preventing HIV.

  26. And you didn’t comment-jack anything, i think your response is interesting, and helpful, and thoughtful :)

  27. 3%? Taking the drugs and having safer sex still gives you a 3% infection rate?

  28. sayencrowolf says:

    I’m on PrEP and have been for several months involving several thousand in the community. The FDA, as well as the CDC approved PrEP back in May of last year

    It’s part of a study sponsored by NIAID and the National Institute of Health. In addition to that, PrEP is widely available through physicians. It’s not cheap, but insurance companies are coming around and picking up alot of the tab, as well as drug manufacturers are releasing copay stipends on occasion.

    Is PrEP some magic bullet that shields you from getting HIV? No, and it shouldn’t be billed that way. PrEP, when used with other safe sex methods, reduces the risk of infection to somewhere around 3%. Not exactly a no hitter.

    PEP is something different (post-exposure prophylaxis), and more commonly used in occupational exposures and as a “morning after” preventative. I’ve been on that two times: once for a condom break, and another via blood-to-blood exposure.

    Do they have side effects? You bet, but they’re far from debilitating. Muscle weakness that I experience immediately after taking the meds, some sleep issues initially but that’s all faded. Part of the study I’m in is biweekly doctor visits to monitor my health and welfare as well as a bit of an interrogation on my sexual activity. Do I sleep with poz guys? Sometimes. Do I have any magical confidence that I can’t contract HIV? Absolutely not.

    The safe sex message of “always use a condom” has become the equivalent of a warning on the side of a pack of cigarettes. Everybody knows bareback sex is bad for you, and they’ve heard the message plenty. But they still smoke while ignoring the big warning don’t they? LOTS of guys are barebacking, knowing full well the consequences. It’s time the message adapted to suit the change.

    I’ve comment jacked this thread long enough. I have an arsenal of PrEP articles I’ve written, as well as references. If you like I’ll provide, or answer PrEP questions in other spots.

    The only thing wrong with PrEP is the misconceptions behind it..


  29. Drew2u says:

    Wasn’t there a study a while back that said people who were not infected who take PEP drugs significantly lower their risk of catching HIV, on top of condom useage? But even so, the risk was never reduced to zero.

  30. Larry says:

    AIDS is the devil we know. I’m concerned about the devil(s) we don’t – namely other pathogens that might be out there waiting for an opportunity to spread like HIV did. If people choose to engage in risky behavior (i.e. lots of hookups, casual sex, etc.) protection is a must. To not use it is to willfully disregard the lesson’s we have learned from HIV.

  31. Yes. I know a guy who is taking them just so he can avoid getting infected and another guy who has them on hand in case he feels he has been put in a risky situation.

  32. Really?

  33. samizdat says:

    Yep. The question is, what doctor in his/her right mind countenance a prophylactic regimen of anti-virals? These physicians should lose their licenses.

  34. Exactly. Also those medicines have side-effects and are probably not great to take anyway. Especially if you don’t need them.

  35. trinu says:

    It the perfect breeding grounds for drug-resistant HIV.

  36. Anyone else know about gay guys constantly taking “prep”? They are just consistently taking HIV meds to avoid infection and having unsafe sex. This seems like a recipe for disaster.

  37. Suemarie says:

    Can you share that research? People in the category of maintaining undetectable viral loads while being on treatment haven’t exactly reached a full lifespan yet.

  38. Houndentenor says:

    There are other STDs besides HIV that you don’t want to get either. And could a new one hit us as off guard as HIV did? Just wear a condom.

  39. Indigo says:

    A healthy reminder. Safe Sex is sensible sex.

  40. AdamSR says:

    This is from a doctor? “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.” The current research has clearly shown the lifespan of people who have undetectable viral loads since early in their infection (before CD4 count dropped below 500ish) is the same as uninfected people. The rest of the article is a bunch of “ifs” and assumptions (monogamy, no anal sex, etc.). But sure, it does make sense to have safe sex, period.

  41. Drew2u says:

    ….because condoms are used for prevention of only pregnancy and HIV?

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