risks in long-term monogamous relationship

[bicycleboy]

Hi all, and thanks for taking the time to read this.  I am hiv- and not in risk at risk.  I met someone online who has been hiv+, in treatment, and has had an undetectable viral load for a long time.  When I say just met, we only just started talking on the phone.  If you are reading this, I'm doing my best to learn from different sources, and not bypassing talking to you.  It's OK to ask me if this message was mine.  My questions right now are about keeping me safe, and where to get the best information,  This isn't just a selfish question.  His health is just as important, just not an immediate one, and a lot of it will come from this doctor.  If it helps answering these questions, we are both looking for a monogamous and lifetime partner, and both male. 

The root of my question has to do with my risk over a lifetime exposure.  I have found some statistics on a per exposure basis, but extrapolating what that means over the long haul may be less clear.  For example, if we had 3000 exposures in a decade, and the per exposure risk was 1/6000 do I have a 50% risk?  It can be less than clear how much confidence to place on the statistics.  There are deeper questions on statistics and methodology I am skipping here right now.  I am hoping for a lot of decades too.  I have looked at a lot of sources on the web, but I haven't found much.  I wrote to a couple organizations and didn't get any reply (yet?).

The 3000 number is for illustration only, don't read more into it

I have read a lot about the basics (and more) as far as safe sex practices, so I don't think I need pointers to that.  Perhaps with one exception.  I see on this forum and other sources condoms referred to as essentially 100% effective when used correctly.  I know "used correctly" is the key.  Still, everything has a failure rate.  Long-term studies would help.  I have read individual success stories here, and they are great, but not what I am looking for.

Another question I have relates to the undetectable viral load.  I know this makes a significant difference statistically.  I don't know much about how this can change over time.  In theory, it could change, and take some time before we found out, or even a temporary and undetected flair-up.

One last question, for now anyhow.  I am not sure if the question is valid, logically, epidemiologically, or psychologically.  A number of risks are near zero, until something goes wrong.  Like condoms.  This feels more risky than a statistical number might suggest, but I'm not sure it's a logical argument.

Thanks in advance for your help and understanding.  Including I hope understanding how much I don't know yet.

[Bowie-esq]

Hi bicycle boy, welcome to the forum.

What you're doing is great, you are educating yourself and that will only make a relationship stronger (and I'm sure if your partner was to read your message he would be pleased that you are taking it seriously and doing so).

As you said, sex can never be 100% safe - with condoms, with undetectable - there is always a minute margin that something can go wrong. I too am in a serodiscordent relationship (I positive, my partner negative).

Learn about PEP, and where in your area is the closest and quickest means to acquire should is be necessary. Also, PRep.

And discuss these concerns with your partner - you will find that he will have information for you, and will be proud that you are looking in to it.

And then remember it's only a small part of who he and you are in your relationship - go to the movies together, drink wine, eat dinners.... In the end it is a relationship like no other.

[bicycleboy]

Thanks so much for the reply, advice, support, and I share your perspective on the relationship.

I am impressed and grateful he told me about his hiv status in the first couple emails we exchanged.  We are postponing too much discussion for a little while.  We want to get to know each other on many other levels, and give me a chance to be better informed.  We aren't avoiding it, but it's an awkward place to start, a least in detail.

If I may come back to the root of my question, it's my risk over a lifetime exposure.  I am hoping there's an objective and expert source that can assimilate and stay up to date on any relevant studies.  I'm not saying this web site isn't.  Still, I have a very hard time evaluating what I have read here so far.  That's not a criticism, I just don't know yet.  Yes, I know lots of things in life aren't risk free.  Some examples:

What numerical levels of risk are expected over a long time, say per decade, and per activity?  Ideally, adjusted for cases where safe practices were not consistent.  What is the nature of the studies used to draw conclusions - is it good science (randomized controlled trials, and the study is reproducible)?  Like HPTN 052.  What is the stability of viral load over time, assuming meds are taken as prescribed?  What conclusions, if any, can I draw from per-event statistics -  here's an example from aidsmap.com.  Receptive fellatio (pretty vague, I am guessing this means he's hiv+ and no condom) has risk as high as 1/2500 per event.  That's a scary looking number over a decade, like multiplying by 1000 events.  Or is that bad science/medicine?

Those are all interesting questions, and I have extensive background in science, engineering, and math.  But, I am not a doctor or expert in this field.  I'm really looking for that expert source (if it exists) for this.

[bicycleboy]

Any comments on this:

www.thebodypro.com/content/74593/long-term-hiv-risk-estimates-for-mixed-status-coup.html

Excerpt below:
The risk of transmitting HIV among serodiscordant couples may be higher than the zero transmissions seen in the PARTNER study, even when the positive partner is on treatment and condoms are being used consistently, according to a study published in the journal AIDS.

.
.

- When consistent condom use only was reported, the one-year risk was 13% and the 10-year risk was 76%.
- When the positive partner was on treatment and consistent condom use was reported (with or without other prevention strategies), the one-year risk was 1% and the 10-year risk was 6% or less.

[Miss Philicia]

read these recent items from aidsmap:

Model shows potential for substantial long-term HIV risk for serodifferent couples, even with new prevention tools

Second analysis concludes that we can't eliminate the long-term possibility of HIV transmission from someone on treatment

[Miss Philicia]

The key is that, while no guarantee of negligible risk, it's quite close.

The only risk that will be zero for someone is no sex with a partner regardless of HIV status.

If you counter that the risk is lower in a monogamous relationship with a HIV-negative partner then you have similar issues that the longer the relationship goes on the less likely it may be to actually be monogamous. At least with a HIV+ partner you have the periodic paperwork to actually prove that the partner is continually undetectable, and assuming you pair this with consistent condom use I'd still argue it's a safer or as safe arrangement than the HIV-negative partner.

It's easy to over-think these dynamics.

[bicycleboy]

Thanks so much for the links, and your thoughts.  I'll check them out, and post if I have new questions or conclusions.

Just to be clear, I am hiv-.  I am always monogamous.  I just can't function any other way.  No sex isn't a good option.  It's clear that a lot is truly next to zero risk, like kissing, pleasuring with your hands, and so on.  More than that, seems less clear. 

The article I quoted indicated under 6% per decade.  I don't know what assumptions to make about viral load, or other factors to make this useful.  That said, 6% per decade is not acceptable to me, nor would I describe it as negligible risk.

[Miss Philicia]

I am always monogamous.

That's nice to say, but it takes two people to be monogamous. So, in fact, you can't actually ever be sure you're in such a relationship, can you?

My point being is you can know if a partner is undetectable -- it's there on paper. You can not tell if a partner is going outside of the relationship, unless you have some magic tracking device I am not aware of.

[zettainaoru]

I bet they'll find a cure before a decade of your relationship.

[bicycleboy]

I sure hope they find a cure, or at least a vaccine at least, and not just for my personal sake.

Here's what I learned so far.  Overall, I am not able to conclude that condoms, ART, PrEP, and PEP result in what I think of as negligible risk.  For me, negligible is probably under 1% per decade.  The biggest unknown or unclear factor is the effect of condom use.  Specifically, condom use when 100% used each and every time, so the risks are presumably from failure (tearing/leaking), slipping off, leakage, etc.  The second most significant factor would appear to be viral load variability, and not just in blood.

Long-Term HIV Risk Estimates for Mixed-Status Couples Is Not Zero
Summary in www.thebodypro.com, published in Journal of AIDS
Study is a mathematical model based on transmission and reduction rates.
Assumptions used may not be predictive of actual risk.
Key assumptions (reductions in transmission risk):
   80% from consistent condom use
   73% from circumcision in hiv- partner
   44% from PrEP
   96% from ART
Key results:
   When consistent condom use only was reported, the one-year risk was 13% and the 10-year risk was 76%.
   When the positive partner was on treatment and consistent condom use was reported (with or without other prevention strategies), the one-year risk was 1% and the 10-year risk was 6% or less.
   Without any treatment, combining PrEP, condoms and practicing insertive anal sex, the one-year risk was 5% and the 10-year risk was 39%.
My questions/opinions:
   80% reduction from consistent condom use seems low, don't know how much is from condom failure, actual vs reported "consistency", or something else
   I don't know what rate would be better, and even if I did, how it would change the results
   Assuming consistent condom use, ART makes a huge difference in the study, but I don't know how stable viral loads are in the real world over time, and in any case wasn't modeled
My conclusions/opinions:
   model predicts up to 6% 10-year risk using all precautions, which isn't negligible
   the results without treatment suggests variability in viral load could have a significant effect on risk
   I don't know the sexual frequency assumed, but could have a huge effect, for example 6 times a month vs daily is a factor of 5 in risk

PARTNER study
Summary in www.thebodypro.com
Key Assumptions:
   no condoms, PrEP, or PEP
Key results:
   maximum risks are predicted by the statistical confidence vs observed infections, and below for the hiv- partner
   insertive anal sex: about 1.37.
   receptive anal sex without ejaculation: about 2.5.
   receptive anal sex with ejaculation: 4, translating into a 10-year risk of about 32%.
My questions/opinions:
   seems obvious, but a condom is prudent, I don't know how much reduction can be expected
   if I use 80% effectiveness for condom, one might calculate a 10-year risk as 32% * 0.2 or about 6%.  Valid or not, it's about the same as predicted by the study above.

<thanks to Miss Philicia for reference>
Model shows potential for substantial long-term HIV risk for serodifferent couples, even with new prevention tools
Summary in www.aidsmap.com 
Note: this discussed the same study published in Journal of AIDS above
Key results:
   even with ART, the model computes that the ten-year risk of transmission in gay couples is 25%.
   The only way of reducing transmission risk further was to use an unrealistic combination of prevention interventions.
My questions/opinions:
   unclear why this article quotes 25% 10-year risk, vs results in bodypro, appears to be condom plus ART, maybe doesn't include other factors
   wonder what this "unrealistic" stuff is about


<thanks to Miss Philicia for reference>
Second analysis concludes that we can't eliminate the long-term possibility of HIV transmission from someone on treatment
Summary in www.thebodypro.com
Note: This article focuses on two studies of heterosexual risks, obviously just as important, but skipping detailed analysis for me, other than noting the 10-year risks mentioned are in the 2-4% range, and not too far off of above studies.

Comments or further information welcome.



   

[bicycleboy]

Miss Philicia,

Just a clarification on my usage of the word monogamy in this context and discussion.  In what follows, I will use the term to apply to exactly the one person referenced, lacking a better term. 

My being monogamous means that if I get infected, then it's extremely likely where I got it.  If my partner wasn't monogamous the theoretical risk is that repeated exposure to hiv, especially if it's a variant strain, or another STD, could result in increased risk.

The former has nothing to do with evaluating my risk, and the latter is a real risk, but not readily subject to analysis.

I know this sounds very clinical, and I am not dismissing everything else that goes along with this, but I want to stay on-topic.

Your point that it takes two is well taken though;-)

[zettainaoru]

Key assumptions (reductions in transmission risk):
   80% from consistent condom use
   73% from circumcision in hiv- partner
   44% from PrEP
   96% from ART

Sorry, im not that smart.
So just like you said, on ART treatment (4% risk) + Condoms (20% risk) results in 1% risk/ year (almost equal to 20%*4%).

So if u combine all that four, the risk would be 20%*4%*56%*27%= 0.12% / year,
or 0.36%/ 10 years.

Its quite low for me.

[mecch]

bicycleboy

I find this thread almost incomprehensible.  And I can read all sorts of texts and information pretty skilfully.

Would you mind putting into a few clear phrases what feedback or information you are looking for the HIV+ community to give you, here?

[bicycleboy]

mecch ..

What you see on this thread from me is mainly my original questions, and subsequent posts from what I found myself or was suggested here.  Now that I have learned more, I might reformulate my original question.

Ideally, I want to know my risk over a lifetime exposure.  I am hoping there's an objective and expert source that can assimilate and stay up to date on any relevant studies.  For sake of consistency, and because studies seem to have results along these lines, risk per 10 years is a number I can work with.  An answer to this obviously isn't as simple as a single number.  At a minimum, it depends on what you do sexually, precautions, medical treatment, sexual frequency, and so on.  Any science/medical based answer will either be a worst case number or a range. 

If that doesn't exist, I will have to try to evaluate various individual studies.  I may have to do this, and while I am a reasonably skilled engineer, scientist, and mathematician, I am not an expert in this field (obviously).

My original post had other questions that are valid.  We can re-start my question with this if it's more clear.  If it still isn't clear, let me know, and I will try again.

[mecch]

My impression is that you are trying to quantify the unquantifiable. You are looking for science to apply to your personal, very individual life.
Relationships come with gifts, and risks. All sorts of risks besides HIV.
You seem a bit OCD about HIV, and deluded about the possibility of codifying everything.

Sounds like a potential partner, has HIV, and you want reassurance.

A person with an undetectable viral load, and furthermore, having protected intercourse, is not going to be a transmission risk. 

And even furthermore, if there were a condom mishap, there is Post-exposure treatment.

And even furthermore, the HIV- partner could take PREP - pre-exposure.

There are so many many ways to avoid a transmission, you can't POSSIBLY, reasonably, hope to quantify all that, can you?  ? ? ?

If you basically can't chill out and overcome the fear of HIV then you have no business being in a serodiscordant relation.  Thats what it comes down to.  Save yourself and the potential partner the waste of time and emotion and intellectual energy.

[bicycleboy]

Hi zettainaoru,

Thanks for the reply.  Don't take this the wrong way, but your analysis isn't correct, though on a per event basis you are on the right track.  If the model was that simple, this wouldn't be published in a scholarly journal.  The source article in the Journal of AIDS describes the methodology, and uses a statistical Bernoulli model.  Let's not get into the math here.  In fact, I freely admit, this isn't my area of expertise.

The result from the study with ART, condom, (with or without other prevention strategies PrEP, PEP, circumcision), the one-year risk was 1% and the 10-year risk was 6% or less.  That's pretty significant (for me anyhow).

Digging into the article further, it assumed 3 insertive and 3 receptive sex acts per month.  If your sexual frequency was daily, maybe multiply the risk by about 30/6 = 5, and now we are looking at 30% or less for a ten-year risk.  Again, I used the frequency as a point of comparison, don't read anything personal into it. I said "maybe" here, because this simplistic multiplication may be misleading because the model may not be linear with respect to frequency.  It's just my best guess.

[mecch]

before entering a relation, are you going to:
calculate the potential partner's genetic risk for heart disease? alcoholism?
are you going to decide who is likely to live longer 40 year later before the relationship starts? consult actuarial charts?
are you going to make decisions before you get in, what method of transport to use, over a a lifetime, and not use, based on risk? what brand of car is safest and the only scientifically supported choice?
what happens if you are falling in love with a smoker?
what happens if 15 years in the relation you get resistant staphylococcus and your partner taking care of you poses a risk to him. Should he leave you at that point?

[bicycleboy]

mecch,

I'm not even sure I should post this.  I'm not sure how to respond without possibly adding conflict.  That is not what I came here for.

The variables I mentioned, are pretty typical variations in terms of protection and sex.  I am not asking for a personal evaluation, or exact answer.  I think it is reasonable to get some sort of bounds or approximate numbers so we can make good decisions.  It's equally important both of us come to a common understanding about the risks.  The point of the studies is in fact to quantify transmission risks.  Presumably the studies were done to help with personal decisions and/or public policy.

I respect your perspective, but I would prefer to get back to my question.  If you don't have any additional evidence-based information, that's fine. 

I started this with the introduction that I am new to this, and learning.  My posts here are just one aspect I will be interested in if the relationship goes further.  I am not going to apologize for taking the time to learn all I can, for both of us, because I care.  And I mean learning about a lot more that just how it affects me.  But, I am repeating myself.

Bottom line, you don't know me well enough to start labeling me with mental disorders, or advising about my possible relationship.

[mecch]

There is a chance that washed prepared salad, and cantaloupe rind, can carry and transmit very dangerous bacteria.  I am sure there are studies in food science on this risk to the population.  Will you consult these before you buy salad and consume salad and cantaloupe.

My point is, you are posting this in an HIV+ forum for HIV+ people. We are careful not to be reduced to a pool of potential disease spreaders and that these risks are absolutely quantifiable from population studies to individual experience. You know that is impossible, and yet you persist. Its irrational.   No you are not reducing HIV people to disease spreaders. I understand. However, my observation is that you may not understand what a relationship requires, nor may not understand how love is experienced...   That is all.   Its not about science and numbers. And HIV does not get special treatment, to allow a relation that includes HIV to become reducible to science and numbers....   
I say this as someone who has been in sero-discordant relationships.  My advice to you is to tread carefully and if the round peg does not fit into the square hole, spare us all the noise of trying to bang it in there anyway.

[bicycleboy]

Maybe the moderators should intervene.  You are making a lot of assumptions about me without foundation.  I came here with a reasonable question.  Answers will help us make better and informed decisions, and base them hopefully on something we can agree on.  I think I came to the forum with good intentions, and the post is on-topic.  I'm not being dragged into a pool of accusations and insults.

[Jeff G]

Im inclined to agree with Mecch . If you are in a relationship with a poz person this is the correct forum to post in . You can do your own research and come to your own conclusions about the risk of HIV .

This is  primarily a online community for people living with the virus and we have this one forum for people who are partnered with or have family that is living with HIV . Its a misuse of our forum to come here and quiz our members about HIV for folks that are just thinking about dating a positive person and will not be tolerated if that is your intent .   

Please only post in this one thread and do not be surprised if it eventually gets locked if others complain .   

[mecch]

The root of my question has to do with my risk over a lifetime exposure.

You don't need a moderator's protection.

Nobody here can answer your question, above. Nobody in science can help you. Maybe some epidemiologists and actuarial who are geniuses in maths and statistics.  I suggest you check with the best medical school in your area maybe you can find an expert with good information.

You know the rules and guidelines to avoid transmission.  Condoms. The HIV+ being undetectable. The availability of both PREP and PEP.  What more do you need to feel at ease?  There is nothing more available.  If you can't feel at ease, you have to move on.

[bicycleboy]

All,

I think I was careful to ask my question such that I was looking for sources of information, and not quizzing members.

In fact, I lot some very helpful links; thank you Miss Philicia.  And warm welcome, thank you Bowie-esq.

If you believe the question is unanswerable, or I need to seek it elsewhere, I respect your opinion, let's just leave it there.  But there is research out there, and would ask respect for my interest in finding it.  In fact, I may never have found it without the help I got here.

Bottom line, I think my question and discussion was valid, on-topic, and not looking for any conflict.  No need to lock a thread, I hope.  Others may have valuable information I haven't found yet.

I would like to think I am still welcome here, or to ask something related.

I would like to think I can post in or start a new thread (if topic doesn't exist) on other subjects.

I think I have been positive, respectful, and non-accusatory here, despite making a couple people uncomfortable.  All I can say is I'm just starting the learning process, doing the best I can.

[Jeff G]

All,

I think I was careful to ask my question such that I was looking for sources of information, and not quizzing members.

In fact, I lot some very helpful links; thank you Miss Philicia.  And warm welcome, thank you Bowie-esq.

If you believe the question is unanswerable, or I need to seek it elsewhere, I respect your opinion, let's just leave it there.  But there is research out there, and would ask respect for my interest in finding it.  In fact, I may never have found it without the help I got here.

Bottom line, I think my question and discussion was valid, on-topic, and not looking for any conflict.  No need to lock a thread, I hope.  Others may have valuable information I haven't found yet.

I would like to think I am still welcome here, or to ask something related.

I would like to think I can post in or start a new thread (if topic doesn't exist) on other subjects.

I think I have been positive, respectful, and non-accusatory here, despite making a couple people uncomfortable.  All I can say is I'm just starting the learning process, doing the best I can.

You have been very polite and we appreciate that . I did mean it when I said ....

This is  primarily a online community for people living with the virus and we have this one forum for people who are partnered with or have family that is living with HIV . Its a misuse of our forum to come here and quiz our members about HIV for folks that are just thinking about dating a positive person and will not be tolerated if that is your intent .   

Please only post in this one thread and do not be surprised if it eventually gets locked if others complain .   

[Jeff G]

This is our standard offering to people who are concerned and wanting to avoid being infected with HIV . Its simple and requires no math . If condoms are not your thing then consider Truvada as PREP ... it really is just this simple .

Here's what you need to know in order to avoid hiv infection:

You need to be using condoms for anal or vaginal intercourse, every time, no exceptions until such time as you are in a securely monogamous relationship where you have both tested for ALL sexually transmitted infections together.

To agree to have unprotected intercourse is to consent to the possibility of being infected with an STI. Sex without a condom lasts only a matter of minutes, but hiv is forever.

Have a look through the condom and lube links in my signature line so you can use condoms with confidence.

Although you did not have a risk and do not need to test for this specific incident , anyone who is sexually active should be having a full sexual health care check-up, including but not limited to hiv testing, at least once a year and more often if unprotected intercourse occurs.

If you aren't already having regular, routine check-ups, now is the time to start. As long as you make sure condoms are being used for intercourse, you can fully expect your routine hiv tests to return with negative results.

Don't forget to always get checked for all the other sexually transmitted infections as well, because they are MUCH easier to transmit than hiv. Some of the other STIs can be present with no obvious symptoms, so the only way to know for sure is to test.

Use condoms for anal or vaginal intercourse, correctly and consistently, and you will avoid hiv infection. It really is that simple!

[bicycleboy]

Jeff,

Thanks for all that info.  The two of us have been talking, and are meeting for the first time soon.  Perhaps a bit beyond just thinking about it.  But I won't make any assumptions about my dating/thinking-about-it status until it's crystal clear.

I will of course respect your posting guidelines.  Oops, sorry, I missed that you were a moderator when I replied before.

[bicycleboy]

Jeff (and all),

We have been talking a lot over the past six weeks, and he just spent the past three days with me.  I got a reciprocal invitation.  He is totally OK with the questions I have, which go beyond this particular thread, and we plan to see our doctors for advice to supplement what's here.  We are going to schedule two visits with his doctor.  The first only to talk about his care, and the second to talk about us.

I would like the restriction on my posting new threads or on other threads removed. Based on the responses, I do not intend to continue on this thread.  I am not going to offer further details about our relationship for the purpose of justifying whether it's appropriate to post.  That's not  meant as a "threat", I just think it should be good enough, and beyond that is a private matter unless we decide otherwise.

Regards,
Jon

[Jeff G]

Hi Jon . As a HIV negative person you are only allowed to post in the someone I care about forum so feel free to do that if you wish to reply in other peoples threads . There is no need to start a new thread if its about you and your BF, we encourage people to post in one thread so that all of your thoughts and concerns are in one place .

[bicycleboy]

Thanks Jeff.  I have a suggestion, sorry if it's been said before.  If I knew this was going to be my personal thread, I would have preferred to have the subject heading as my username.  I'm not sure I want to be indelibly remembered by the first question I posted.  The subject line is editable, but I'm not sure that changes the subject of the entire thread or what.

Thanks,
Jon

[Jeff G]

Its not a big deal ... if you wish, simply start a new thread and abandon this one . My advice was that there is no need to start a new thread on the same or similar subjects .