transmission likelihood in serodiscordant hetero couples (need NEW info)

[midland moe]

I know this subject has been discussed in thread after thread, but none I find include much of the newer risk asessments Ive read, and take into consideration viral load status.


I have been married ten years to my wife, and found out I was poz in 08. I found out due to AIDS defining illness (pneumonia) and it landed me in the hospital for two weeks. my viral load was 570,000 and my cd4's were 85...within 6 months I was undetectable and my cd4's have climbed to 667 as of a month ago.

My wife tested negative, thank god, and at the time of my diagnosis she told me if we stayed together there would be no intercourse, end of discussion. We still have intimacy, just safe intimacy, but the subject of intercourse has come up again, and I asked her where her mind was on the idea of us having sex again....she said I dont know and since then has asked about a couple articles like the swiss study and the one that just got published about the foam or cream with antiviral medicine in it...so I want to look at my situation and try to come up with a better idea of what were facing, with the latest information available...


heres where i start....

with an undetectable viral load going on 1 1/2 years now     the swiss study would put unprotected sex at NO RISK. another study I read puts undetectable viral load for a period of time > than 6 months at a 91% reduced risk over what? If I read correctly undetectable viral load reduces transmission risk a great deal but detectable viral loads increase transmission risk the higher they go.

so is it a 91% reduced risk over a 500,000 viral load or only a 75 copies +(barely dectectable) that i couldnt find out.

if we did have intercourse it would be with a condom and that provides ANOTHER  huge barrier to transmission 100% barring condom failure...failure rate even at 8 or 9% most of the time Id notice before and fluid transfer took place so careful condom use even with failure rate factored in puts transmission risk at almost nil...yes?

given that in addition to my viral load being undetectable making transmission anywhere from 91-100% less likely and that likelihood only comes into play if a condom failed and it went unnoticed or occured at a time when some fluids were exchanged

From what I read hetero transmission while not impossible is given a rate of 1 in 1000 chance of transmission per exposure from a poz male to a neg woman...


I am horrible at math and I know these are not hard fast numbers but my conclusion, and Im only offering it because I want opinions and for anyone who thinks my logic flawed to point it out...

my conclusion is that hetero intercourse wearing a condom and having undetectable viral load for a period of 18 months and counting has got to be as close to 100% safe as can be....


would that be a "more likely to get struck by lightning odds?" "better chance to hit the powerball lottery than to give her hiv?" a million to one?

i know in reality people do get hit by lightning and they win the lotto....if there was anything more than a theoretical likelihood that she could catch it from me, I dont think id even want to discuss it with her. im just lucky she stayed.

[Ann]

my conclusion is that hetero intercourse wearing a condom and having undetectable viral load for a period of 18 months and counting has got to be as close to 100% safe as can be....

This is correct.

If you use condoms correctly, they are highly unlikely to break. The main cause of breakage is not pinching the tip when putting one on, thereby leaving an air bubble in the tip which can cause the condom to burst. Another reason is using a condom that has passed it's expiry date or has not been stored properly. Another reason is using an oil-based lube with a latex condom. Only water-based lube should be used with latex. One more reason is not using any lube. Please read through the condom and lube links in my signature line for more information.

There are many serodiscordant couples who enjoy full sex lives without the negative partner ending up poz. You could be one of them.

[midland moe]

thanks for your reply...im trying to have this discussion with my wife coming from as informed a position as can be, and some of the older info about safer sex didnt take viral load into account, and alot of the info wasnt addressing the risk for hetero contact...or the hetero info was buried in with transmission risks for other lifestyles....


if the prevailing opinion is "sex with undetectable viral load, good adherence and correct condom use for all intents and purposes is SAFE" any "theoretical" risk is negligible so the real barrier will be overcoming a very real but uninformed fear". then i should have a chance to sway her decision...

[veritas]

mm,

The advice that Ann gave you is spot on. You have been ud for quite awhile, your cd4s are rising as is your cd4%----- all good signs.

Your statement of the theoretical risk being negligible and the real barrier is overcoming fear is very true.

Give her time. The fear can be very real. Knowledge is power with HIV.

Good luck,

v

[Boze]

You misunderstood the research regarding 92% reduction in transmission. It's not your fault - i find the study conclusion to have no bearing on what they actually found.

Abstract: http://retroconference.org/2010/Abstracts/39222.htm

Basically there were 103 couples in Africa where one partner had HIV. They were followed for 256 person-years - ie about 2.5 years on average. ONE person transmitted ... BUT - and this is very important - "the single HIV transmission after ART initiation, the HIV-infected partner initiated ART 18 days prior to their partner’s first HIV seropositive test (HIV seronegative 90 days prior)." What it means is that the transmission most likely took place BEFORE HAART was started and the individual was NOT undetectable.

My takeaway from this study is that there was not a single transmission among 102 serodiscordant couples on HAART.

This agrees with the Swiss statement which was based on the observation of heterosexual couples in Switzerland, where no transmission took place.

And the last thing. Out of millions of people on HAART, there has not been a recorded case of a transmission in a straight couple where the person was UD.

So to me the evidence is pretty strong that risk of transmission is extremely low if Swiss Statement conditions are met.

[newt]

Yer, but it's his partner's body and her decision

[Boze]

Yer, but it's his partner's body and her decision

absolutely - i was very careful to not give any advice as to what they should do - that's for them to decide. I only wanted to provide context on what science knows today about the issue.

[hotpuppy]

Let me make another analogy for you.

If you have 20 beers and go for a drive you are probably very dangerous.
If you have 1 beer and go for a drive you are still impaired, but not as much.

At a viral load of 30K you have quite a bit of virus.

At "undetectable" you have a viral load below the limit of the test, which is 50 copies per ml.  We don't know if you have 49 or 3 copies per ml.  We just know it's below 50.

So, if we call it 40, for conversational purposes.... you still have 137,500 copies of virus in your blood.
(5500 ml x 40/ml)

So back to my original point..... when you are undetectable you are less infectious, but still capable of transmitting the virus.

The odds go from something like 1 in 7 to 1 in 10,000.  I can't back that up, I'm using it to illustrate a point.

So the odds are pretty good unless you are the 1 in 10,000.

The swiss study cited couples who were serodiscordant, poz undetectable > 6 mos and had sex to conceive.  No infections were cited in 1000 couples (approx).... so that's pretty good.

If you want to conceive, you should also look at the article on Norvir as a prophylactic gel.  it suggests that monotherapy may be sufficient to prevent infection.  The artcile (on Poz.com currently) talks about using a gel as the drug delivery mechanism, but they refer to blood levels of the drug... so a pill would accomplish the same thing.  My point here is to involve your doc in your planning so that you can keep your wife neg.

Btw, congratulations on the success of your relationship.  I know there are a couple of newbies who would benefit from your mentoring if you wanted to contact them. 

[Boze]

At "undetectable" you have a viral load below the limit of the test, which is 50 copies per ml.  We don't know if you have 49 or 3 copies per ml.  We just know it's below 50.

So, if we call it 40, for conversational purposes.... you still have 137,500 copies of virus in your blood.
(5500 ml x 40/ml)

So back to my original point..... when you are undetectable you are less infectious, but still capable of transmitting the virus.

Hotpuppy,

OP isn't giving blood to his wife, they're considering sex options So the total amount of virus in the blood isn't a relevant number.

So we want to consider a more relevant benchmark - sperm. An average ejaculation is 2 to 5ml. I also think that the virus is somehow similar to sperm - it requires a minimal certain amount to get through because the body has certain natural defenses which kill the virus. So maybe the first 5,000-10,000 die and only the following ones have a shot at catching on.

I found these chart illustrative:




http://papamamanbebe.net/a8238-les-personnes-seropositives-ne-souffrant-d-a.html#photo7153

[Matty the Damned]

Would you care to discuss the import of these charts?

MtD

[Etay1207]

10 years of marriage and unprotected sex and she's negative? Does anyone else have a problem with that besides me?

[Matty the Damned]

10 years of marriage and unprotected sex and she's negative? Does anyone else have a problem with that besides me?

I would have thought you'd be wrestling with bigger problems than somebody else's sex life.

MtD

[leese43]

10 years of marriage and unprotected sex and she's negative? Does anyone else have a problem with that besides me?

Nope, it's not unusual. I've chatted to a couple of guys that have had the same story. Poz before marriage but unaware until they were almost at deaths door. Wives remain negative after 10+ years of marriage.

[RapidRod]

It's luck. They keep having unprotected vaginal or anal sex and she'll become infected.

[leese43]

It's luck. They keep having unprotected vaginal or anal sex and she'll become infected.

Oh, I wasn't saying they were. In the cases that I know of there was no unprotected sex once they were diagnosed..

[Boze]

Would you care to discuss the import of these charts?

MtD

UD don't seem to transmit.

It's luck. They keep having unprotected vaginal or anal sex and she'll become infected.

If he's UD and they stick to vaginal it's very unlikely.


I'd like to stress that this is not MY opinion - I just cut/paste what the studies have shown. The reason that scientists are against actually saying this is because they are afraid of giving HIV+ individuals a carte blanch to go out and bareback since people would just dismiss the qualifications of Swiss Statement (ie vaginal sex/stable couple/no other STDs)

[Stanley5739]

I see a well known HIV practitioner in NYC who has a great reputation.  According to him, one partner being undetectable is significantly safer, but without protection, not conclusively safe.  His reason being that in a male serodiscordant couple, when a partner of his current patient (with a rare HIV strain) seroconverted, the partner swore he had not been playing around and was believed only when his HIV strain matched the rare strain of the current patient.  I realize this is anecdotal, as does my physician, but the rarity of the strain was instructive.

By the way, thanks to my doctor, I remind all men to have a rectal "pap smear" if they haven't already.  To my surprise I found I had warts, though it turns out they were benign.  Apparently, not everyone or every doctor thinks of this.

Good luck with your wife.  I envy you that you have any intimacy with yours.

[RapidRod]

UD don't seem to transmit.

If he's UD and they stick to vaginal it's very unlikely.


I'd like to stress that this is not MY opinion - I just cut/paste what the studies have shown. The reason that scientists are against actually saying this is because they are afraid of giving HIV+ individuals a carte blanch to go out and bareback since people would just dismiss the qualifications of Swiss Statement (ie vaginal sex/stable couple/no other STDs)

http://www.who.int/hiv/events/artprevention/wilson_relation.pdf
http://www.hivandhepatitis.com/2009icr/croi/docs/022409_c.html

[tednlou2]

I'm terrible at math as well and often have a hard time understanding studies with tons of numbers.  I have been really surprised that Dr. Gallant talks to people a lot that it is virtually impossible to pass HIV with and UD viral load.  Most docs shy from statements like that, because they think it will give people a license to go have unprotected sex when they may not be UD. 

About you wife's concerns--  I must say that if my partner were the one poz, I would have fears even with condoms.  With condoms, I know that is irrational.  But, I think I would always been wondering what if the condom broke.  I'd probably get over it eventually.  My partner performs oral sex on me.  If the other way around, I just don't think I could do that.  I would be afraid of being one of those very, very rare people who got HIV that way.  But, I'm a worrier.  With facts, I'm sure your wife will come around that it is safe--especially with a condom.  I wish you both really hot sex!

[Boze]

http://www.who.int/hiv/events/artprevention/wilson_relation.pdf
http://www.hivandhepatitis.com/2009icr/croi/docs/022409_c.html

Thanks you for the relevant studies - however i don't see how these research pieces dispel my view:

First: "A total of 34 instances of HIV transmission occurred during 396 person-years (PY) of follow-up prior to ART initiation, an incidence rate of 8.6 per 100 PY. In contrast, no transmissions occurred during 25 PY of follow-up while on the positive partner was on ART. Prior to ART, the median viral load was about 44,000 copies/mL. After starting treatment, 79% achieved undetectable HIV viral load (< 40 copies/mL) at 6 months and 95% had at least 1 detectable measurement within the first 18 months. "

Second piece is a MATHEMATICAL model that concludes  that in a population of 10,000 serodiscordant couples observed over 10 years, it expects to have 215 male-to-female and 425 male-to-female transmission and 3,524 male-to-male transmissions. However - we've had probably MORE people in serodiscordant couples over last 10 years and have not observed such levels of transmission. Therefore the ASSUMPTIONS used for that model are clearly wrong.

[RapidRod]

Thanks you for the relevant studies - however i don't see how these research pieces dispel my view:

First: "A total of 34 instances of HIV transmission occurred during 396 person-years (PY) of follow-up prior to ART initiation, an incidence rate of 8.6 per 100 PY. In contrast, no transmissions occurred during 25 PY of follow-up while on the positive partner was on ART. Prior to ART, the median viral load was about 44,000 copies/mL. After starting treatment, 79% achieved undetectable HIV viral load (< 40 copies/mL) at 6 months and 95% had at least 1 detectable measurement within the first 18 months. "

Second piece is a MATHEMATICAL model that concludes  that in a population of 10,000 serodiscordant couples observed over 10 years, it expects to have 215 male-to-female and 425 male-to-female transmission and 3,524 male-to-male transmissions. However - we've had probably MORE people in serodiscordant couples over last 10 years and have not observed such levels of transmission. Therefore the ASSUMPTIONS used for that model are clearly wrong.

Your view is mute. Just because you have an undectectable viral load does not mean your semen viral load is undectectable which makes you still infectious and the ability to infect others.

[Boze]

Your view is mute. Just because you have an undectectable viral load does not mean your semen viral load is undectectable which makes you still infectious and the ability to infect others.

Let's back up the truck, Rod, on telling ppl that their view is mute because it differs from your opinion. Stick to scientific arguments, ok?

Now - while a certain percent (some studies say 3%, some 14%) of people have a detectable amount of HIV virus in semen while being UD - that does NOT equate to transmission risk. If it were true, we'd have hundreds of cases of UD transmitting - but so far we have one for msm sex and none for straight (where the UD status was confirmed - Rokai cohort didn't have those details, only presense of ART).

As a matter of fact, a study showed that BLOOD viral load is a better predictor of transmission risk than semen:

"A small US study among men who have sex with men has added new information to the debate around the links between HIV transmission and viral load levels in semen. The study, published in the August 20th issue of AIDS, found that blood viral load correlated better with transmission than seminal viral load.

...

Upon multivariate analysis, blood viral load was significantly associated with transmission; semen viral load was not. The range of blood viral loads among transmitters had a higher maximum and narrower range of values than the non-transmitting group. However, the range of semen viral loads for transmitters fell completely within the range of semen viral loads for non-transmitters."

http://www.aidsmap.com/page/1431458/

[RapidRod]

Let's back up the truck, Rod, on telling ppl that their view is mute because it differs from your opinion. Stick to scientific arguments, ok?

Now - while a certain percent (some studies say 3%, some 14%) of people have a detectable amount of HIV virus in semen while being UD - that does NOT equate to transmission risk. If it were true, we'd have hundreds of cases of UD transmitting - but so far we have one for msm sex and none for straight (where the UD status was confirmed - Rokai cohort didn't have those details, only presense of ART).

As a matter of fact, a study showed that BLOOD viral load is a better predictor of transmission risk than semen:

"A small US study among men who have sex with men has added new information to the debate around the links between HIV transmission and viral load levels in semen. The study, published in the August 20th issue of AIDS, found that blood viral load correlated better with transmission than seminal viral load.

...

Upon multivariate analysis, blood viral load was significantly associated with transmission; semen viral load was not. The range of blood viral loads among transmitters had a higher maximum and narrower range of values than the non-transmitting group. However, the range of semen viral loads for transmitters fell completely within the range of semen viral loads for non-transmitters."

http://www.aidsmap.com/page/1431458/

Use a condom correctly and consistently and you don't have a concern of TRANSMITTING HIV nor a concern for most STDs. Boze you know enough to be dangerous.

[Hellraiser]

Your view is mute.

Rod, this is driving me nuts, no ill will intended.  The word you want to use is moot.  You're not the only person who has misused mute in it's place.

Now you guys can continue with your size contest.

Oh also, Boze you seem to propose that anal sex is somehow more likely to transmit hiv than vaginal sex.  According to the old idea that the virus needed minor tears to infiltrate the body that would have been correct as the rectum was more likely to tear during sex (supposedly), but since the virus can seep right through mucous membranes (which the vagina has plenty of) then anal sex and vaginal sex are on par with one another.

[Ann]

Oh also, Boze you seem to propose that anal sex is somehow more likely to transmit hiv than vaginal sex.  According to the old idea that the virus needed minor tears to infiltrate the body that would have been correct as the rectum was more likely to tear during sex (supposedly), but since the virus can seep right through mucous membranes (which the vagina has plenty of) then anal sex and vaginal sex are on par with one another.

Wrong. Anal is more risky than vaginal, especially for the bottom. While hiv doesn't NEED small cuts or tears to enter, they will certainly facilitate it. Look at any risk chart and receptive anal will top it (er, no pun) every time.

[RapidRod]

Rod, this is driving me nuts, no ill will intended.  The word you want to use is moot.  You're not the only person who has misused mute in it's place.

Now you guys can continue with your size contest.

Oh also, Boze you seem to propose that anal sex is somehow more likely to transmit hiv than vaginal sex.  According to the old idea that the virus needed minor tears to infiltrate the body that would have been correct as the rectum was more likely to tear during sex (supposedly), but since the virus can seep right through mucous membranes (which the vagina has plenty of) then anal sex and vaginal sex are on par with one another.

I see you didn't have any trouble understanding what I meant. 

[BroodyChick]

Hi Midland

just my 2 cents' worth: I am a HIV- female and my partner is poz.
I knew about his status before we got together; also that he's been on the same treatment and undetectable for the past 7 years!

I was nervous initially, but happy to get intimate when he wore a condom, which he always did no questions asked. His ex partner never got infected either, in fact he never passed it on to anybody although before his diagnosis they relied on the "withdrawal" method for a few months.

Another poz friend pointed me in the direction of the Swiss Study, which I found lots of material about online.

All the reading and research I did, as well as chatting on a fertility forum to other HIVnegative females with poz partners reassured me enough to try for a baby naturally.

Using the limited conception method we limited our unprotected intercourse to one day a month when I was at my most fertile, using condoms the rest of the time.

Unfortunately our attempts were unsuccessful and we are now waiting for the sperm washing and IUI procedure in order to conceive, but I never caught the virus in six months.

Of course it is down to your wife what she is comfortable with, but she should be ok over time and feeling reassured if you keep using condoms for intercourse.

Best of luck!

[midland moe]

well this was the conversation that never was....we split up. and i never said i had hiv for 10 years throughout our marriage, but i certainly did have it for the last 2 years plus at least 4 more...just didnt see the need to share my fidelity failures in a topic relating to likelihood of transmission. it isnt impossible i had it before we got married, but doctors have told me its unlikely given my lifestyle (drugs, alcohol etc) that it would take 10 plus years to go full blown...but there was certainly a period of time where my wife and i had sex regularly without protection and i was infected that is a fact, how long that period of time was...not sure. a minimum of 4 years...because i hadnt been with anyone except my wife since 2004, diagnosed in 2008.