"HIV-unprotected sex is possible" ?

[Dachshund]

Ann, rarely is not zero.

Jacques

Oh really Jacques? Rarely is not zero? Wow, thanks for that erudite clarification. C'mon Ann, the Greek chorus demands a retraction. However, we can say that a condom that remains intact does not break.

[hartiepie]

Jacques is correct: Rarely = not zero. Why needle him? It isn't advancing any information here to do so.

[Dachshund]

Jacques is correct: Rarely = not zero. Why needle him? It isn't advancing any information here to do so.

It isn't advancing anything to point out the obvious. Not looking for any argument here, just sayin...

[Cerrid]

I just found this study, published before the Swiss one, which seems to directly contradict several of the Swiss findings. 
http://www.aidsmap.com/en/news/167784F9-FD3C-4148-8AB3-F669FE941BB3.asp

Thank you for pointing this out, because this study doesn't contradict the Swiss statement, it strengthens it. In the study you quoted, the investigators  stress, "in fact, the studies with the lowest correlations between blood plasma viral load and semen viral load are those that are most likely to have included men with co-occurring sexually transmitted infections."

That's why the Swiss researchers put special emphasis on the subject of STD. If there are STD present, one of their three criteria for unprotected sex isn't met.

The authors of the quoted study also state: "Poor adherence to anti-HIV therapy was associated with detectable HIV in semen in some studies, and another study showed that the men who missed the fewest treatment doses had the greatest degree of HIV suppression in semen over time. The same is true for adherence."

That's another point the Swiss researchers put into account: If there's poor adherence, another one of the three crucial criteria for unprotected sex isn't fulfilled.

Only if all three conditions are met, it's safe. Or as the Swiss say: the risk is negligible. Don't forget there has never been a single documented case where someone who's on meds has infected his or her partner, gays and straights included. So that's a most negligible risk. Even the study authors you quoted don't present such a transmission case. They talk about virus concentrations and theoretical risks, which is a totally different pair of boots.

Interesting topic this is.....There was enough medical jargon to make my eyes cross.... It would be nice if someone could just break it all down in plain layman's terms so those of us who can't make head or tails of it all could really make responsible decision. Bottom lining it all, it really comes down to the individual.

Lemme try...

If you're taking meds, then there are three conditions which have to be met to rule out transmission. The Swiss docs make it pretty clear where the limits are, and these limits are totally based upon your medical situation - no matter if you're a boy or a girl, gay or straight, young or old. If there are STDs present, you should use a condom. If your VL is detectable, use a condom. If your VL has been undectectable for less than six months in a row, use a condom. If you're not adherent, use a condom.

If you fulfill the criteria, but feel uncomfortable with the situation and still fear a risk, use a condom. It's your decision. But now you have a choice!

Hope this helps!

[RapidRod]

I don't know anyone in their right mind that would even take a chance of having unprotected sex with anyone that is known to be HIV positive when they are negative. I can't fathom anyone taking that chance.

[hartiepie]

I don't know anyone in their right mind that would even take a chance of having unprotected sex with anyone that is known to be HIV positive when they are negative. I can't fathom anyone taking that chance.

The studies are full of them. That's how they got the data.

Just for the record, I advocate condoms.

[John2038]

I don't know anyone in their right mind that would even take a chance of having unprotected sex with anyone that is known to be HIV positive when they are negative. I can't fathom anyone taking that chance.

I will (sorry) only to have babies (and the partner have something to say of course, and my doctor as well).
And if otherwise the condom break, then its good to know that the risk of infection is epsilon.

I also believe that the risk is more psychological than real (see graphs and studies).

This study is also interesting if we try to translate it to a POZ/POZ relationships (assumption!):

Between 2 POZ, undetectable since at least 6 months, having no STDs and being 100% adherent, the risk of super infection is epsilon. Do you feel the epsilon now ? 

[Teresa]

As the negative half in a poz/neg relationship, there is NO way I would have sex without a condom.

I guess according to this article that if the condom was to break I wouldn't be at so much of a risk as I thought I would be. That would be some peace of mind, I suppose, but i would still call the Dr and see what she thought.

Like others have said its just up to the individual as to how much of a risk you are willing to take. For me its using condoms each and every time.

[Iggy]

You are absolutely right. Sorry for the misunderstanding, but it was assumed (in my mind) as the details of this research have been discussed previously. The research have to be pursued for the others ocouple couples.

Interview in english of Pr Hirshel
Patients treated for HIV, with undetectable viremia, are no longer infectious: arguments for and against

http://papamamanbebe.net/a8205-patients-treated-for-hiv-with-undetectable.html

John,

You are kind of funny with this.  You  admitted that my point (that this study is selective and that you can't make such broad statements) and then in the same breath you repeat the falsity as declared in the headline of that report.

The bottom line is that the study is but one group's findings on a select population that needs to be explored and not tooted as a definite statement of HIV in general.

Did it ever occur to you that continued promotion of this study without the context of the broader truth is very similar to certain AIDS Denalists statements?  They have a habit of taking non representative findings out of context too.

[John2038]

Nice try Iggy.

Initial post:

HIV: unprotected sex are possible

..
This is the conclusion of a study of 393 heterosexual couples in which one partner is infected.

Three conditions must be met for the virus to not be transmitted through sexual contact.

[Iggy]

John,

When I brought up this:

Quote from: John2038 on 01 February 2008, 10:30:50

It gives the confirmation that being poz and having a normal life is possible.
It allows to more s- to more easily consider having a long term relationships with a s+, without having too fear so much.
It make this disease less awfull, give us energy, and hops.

I don't see it as doing those things at all.  I'm glad that this encourages you and I find very interesting findings that are worth exploring in this study, but I think you are reaching with these three above listed statements.

your response was:

Yes, but it's not published in this thread. 

While talking about the cases of infections while undetectable, Pr Hirshel says:

Despite major efforts, we found no cases published in the medical literature [of HIV infections while undetectable], which contains over 100,000 articles and books about HIV.

Source: http://papamamanbebe.net/a8203-viremie-et-contamination-bernard-hirschel-d.html

No. It's just a consequence of :
These Swiss renewed doctors have the know how and the expertise to publish such reports.

I believe that publishing such reports is not something you do without a very high degree of certainty.
I also believe that there is still a risk, but that this risk is comparable to any others in the life.
Do we stop driving car ? Finally, I say that this is a great news. A fantastic news. Up to both partners now to decide: risk 0 or epsilon. At least, we know now that the risk is epsilon (0.0..1%), and not let say 10%.

How am I making a nice try?  I said in the beginning and I repeat again - you making broad statements such as these based off of misleading data that does not have the full support of the scientific community (at least other studies that significantly back up this point) is misleading and it is damaging to real prevention efforts.

[John2038]

I have nothing to respond, your interpretation is biased. 

[Iggy]

I have nothing to respond, your interpretation is biased. 

I see...

[edfu]

Cerrid,

I can selectively quote as well as you to prove that the January 2008 study does indeed contradict the Swiss study.  For example:

"Prevention messages should stress the importance of condoms and other risk reduction strategies, regardless of whether a patient is taking effective anti-HIV therapy, recommend the investigators, as HIV transmission is possible even if a patient has an undetectable viral load in their semen....

"Most of the studies showed that anti-HIV therapy suppressed viral load in semen. But there was also evidence that some anti-HIV drugs did not penetrate the blood and semen with equal efficiency. But in ideal conditions, when men were taking an effective antiretroviral regimen, were fully adherent to their therapy, and did not have a sexually transmitted infection, then there was a 95% certainty that below 4% of men with an undetectable viral load in their blood would have a detectable viral load in their semen. However, the investigators note, 'these optimal conditions are rarely met outside of research settings.'...

"Men who are treated with anti-HIV therapy can develop drug-resistant virus in their semen, and there is evidence of multi-drug resistant strains of HIV developing in the genital tract but not blood....

"Furthermore, the investigators note that semen that has an undetectable viral load is still potentially infectious, and that cells in semen can contain HIV proviral DNA and can act 'as vehicles for sexual transmission of HIV.'...

"The investigators recommend that 'HIV prevention messages targeted to both infected and uninfected persons should communicate the importance of condoms and other risk reduction strategies regardless of HIV treatment status and at all stages of HIV disease....'"



 

[edfu]

UNAIDS and the World Health Organization respond to the Swiss study:

http://afp.google.com/article/ALeqM5j1FyuW1cJTGZubudNzH5DbgDH65w

[SteveA]

The only possible benefit I see to this study would be for Heterosexual couples where the couple was actually interested in conceiving a child during the safest possible window of conditions. Beyond that I'd still say safe sex is required.

[Sean Strub]

long-term non-progressors are individuals who have at least one of the sets of chromosomal deletions associated iwth much slower progression of the disease, although they are hiv positive. Indiviiduals with both sets of deletions appear to be associated with a near-certain inability to acquire HIV and they then not positive.  There is another category the poster might have meant, which is often called Exposed SeroNegatives.  People they know have been exposed and can even isolate viral particles from their bodies, but they have not sero converted and tested positive on the antibody test and it is assumed (largely untested) that they cannot pass the virus on to others as their dose was too weak to cause antibody reaction in thier own bodies.

[Sean Strub]

The othe rissue with the Swiss study is that it raises the question of when and to what extent are people with HIV ought be morally and lesgally obligated to disclose their status.   If this dramatically reduces the chance of transmission, perhaps to the level of average condom use, must serostatus be disclosed?  What if the risk of seroconversion much more, perhaps to once in a million encounters.  Must that be disclosed?  And the level of risk likely to be present in any sexual encounter depneds on the individuals, their specific sexual practicies and what is going on in their bodies at that time,in terms of infectivity and susceptibility.  Venues and partners impact the obligation to disclose.  When a 50 year old man with HIV has sex with a 20 year old, the elder's obligation to disclose is that much greater.  On the other hand, when that same 50 year old is in a sex club, where men are expected to grunt more than talk, disclosure is deemed not only unnecessary, but also specifically unwanted.

This announcement by the Swiss is an importnat one, perhaps a profound milestone for our community, the point where we enlisted the help of science to give us back our right to more normal lives.  That' why this is so threatening.

Sean Strub
PS I apologize for the typos, but I am on an unfamiliar keyboard nad am typing in the dark.  Ann or Andy, feel free to take license if you see obvious problems.  Thanks.

[planonstaying]

There are a lot of new infections in the western world where there is good  access to meds. Does this mean  all new infections are from the under/untreated/ignorant of status?  I know a lot of people have no idea of their status  but damn.  Transmission  rates arent that different from 1995 are they? I dont know that fact.   It sure would seem like a mantra  to scream for increased testing if that's the case. 

[racingmind]

This all seems like a "grabbing at straws" situation.  I'm poz and undetectable. My partner is negative.  There is no way in hell I would ever consider anal sex without a condom no matter what studies are out there to the contrary.  It's simply not worth the risk.  It would be a shame to find out that you were the exception to the rule....

[J.R.E.]

This all seems like a "grabbing at straws" situation.  I'm poz and undetectable. My partner is negative.  There is no way in hell I would ever consider anal sex without a condom no matter what studies are out there to the contrary.  It's simply not worth the risk.  It would be a shame to find out that you were the exception to the rule....

There is no way I would toss the condoms either ....


Ray

[aquariusfrance]

It would be good if we could leave condoms behind....  but I was infected by a girl who was on HAART meds, ... I saw her taking the meds in the restaurant before we spend " the night " together....  she said that it were "vitamins".... we had 3 times sex during that night... 1 time without condom untill she said - after I asked - that she was not on birth control pills....  and 2 times with a condom she took out of her purse of which I saw the next morning that it was a lambskin condom... not protecting for HIV....  18 days later i seroconverted and was diagnosed hiv positive...  vl load > 300.000 ...... CD4 1250 45 % they gave me HAART including Kaletra.... that's when I immediately  recognised the "vitamins" the girl had been taking in the restaurant.... the large orange Kaletra pill....  I had no other sex with other people in the 3 months before nor in the 18 days after this "night", exept with my real gilfriend with whom I was living with at that time.... and she turned out to be negative after I seroconverted.... we had a lot of sex together in the 18 days between that restaurant night and my seroconversion and she did not get infected even with my high viral load.... so I think it is more of  personal resistance to infection that plays a big role if you get infected or not. i think the girl that infected me was on meds since a long time as she was taking the 3 or 4 large pills as if it were really .... vitamins...  for info my real girlfriend left me after a couple of months and i am now living with a positive girl that I met on your poz personals website and we enjoy a lot of sex... without condoms.... and we are both not on meds with high CD4 and low VL... and I hope it stays like that for a long time to come.

[J.R.E.]

It would be good if we could leave condoms behind....  but I was infected by a girl who was on HAART meds, ... I saw her taking the meds in the restaurant before we spend " the night " together....  she said that it were "vitamins".... we had 3 times sex during that night... 1 time without condom untill she said - after I asked - that she was not on birth control pills....  .

Hi,


Just wondering, were you a member of the forums at another time. I seemed to have read same similar incident, quite a while back...


Ray

[newt]

I don't know anyone in a positive-negative relationship who use condoms apart from me.  But there must be, this is only 9 couples eh?

All the +ve folk are on treatment and have undetectable viral load.

This is (a) their choice(b) an unscientific sample -- clearly they have made their own risk assessment. 

I note:

1/ I tend to know "progressive" aka leftfield people -- I m not sure the science is a factor, they just don't wanna...

2/ There is no "right" answer to this question really, it is up to the people concerned

3/ They don;t -- ahem -- play away

4/ They's a mix of straight n queer folk

5/ 1 guy has ended up HIV-positive but, on reflection, he played away several times....hmmm

6/ 8 have maintained their sero-difference (and they are shagging)..none played away...hmmm

I personally..in truth I dunno, prob would end up being unintentionally inconsistent on condom use and therefore anxious, celibate or in a relatonship with another HIV-positive person (currently first option).

Science/informed opinions are not a good aid to anxiety management.

We aim to stage a London head-to-head of the Swiss lot n someone else to argue the case for and against later this year.  Meantime, if you get to/follow the BHIVA Belfast conference this Spring the community slot is on exactly this issue, and will hear from DR H or one of his confederates and a UK doc who is more cautious in his conclusions. This debate will be thoroughly reported and I will (remember Matt please) post a link to the write-up.

- matt

[BT65]

We aim to stage a London head-to-head of the Swiss lot n someone else to argue the case for and against later this year.  Meantime, if you get to/follow the BHIVA Belfast conference this Spring the community slot is on exactly this issue, and will hear from DR H or one of his confederates and a UK doc who is more cautious in his conclusions. This debate will be thoroughly reported and I will (remember Matt please) post a link to the write-up.

- matt

Matt, I look forward to your report.

[John2038]

A dangerous precedent in HIV
Published: Thursday, 24-Jul-2008

Infection with HIV could quadruple in certain populations if people with HIV follow potentially misleading advice contained in a statement from the Swiss Federal Commission for HIV/AIDS, University of New South Wales (UNSW) research warns.

The research from UNSW's National Centre in HIV Epidemiology and Clinical Research (NCHECR) calls into question the conclusions reached by experts from the Swiss Federal Commission for HIV/AIDS that stated that people with HIV receiving effective antiretroviral treatment could not transmit the virus to their HIV-negative partner through sexual contact.

"If the Swiss Commission's conclusions were adopted at a community level and resulted in reduced condom use it would be likely to lead to substantial increases in infection," says Dr David Wilson, a mathematical modeling expert from NCHECR.

The new research which is published in The Lancet this week (Friday 25th July) also notes potential legal implications for people who believe themselves to be non-infectious but go on to have unprotected sex and infect their partner.

Dr Wilson is the first author on a paper that predicts that HIV transmission over a ten-year period would be four times higher in serodiscordant couples who abandon condom use than if condoms had been used.

The research is based on mathematical modeling in a population of 10,000 couples where one is HIV positive and the other is HIV negative. It found that there would be 215 female-to-male transmissions, 425 male-to-female transmissions and 3,524 male-to-male transmissions in each 10,000 couple group.

"While it is true that the individual risk of HIV transmission per act is fairly small for people on antiretrovirals, the risk of transmission over large numbers of acts could be substantial," says Dr Wilson.

"When the viral load goes down in the blood due to antiretrovirals, it might not go down in the semen or vaginal and anal fluids," says Dr Jonathan Anderson, the president of the Australasian Society for HIV Medicine, who is also based at NCHECR. "This may be confusing. Antiretrovirals can complement consistent condom use but replacing condom use with medications may end in disaster."

Other factors that increase the risk of HIV transmission include incomplete adherence to therapy, changing drug regimes and infection with other sexually transmitted diseases.

"People who are diagnosed with HIV infection tend to reduce their number of new sexual partners, use condoms more consistently and disclose their status to their current partner or partners," says Dr Anderson. "We are concerned that there may not be the same behaviour if people believe themselves to be non-infectious."

The Australian Federation of AIDS Organisations, the National Association of People Living with HIV/AIDS, the Australasian Society for HIV Medicine and NCHECR have produced a statement on antiretrovirals and infectiousness.

Australasian statement on antiretrovirals and infectiousness

Consistent use of effective antiretrovirals will, in most cases, lead to an undetectable viral load, as measured in blood, semen and vaginal fluids. As a result, the average viral load of the community of people living with HIV will be reduced.

By reducing the viral load, antiretrovirals will also complement the benefits of consistent condom use and effective STI detection and treatment, in preventing HIV transmission that may otherwise occur due to condom failure.

However, there are no data to suggest that a population HIV prevention strategy based solely or predominately on the use of antiretrovirals and associated with a reduction in condom use, will lead to fewer people becoming infected in the Australian and New Zealand populations, especially in the context of rising rates of sexually transmitted infections.

The Australian Federation of AIDS Organisations, the National Association of People Living with HIV/AIDS, the Australasian Society for HIV Medicine and the National Centre of HIV Epidemiology and Clinical Research (NCHECR)

http://www.news-medical.net/?id=40257

[edfu]

Thank you, Australia, for some sanity in this controversy.   

[John2038]

The mathematical model (without consideration of the drugs) found that the cumulative probability, with an average of 100 per annum sex without protection, was:

*   0.22% per annum for transmissions woman to man
*   0.43% for transmission from man to woman
*   4.3% for transmission between men.

[planonstaying]

   

May 22, 2008

HIV Infection Often Results From Single Copy of Virus in Cell



While such sexually transmitted diseases as gonorrhea and syphilis invade the body with as many as 10, 20, 100 or 200 bacteria, , scientists from the University of Alabama at Birmingham (UAB) have found that most HIV infections are the result of a single copy of the virus penetrating the body’s defenses, The Birmingham News reports (al.com, 5/20).

“In the vast majority of cases a single virus has gone across the sexual mucosa, and that virus has infected a cell,” said George M. Shaw, lead author on the UAB study published online on Monday by the Proceedings of the National Academies of Science. “That cell then makes a lot of virus. Now you just have a firestorm of HIV replication in the next couple [of] weeks. Very quickly the person is populated by millions of viruses.”

In addition to breaking new ground in understanding the HIV transmission process, this study also showed why condoms are so effective in preventing infection and why efforts to develop viable microbicide gels have proven less so. Shaw told The Birmingham News that unlike microbicides studied thus far—which may not stop all individual viruses from entering the body—a properly used condom stops all of them.












 That would suggust there is no  fully safe BB   

[John2038]

Systematic review unable to confirm or deny Swiss statement on infection risk with undetectable viral load
A systematic review of studies of serodiscordant couples where the HIV-positive partner was on antiretroviral treatment could neither confirm not disprove the recent Swiss declaration of a negligible risk of HIV transmission from a pesron on treatment with undetectable viral load, according to data presented during Thursday afternoon’s late breaker sessions at the XVII International AIDS Conference in Mexico City.

However, the review revealed some new information – that HIV transmission, from an individual not on treatment, had occurred in a 2005 Spanish study at a blood plasma viral load of 362 copies/ml.

The Swiss statement – which has caused controversy since it was published in January 2008 and which was discussed at a pre-conference satellite session last week – asserted that the per sexual act risk of HIV transmission from an HIV-positive individual on treatment with an undetectable viral load and no sexually transmitted infections to their HIV-negative partner is below 1 in 100,000.

To assess whether this was indeed the case, investigators from the University of Bern conducted an extensive search of published studies and conference presentations involving serodiscordant couples since 1996, when effective antiretroviral treatment first became available.

Out of a total of 252 published articles and abstracts only 14 were found to be potentially eligible due to duplication, irrelevant topic or study design, or lack of additional data from the study authors – of these, seven were published or were about to be published, and seven were conference abstracts.

However, their systematic review did not identify any studies that fulfilled the exact criteria of the Swiss statement – where the HIV-positive partner is on antiretroviral treatment, with an undetectable viral load (below 40 copies/ml) for longer than six months with no other sexually transmitted infection (STI), which they defined as syphilis, chlamydia, gonorrhoea, or genital herpes.

Consequently, they included cohorts where the HIV-positive partner was not on treatment; that defined a higher threshold of undetectable viral load (400 copies/ml); and/or where the HIV-positive partner’s STI status was unclear.

The greatest number of discordant couples in these studies came from Africa (1822) with only 424 from Europe. Just one study included gay men or other men who have sex with men (accounting for just 43 couples) with the remaining thirteen cohorts including heterosexual couples. However, none of these studies included detailed information about the specific sexual acts they practised – oral, vaginal and/or anal sex.

Only nine cohorts reported use of antiretroviral therapy in the HIV-positive partner, accounting for 428 couples.

Only one study, from Castilla and colleagues in Spain, published in 2005, reported on HIV-positive individuals on antiretroviral treatment with an undetectable viral load, although the STI status of these individuals remains unclear. In this study, there were no transmissions per 100 person-years from 283.2 person-years of follow-up.

The authors of the systematic review calculated a summary estimate of the HIV transmission rate per 100 person years with a 95% confidence interval (CI) resulting in an upper confidence interval of 1.06 transmissions per 100 person-years.

In the four studies that included HIV-positive individuals with a viral load below 400 copies/ml who were not on treatment but where there was no clear information on STI status, only one transmission occurred over more than 600 person-years. This resulted in a transmission rate of 0.16 per 100 person-years and an upper confidence interval of 1.16 transmissions per 100 person-years.

This single instance of HIV transmission occurred at 362 copies/ml in the blood plasma viral load. This is new information not included in the original article in Journal of Acquired Immune Deficiency Syndromes. Previously, the highest blood viral load threshold published for HIV transmission was around 1500 copies/ml by Quinn and colleagues.

She noted that a recent Australian study, using a mathematic model that assumed there was no threshold viral load level below which transmission would not occur, had concluded that transmission may still occur from gay men who fulfilled the provisos of the Swiss statement and who practised anal sex.

In an online editorial responding to this Australian modelling study, Swiss Federal AIDS Commission President Professor Pietro Vernazza strongly suggests that the Australians’ assumptions are flawed, and highlights the accompanying editorial by Garnett and Gazzard, which pointed out that even if the assumptions in the model were correct, the risks of transmission over 100 sexual acts were similarly low for 100% condom use and unprotected sex on treatment with an undetectable viral load and no STIs.

Systematic review lead author Suzanna Attia conceded that, “a body of indirect evidence suggests that HIV transmission at very low viral loads is very rare. We did not identify any studies or case reports where transmission occurred below 40 copies/ml.” However, on the basis of current evidence, she and her co-authors were unable to confirm or disprove the Swiss statement’s suggested 1 in 100,000 risk of HIV transmission for an individual taking effective HIV treatment with no STIs.

She concluded by stressing that their review was ongoing, and it was hoped that incoming data would allow them to increase the precision of their estimates. 
http://www.aidsmap.com/en/news/F2E2BCFF-26CF-4400-B5AC-0549FBAC940D.asp

[newt]

The mathematical model (without consideration of the drugs) found that the cumulative probability, with an average of 100 per annum sex without protection, was:

*   0.22% per annum for transmissions woman to man
*   0.43% for transmission from man to woman
*   4.3% for transmission between men.

The more correct assertion here is perhaps for the first two between men and women having vaginal sex and for the last between men and women OR men and men having anal sex.

Boy, you don't wanna know how fragile the rectum is re: HIV infection.....

- matt

[edfu]

Boy, you don't wanna know how fragile the rectum is re: HIV infection.....

- matt[/font]

Well, I would disagree with that, Matt.  It is imperative for better prevention that everyone--especially MSM-- knows how fragile the rectum is in this regard.  The fact that this biology is not more widely promulgated in safer-sex campaigns is a scandal.

Compared to unprotected vaginal intercourse, unprotected anal intercourse is 10 to 100 times more likely to transmit HIV.  The lining of the rectum is far more fragile than that of the vagina, and the cells that are open to infection are much closer to the surface.  During anal intercourse this lining may rupture, allowing HIV to break through and infect cells.   

[Tempeboy]

Tricky topic - great thread.  Some more for the mix:

1.   Undectable does not equal zero

2.   Not all meds achieve undectable viral load in seminal plasma - even if a given combo acheives and maintains undetectable plasma viral load in
      blood. 

3.   This is thought to be because not all meds penetrate the seminal vescicles equally - a bit like penetration of the blood brain barrier.

4.   Undectable viral load in seminal plasma does not equate to the absence of HIV in the tissues of the genitals, urinary system or rectum.

5.   If these tissues are compromised because of a lesion resulting from an STI, UTI or other trauma HIV is released into surrounding fluid (blood or
      cum)

6.   The presence of a lesion can be symptomatic or asymptomatic - ie known or unknown.

7.   There are thought to be other unknown causes of viral blips in blood - related causes in cum not inderstood

So.................

If you are able to take certain meds ie allowing for side effects, resistance and availability

and

You can guarantee 100% medication adherence for yourself and partners

and

If you can guarantee absence of STI's, UTI's or trauma in yourself and your partner(s)

and

You have a teflon rectum

and

You are happy to take the risk of superinfection, other STI's including HCV  -  10-13% of people with HIV are HCV positive as well - higher in areas without access to clean condoms and injecting equipment.

...........then give it a go.  The theory that these strategies might work fall down when we consider that they all hinge on the ablility of the participants to be open and honest about sex with all of their partner's. 

I can hear it now 'No we don't need to use condom's, I'm undetectable and STI free.  Here have another line and let's........"

This model does have proven success with couples trying or needing to conceive naturally.  During the time when the coupld plan to conceive the positive partner is on meds with 6months consistent undectable results and the neg partner is given PrEP.  Couples can choose to conceive naturally or 'spin the sperm' also called sperm washing.  This is good news for people who don't have access to other family planning options but should not equate to messages suggesting that we can dispense with condoms.  It is important to note also that couples trying to conceive are good will do just about anything for a healthy baby.

[John2038]

I posting this here to have all in one thread.

Shouldn't this a case be reported as HIV transmission occurring while undetectable ?

A 50-year-old GWM was diagnosed with acute HIV seroconversion in November 2003 after failing post-exposure prophylaxis (PEP). His risk factor for HIV infection was anal receptive intercourse with ejaculation after a broken condom occurred on 9/21/03. His partner was known HIV positive, and had by report an undetectable viral load (VL) on an unknown antiretroviral regimen. The patient reportedly received 28 days of PEP with Combivir (CBV) + lopinavir/ritonavir (LPV/r, Kaletra). The time after exposure to starting PEP was unclear but was likely within 24 hours. He reported complete adherence with the PEP regimen. In November (11/26/03) the patient experienced night sweats and fatigue with a negative HIV antibody test and a high VL. He was enrolled in the Options research project for recent HIV seroconverters.

Source

[newt]

The trouble with case reports is the report bit. Given the man's extensive very treatment related mutation profile it is at least possible we do not have the whole truth.

There's also this (perhaps more compelling) report:

Case report of sexual transmission when viral load suppressed to <50 copies/mL in monogamous male couple
http://www.i-base.info/htb/v9/htb9-9-10/Case.html

Nonetheless, viral suppression reduces the risk many, many hundreds of times, and, from a public health point of view, it is a good question whether it is right to emphasise very small risks.

If oral sex between men of unknown HIV status is not considered a major driver of the epidemic then sex between people of different antibody status where the HIV-positive one consistently has very low viral load is not one either. The risk is comparatively the same (or even less on current estimates). But that don't mean there will be no cases of transmission by either route.

Nerdy types interested in heterosexual risk estimates may enjoy:

Common estimate of heterosexual HIV transmission risk sometimes far too low
http://www.i-base.info/htb/v9/htb9-9-10/Common.html

- matt

[mecch]

I have been doing an survey of the limited number of gay guys I can manage to chat with who are hiv positive, willing to say so, and willing to answer this question: do you use condoms when you have sex with another hiv+ guy.  Most say No. Rarely. Why bother.
Maybe my survey is fucked on a number of counts.
Anyhow, I guess I thought it might be easier to have sex with other poz guys, but now I'm thinking the safer sex questions are going to be just as challenging with hiv+ guys as with a hiv- guys.  Shit.

[John2038]

German NGO endorses treatment as prevention
Tuesday, April 21, 2009

Deutsche AIDS-Hilfe, the largest HIV voluntary sector organisation in Germany has issued a position paper on the role of treatment in HIV prevention which broadly echoes and supports last year’s landmark Swiss statement on the limited risk of a person taking effective HIV treatment passing on their infection.

Whereas the Swiss had stated in definitive terms that people on effective combination therapy and without any sexually transmitted infections cannot sexually transmit HIV, the German paper describes transmission in these circumstances as “unlikely”, and suggests that this approach is as effective as the use of condoms.

Moreover, the Germans stress the importance not only of sexually transmitted infections, but also of other health problems which can damage mucous membranes, and so increase the risk of HIV transmission.

January 2008’s statement from leading Swiss HIV doctors argued that HIV-positive people who were taking antiretroviral therapy with an undetectable viral load in their blood and no sexually transmitted infections could not pass on HIV to their sexual partners.

According to Deutsche AIDS-Hilfe, if the following conditions are met, the sexual transmission of HIV is unlikely:

    * The HIV positive partner’s viral load has been undetectable for at least six months.
    * There is good adherence to antiretroviral treatment.
    * There is no damage to mucous membranes.


They say that in these circumstances, the risk of HIV transmission is negligibly low, and is comparable to the transmission risk with 100% condom use. If an individual combines condom use with controlled viral load, then the transmission risk is described as close to zero.


More

[bocker3]

    * There is no damage to mucous membranes.

Yet the sexual intercourse itself could damage mucous membranes................... 
Seems like this condition alone still leaves more risk than I would be willing to take, as you can't ever know if you've "broken" the condition until after.

Mike

[dtwpuck]

I have been doing an survey of the limited number of gay guys I can manage to chat with who are hiv positive, willing to say so, and willing to answer this question: do you use condoms when you have sex with another hiv+ guy.  Most say No. Rarely. Why bother.
Maybe my survey is fucked on a number of counts.
Anyhow, I guess I thought it might be easier to have sex with other poz guys, but now I'm thinking the safer sex questions are going to be just as challenging with hiv+ guys as with a hiv- guys.  Shit.

Meech...   I have been poz for 13 years.  In the first 11 years of that time I  had sex more times than I can count with other poz guys.  I confess to serosorting.  Not once did any other poz guy want to use a condom.  Not once.  Ever.    You'd think that I'd run into someone who wanted to.    Anyway, it never happened.      So maybe your survey is fucked.  Maybe not.  But, I personally believe that when the rubber hits the road, so to speak, men will be men, and will choose not to use them.   

[lonewolf]

As uneducated as I am and only being POS for the past 3 years or so.
To me the bottom line and common sense is:
We are infected with HIV,  an incurable virus, undetectable or not.
Safe sex is ONLY with a condom.
I certainly would not want to go with the mindset that I am "undetectable" and can fuck around as I see fit, whether it be hetero, or bi, or gay.   

Until they find a cure to completely ELIMINATE  this virus from every cell of my body,  safe sex is the only way to go, for me, and for my partner.

[edfu]

Recent frightening studies have shown almost universal (70-98%) anal infection with HPV (human papilloma virus) amongst gay men, with a rate of 70% in HIV-negative men, and 94-98% in HIV-positive men:

http://www.aidsmap.com/en/news/44684313-9869-4FE9-BFE4-2B7CB5859216.asp

http://www.aidsmap.com/en/news/1D283AC1-8C8B-4DDB-88EB-E490C194B13D.asp

http://www.aidsmap.com/en/news/7C545A52-BBA5-4CCE-AC5B-92E6437E0E66.asp

It seems to me that these findings indicate an extremely high potential for damaged anal mucous membranes.  How can it ever be assumed, therefore, that a gay man does not have low-grade anal lesions or high-grade pre-cancerous lesions?     

The failure of Deutsche AIDS-Hilfe to address this problem is simply astonishing to me. 

[Ann]

January 2008’s statement from leading Swiss HIV doctors argued that HIV-positive people who were taking antiretroviral therapy with an undetectable viral load in their blood and no sexually transmitted infections could not pass on HIV to their sexual partners.

How odd. Maybe Deutsche AIDS-Hilfe read a different version of the Swiss Statment to the one I read. I could have sworn that the Swiss Statement I read stated that it was UNLIKELY for a patient meeting their criteria to pass their virus on, not that they COULD NOT pass their virus on.

But anyway, this article isn't looking at poz on poz sex (I don't understand where the poz on poz comments have come from), it's looking at poz on neg sex. It's foolish for them to write this article in such a way that it makes it sound ok to have poz/neg sex without condoms, as long as the poz partner is and has been undetectable for six month or more. I would have been happier if the emphasis was on reassuring people that a broken condom on an insertive poz partner would be unlikely to result in transmission to the neg bottom or neg vaginal partner.

It makes me worry that some poz people will take this as license to bareback with negative partners, given the way this article is written. While it may be appropriate in the context of a long-term, monogamous relationship where the pros/cons and risk levels have been thoroughly discussed and agreed upon, it's not appropriate AT ALL to release a news item that makes it sound like it's ok right across the board.

~sigh~

Ann

[mecch]

 unprotected sex between HIV+ and HIV+ gay men seems to be a quagmire, and incredible difficult subject, if not act (what could be more "natural").

Ann says "It makes me worry that some poz people will take this as license to bareback with negative partners, given the way this article is written."

Ann, ask around London. Its already true in some gay capitals.  And I know a few gay HIV+ guys in switzerland who will bareback anyone, HIV+ or HIV-, under the rationale, "I'm undetectable."  They do NOT annouce this, but do respond honestly when questioned.  When not announced, the rationale is, "HIV- people should protect themselves, and anyway, I am undetectable."

I know one untreated HIV+ guy who will bareback with anyone and he also does not announce.

I think in a few years, it will be quite common for an all new kind of sero-sorting. (Is it already?)

We will have:
HIV- (and recently and regularly tested)
HIV+ and untreated
HIV+ and undetectable
"Don't know"

These HAART treated guys I refer to above almost promote themselves as "undetectable" in a way that pushes many people's buttons.

We will see who will be doing whom, and whether safe sex or not.

William F. Buckley (RIP), odious type, in 1986, proposed tatooing HIV+ status and it was horrible and interesting suggestion because the point was, we need a lot more honesty and clarity but there is an human inclination to not ask, or not tell.  We got safe sex out of that, which works, but then it started to all be negotiable again (as a population, when for many never negotiated as an individual). And then infections rose again in the Gay community.

I was reading an article recently about HAART developments and the scientist said, well, isn't it interesting that we have a very treatable disease, that is transmissable, and keep asking the question, when to start the treatment?   

The other thing is that we're at the point now where we've got this disease that's quite easily treatable with very effective treatment. I'm trying to think of some other infectious disease where you would have to prove that it was OK to treat.

HIV is unique in that the burden of proof seems to rest on those who want to treat early. Whereas for another infectious disease, you'd say, "Show me that I can wait. Show me that it's safe to wait." The reason for that is historical. It's not medical.

It's because first we didn't have treatment. Then we had lousy, ineffective treatment. Then we sort of had lousy, effective treatment. Now we have good, effective treatment. And because it's gone in that direction, we've approached it from the opposite direction, where the default is not to treat, and what you have to prove is a reason to treat.

http://www.thebody.com/content/confs/croi2009/art50660.html

So treatment has individual health benefits, at the right time, and looks like the pendulum is going to swing back to treatment at acute phase. But the quagmire results because doctors and researchers are increasingly talking about how effective treatment has benefits for a POPULATION.

In a perfect world, if everyone were routinely tested and universally treated if infected with HIV, how long before the epidemic runs its course and number of new infections drop dramatically??

The only problem with that is, yes, people have the right to refuse treatment. But then, do they have the "right" to all the fun and games of "unsafe" sex?

Does ANYONE know statistics from Berlin, recently. BB is quite the norm in cruisy situations. Have infections gone up, or are most HIV+ people "undetectable" and infection rates staying the same?

What a quagmire.

[Ann]

Mecch,

One of the problems I have with poz, undetectable people barebacking with negs is that chances are going to be better than usual that they're going to have one of the bacterial STIs - and the presence of STIs have been shown to increase the amount of virus in the genital tract. We already know that men can have detectable levels of virus in their semen, even though they are undetectable blood-wise.

A quagmire indeed.

I'm not so sure about the push to treat right away, even when numbers don't indicate. Although the meds today are better, we only know about them in the short-term so far. I'm twelve years med free and I'd be pretty damned pissed off if someone tried to tell me I HAD to go on treatment because of the onward-transmission factor. I'm an adult, I use condoms with people of unknown or negative hiv status. I feel like it's saying - here, take these heavy-duty meds that may or may not come with side-effect, just because we can't trust you to use condoms.

Total nanny-state thinking.

Maybe we'd just do better to shut these idiots up (like Deutsche AIDS-Hilfe) who claim that the Swiss Statement says that undetectables CANNOT pass their virus on - because it's simply NOT TRUE.

Ann