Article by Shay Keating, published for Aids West.
Maybe I’m getting old, reminiscing about the past, good and bad. I remember being a lowly research Fellow in the University of Berkeley in 1984: a great time in my life, my first time living outside Europe. 1984 was not such a good time for others though. It was the year the Human Immunodeficiency Virus (HIV) was identified as the cause of what was later to become known as Acquired Immunodeficiency syndrome (AIDS). In the coming years, large cohorts of the young sexually active population, particularly men who have sex with men (MSM) were wiped out.
Moving 30 plus years on to 2015, HIV disease is not curable – yet, but is a very treatable infection, if diagnosed before advanced immunodeficiency has manifested itself clinically. Now, the majority of people in the developed world living with HIV are on appropriate medication, anti retroviral therapy (ART) that can almost guarantee that their disease is not progressing: they have healthy immune systems and are effectively not infectious to others. As I alluded to in a previous article, in 2008, the Swiss National AIDS Commission issued a statement that ‘an HIV-infected person on ART with completely suppressed viraemia (“effective ART”) is not sexually infectious, i.e. cannot transmit HIV through sexual contact’. There were some caveats to this assertion however
- The person must be adherent to ART, the effects of which must be evaluated regularly by the treating physician; and
- The viral load must have been suppressed below the limits of detection (i.e. below 40 copies/ml) for at least six months; and
- There are no other sexually transmitted infections (STIs).
Now we have a different playing field and with this come some questions. One of the most commonly asked is ‘is it safe for an HIV positive person to have sex with another HIV positive person?’
Over 40% of men who have sex with men (MSM) diagnosed with HIV in the US have unprotected sex but there was evidence that those engaging in unprotected sex were attempting to limit the risk of HIV transmission to partners by employing the strategy of “serosorting” (sex with other HIV-positive men). There was no evidence that clinical factors such as adherence to HIV treatment, or an undetectable viral load affected unprotected sexual activities. Following a HIV diagnosis many people reduce their HIV risk behaviour, but others continue to have unprotected sex and this may involve a risk of HIV transmission to others, or exposure to sexually transmitted infections.
By serosorting, people can be comforted in the fact that they will not be stigmatised: their sex partners are ‘in the same boat’. Or are they? Back to the Swiss Statement. For someone to be non infections with an undetectable viral load, they must be on ARVs and be seen regularly in HIV services usually twice to three times a year. Probably just as important, they should not have another STI at the time of sex which could theoretically increase the viral load particularly in genital secretions. Given a breakthrough in viral load and possible rise in infectiousness there is a theoretical risk of super infection of the partner with a ‘strain’ of HIV that they have never been exposed to. Again, theoretically this super infection could lead to failure of their current ART regimes.
The second potential disadvantage of serosorting and not practicing safer sex is transmission of other sexually transmitted infections (STI)s such as chlamydia, gonorrhoea and syphilis. Treatment of syphilis can be complicated in the setting of HIV infection and the risk of neurosyphilis is higher in HIV positive individuals. It has been shown that serosorting may contribute to high rates of bacterial STIs. It has also been reported that serosorting has been linked with the emergence of hepatitis C infection in the MSM population in the UK and Ireland.
Sometimes you just have to ‘go for it’. Two HIV positive partners in a monogamous relationship: enjoy life and each other.