If my viral load is undetectable, do I have to use condoms?
In my work in AIDS Action’s Health Library, I’m often asked this question.
Last week, a group of Swiss HIV experts issued a statement basically saying: “No, condom use isn’t necessary – provided that certain other conditions are met.” [Emphasis mine]
Before going into more detail, I think it’s important to note that some other expert groups have disagreed with the Swiss group’s conclusions. The U.S. Centers for Disease Control and Prevention (CDC) issued a brief statement, saying that the CDC “underscores its recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners.” Likewise, UNAIDS and the World Health Organization stated that, to prevent transmission of HIV, they “strongly recommend a comprehensive package of HIV prevention approaches, including correct and consistent use of condoms.”
So, what exactly did the Swiss experts say? And why is it controversial?
In brief: Based on their review of several medical studies, the Swiss group concluded that an HIV-infected person who is on HIV treatment and has a consistently undetectable viral load “is not sexually infectious, that is, cannot transmit HIV through sexual contact.”
However, according to their statement, the following conditions must also be met:
• Their viral load must be undetectable (<40 copies) for at least 6 months.
• The person must have no other sexually transmitted infections (STIs).
The Swiss group also acknowledges that “medical and biologic data available today do not permit proof that HIV infection during effective antiretroviral therapy is impossible,” but they believe that the risk is “negligibly small.”
Critics of the Swiss statement have emphasized that research on HIV transmission and viral load has focused on heterosexual couples and vaginal intercourse – and does not necessarily apply to anal intercourse.
A number of people have also pointed out that, even if the Swiss experts are right, their conclusions about unprotected sex would apply to only a small number of HIV-infected persons: people who have excellent adherence to their HIV regimen, a consistently undetectable viral load, and no other STIs.
Practically speaking, the “no STIs” restriction could probably be met only within a monogamous relationship in which both partners were tested for STIs before stopping condom use. STI testing would be essential, because many people with STIs have no symptoms.
The bottom line for me:
Several studies have shown that reducing a person’s HIV viral load tends to reduce their risk of transmitting the virus. This is very heartening, but it does not mean that people with undetectable viral loads have no risk of transmitting the virus.
Given the limitations of current data, I personally believe it would be unwise to endorse a “no-condoms-needed-if-your-viral-load-is-undetectable” approach.
However, recent studies on viral load and HIV transmission give reason to hope that, if effective HIV treatment were widely available worldwide and properly used, the number of new HIV infections could be substantially reduced.
Universal access to treatment could be an important element in a comprehensive HIV prevention strategy that would include widespread access to HIV testing, use of the full range of existing prevention techniques and technologies, and the continued research and development of new prevention technologies, including microbicides and vaccines.
If you’d like to read more about this topic, check out the following links:
“Swiss experts say individuals with undetectable viral load and no STI cannot transmit HIV during sex.” - This article from the aidsmap.com website has a detailed summary of the Swiss experts’ statement.
“CDC underscores current recommendation for preventing HIV transmission.” - This is the brief CDC statement made in response to the Swiss report.
“Statement by WHO and UNAIDS: Antiretroviral therapy and sexual transmission of HIV.” - This is the WHO and UNAIDS response to the Swiss report.
“Experts say positive people on effective HIV meds aren’t sexually infectious.” - This is POZ’s article about the Swiss statement. The many comments posted after the article express a wide range of opinions about this news.
“Reactions to the Swiss news about ARV’s.” – This blog item contains a number of reactions to the Swiss statement. The Lifelube blog also has another posting worth looking at: “Swiss deconstruction - Undetectable = safe?”
