At a recent medical conference, doctors debated whether men living with HIV who have an undetectable viral load should be advised to wear condoms.
Dr Lisa Winston argued that condoms were still needed for three main reasons:
- Condoms prevent transmission of other sexually transmitted infections (as well as HIV). These infections are not always easy to treat (e.g. drug-resistant gonorrhoea) or without serious consequences (e.g. hepatitis C).
- HIV that is undetectable can become detectable, for a variety of reasons including missing doses of antiretrovirals and concurrent illnesses.
- HIV transmission is theoretically possible when viral load is undetectable in plasma or semen. "If you observe enough people for a long enough period of time, you probably will see occasional transmissions – they will be rare, but they are likely to occur," Dr Winston said. "What is your appetite for risk when advising patients?"
Countering these arguments, Dr Roy Gulick reminded the audience of the many studies of HIV transmission within serodiscordant couples which have not identified any linked infections when the HIV-positive partner was on treatment with an undetectable vial load. These include the key randomised study known as HPTN 052, the PARTNER study which has data on 58,000 sex acts and a meta-analysis of six studies with a total of 7000 couples.
"Lisa tried to scare us, as people have been doing for many years," Dr Gulick said. "We should not spend time worrying about things that don't happen very often at all. I've presented data on more than 15,000 serodiscordant couples, all suppressed on antiretroviral therapy. How many transmitted HIV to their seronegative partner? Zero."
Nonetheless, two-thirds of the audience of clinicians voted to recommend that HIV-positive men with undetectable viral load should always wear a condom. It’s possible that healthcare providers may be more risk-averse about health-related behaviour than the population at large – especially when it comes to sex, and even more so gay sex.
For more information, see NAM’s factsheets ‘Viral load and transmission – a factsheet for people with HIV’ and ‘Unprotected sex’.