My patient wants to know if he can have sex with his HIV-negative partner without a condom. My patient has an undetectable viral load on his medication. His T cell count is normal.
What should I tell him?
The risk of transmitting virus is very low. But would anyone say it’s nonexistent? I don’t think so. In Switzerland not long ago there was an article that supported unprotected sex in monogamous HIV-positive couples who have undetectable viral loads. We are perhaps more conservative than the Swiss? That seems like an odd notion!
I continue to advocate for safer sex practices with all my patients, even those who have undetectable viral loads. It may be overly conservative at this point and I usually acknowledge as much when I’m speaking to patients. But for now I feel it is the best advice to try to keep my patients safe.
Unfortunately the monogamy issue can be a very big elephant in this room. On more than one occasion I’ve had a patient acknowledge that they or their partner has had sexual encounters outside of their primary relationship. Patients have come in with new infections with syphilis, chlamydia and gonorrhea. Even with a condom Herpes can be transmitted from skin against skin. For partners who are serodiscordant (one with HIV and one without) the risks of not-monogamy combined with not using a condom can be life-altering. For couples who are both HIV positive there is the risk of transmission of resistant virus; even when that risk is very, very small.
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Very thoughtful and informative narrative. Thank you for discussing a topic that many people are reluctant to talk about. The fact of the matter is that people are not always honest in many parts of their lives but sexual dishonesty may result in life altering infections. We are a complicated species – Swiss or not.