How should serodiscordant couples show intimacy?
Do they need to use condoms to prevent HIV transmission? Is treatment as prevention enough? What about PrEP (pre-exposure prophylaxis)? On his personal Tumblr, Joel Gallant, M.D., M.P.H, an HIV doctor at Southwest CARE Center in Santa Fe, New Mexico, answers questions from people living with HIV who are concerned about a number of issues, including undetectable viral loads and safer sex practices.
Hi Joel! I'm having trouble and feel like I struggle with counseling around condoms versus no condoms in serodiscordant couples vis-Ã -vis the HPTN 052 trial. What is your spiel? I know monogamy is key here, but I would love to know how you present this to your patients. I know there is a camp that feels condoms are necessary regardless of the data given the small risk ofinfection, but I feel that's so impractical in certain scenarios. Help!
I tell patients that having an undetectable viral load reduces the risk of transmission either to zero or very close to zero, based on the HPTN 052 and the PARTNER studies. I add the caveat that a viral load that was undetectable 3 months ago may not be undetectable today. But in someone whose virus has been suppressed for several years, a sudden, unexplained failure is extremely unlikely. Therefore, from an HIV standpoint, I view having an undetectable viral load as a form of "protected" or "safe sex" --possibly more protected and safer than a condom, which can break or be used incorrectly.
Therefore, in talking to a stable and monogamous discordant couple in which the positive partner's viral load is suppressed, I present condoms as an option, but I tell them that having sex without condoms is a perfectly reasonable choice to make. If they're not monogamous, then my counseling is somewhat different. If the HIV-negative partner has other partners, he should consider PrEP to avoid HIV infection and/or condoms to prevent infection with both HIV and other sexually transmitted infections [STIs]. Likewise, if the HIV-positive partner has other partners, he should use condoms to prevent STIs.
Theoretically, if both partners consistently wore condoms outside their relationship, they could dispense with the condoms when they're together, though people rarely follow rules so perfectly. In non-monogamous relationships, the introduction of STIs into the relationship is always a risk.
Paul Semugoma MD.