After much consideration, one feels obliged to write this article and I fully expect to be criticized. To the point, in January 2008, a prestigious panel of experts from Swiss Federal Commission for HIV/AIDS have produced the first-ever consensus statement saying that HIV-positive individuals on effective antiretroviral therapy or completely suppressed virus in the blood, and without sexually transmitted infections (STIs) are sexually noninfectious (Bulletin of Swiss Medicine); they cannot transmit HIV through sexual contact.”

In laymen’s terms, this means that barebacking among HIV infected persons who are on the cocktail and have undetectable viral loads, would not transmit HIV to their partners.

History

Sexual behavior has been in evolution for each one of us personally, and for the gay community. We’ve tasted sexual revolution within the AIDS era dynamic.

Prior to the AIDS epidemic, there was little caution during sex and places such as bathhouses were a booming business. When the AIDS epidemic hit, individuals were in fear of contracting the virus and practiced safe. HIV was at that time, an incurable, progressive disease. In fact, bathhouses were closed in various cities, and clientele dropped sharply. Bathhouses were felt to be a reservoir for HIV transmission, though none were closed in Chicago.

Real progress finally occurred in the field of HIV treatment with the arrival of the “cocktail” and coincided with patients achieving undetectable levels of virus. The practice of safe-sex was still heavily promoted, but this eventually led to a “safe sex fatigue.” Safe Sex Fatigue (I am coining here, and SSF for short) is common. Some individuals felt condoms were an inconvenience, not to mention the reduction in pleasurable sensations during anal intercourse. Not uncommon, condoms cause some guys to loose their boners (erections).

Confronting safe sex, too many HIV-positive individuals avoid having the “conversation” about their HIV status. They’ve grown tired of the need to re-assure their negative partners about reduced transmission. There’s already been the consensus in our community that patients being undetectable, only remotely pose risk for HIV seroconversion. Anyhow, oral sex or blow jobs, rimming or ass licking, deep French kissing or smooching has never been considered to be much HIV risk, and in my mind has never been adequately proven to cause HIV infection. However, commonly, a solution for HIV-positive men had been to “bottom” for someone HIV negative, thereby further limiting exposure to their partner.

It is unfortunate, that guys avoid discussing their HIV status when hooking up. We are at the point that encountering HIV is common and not longer considered a “big deal” for most. It can actually be a very positive experience for a partner to disclose status and have a discussion. In particular, it is of great relief to both partners when discovering what they’re each dealing with. If it is revealed that both partners are positive, it’s a stress reducer for both. Alternatively, if only one partner is positive, it at least opens the conversation about harm reduction. The worst that can happen is that a negative person doesn’t want to proceed with the situation and thus neither need waste the other’s time.

Undetectable Patients: HIV nontransmission

The Swiss experts statement had been has been down-played in the media, not openly discussed, for fear of encouraging unsafe sex. However, from my perspective, we should use this to encourage all individuals to get tested and begin HIV therapy, if HIV positive. This would slow the transmission of virus within our community. The Swiss statement and referred studies however, were criticized due to being heterosexually based and debated as to its application to our gay community. I believe it generated irrational fear that HIV transmission would get more out of control.

To critics, I explain that effective antiretroviral therapy eliminates HIV from genital secretions and HIV-RNA in semen and sperm. Moreover, sperm viral particles rise only after increases in blood viral load. Cell-viral gene particles are present in genital secretions, on antiretroviral therapy are actually non infectious -lack viral proliferation associated LTR-DNA.

It needs to be understood that “undetectable” does not equal “no virus.” Lab testing report undetectable to a level of less than 50 copies, but virus present at <49 copies per droplet of blood is present, just not detected.

It’s logical to abstract that less virus (undetectable) translates to less ability to transmit HIV to others. There can never be a prospective ethical study designed to test this hypothesis; one can’t ask HIV-negative individuals to participate in having unprotected sex with positives. However, patients infected with Hep-C can transmit Hepatitis C sexually. Thus, unsafe sex, although protective for HIV if the partners are undetectable, does not protect against detectable Hepatitis C.

Harm reduction

Let us reconciliate ourselves to widespread Safe Sex Fatigue, but what we do in our bedrooms is private and our own personal choice. While many HIV+ men abandon safe sex, some choose to have sex with only other HIV positive guys. Crazily, many HIV-negative friends and patients have accepted that they’ll probably get HIV sooner or later - they don’t fret over it.

However, addiction has had a major impact on our behavior. Addiction can result in irrational and relentless search for lust and sex and has been associated with HIV seroconversions and other STD’s. Individuals engaged in crystal meth are often missing doses of HIV meds and have more HIV in their blood. Meth is associated with higher-risk behaviors and multiple partners. As a physician busy within our community, I make no mistake in observing a burgeoning epidemic of more HIV and Hepatitis C combined with frequent infections of syphilis and MRSA (resistant staph infections).

On the positive side, individuals taking precautions are better off. Know that the HIV and/or Hepatitis C infected person faces tough consequences. Having to take medications, frequent blood draws and doctor visits, the cost of treatment, not to mention possible side effects can and should be avoided. Hepatitis C, often contracted due to meth use or having sex with a meth user, posses health challenges, including cirrhosis, liver failure and liver cancer. Treatment for Hep C is comparable to being on cancer chemotherapy.

Sexually active men should be responsible and have frequent STD testing for syphilis and hepatitis B and C. Anal warts should be treated quickly to discourage the transmission of HPV (human papillomavirus). Anal paps smears should be done and consider getting vaccinated for HPV. At Northstar Healthcare, we’ve started a program for prevention and offer Gardisil, the HPV vaccine, for our patients and community members. Eventually one hopes that vaccination reduces transmission of HPV, anal warts and anal cancer, a quickly rising problem among our patients. Since Gardisil is new, it has not been studied in gay or HIV-positive men, but approved for prevention of HPV and cervical cancer among young women.

Being a single gay man, and a known HIV specialist physician, I am confronted with these problems in the exam room daily. It creates tricky personal circumstances in the bedroom. Living with the challenges of being gay makes confrontations and individualized decisions with sexual partners intimidating at times. Though deeply personal, discussing them among the community is important. Being ballsy, this article is being written and placed out there for the hope of invoking stimulating open discussion. We should be proud to do so.

Conclusion

Sexually active HIV-positive individuals are better off undergoing treatment to suppress virus and reduce transmission within our community. Since there’s the prevalence of resistant virus individuals that have persistent viremia, it should be on therapy that is truly effective. Many new class antiviral drugs are available and can suppress HIV, even in patients who have “triple class resistance.” Also patients that are on these new drugs should be responsible enough to take their medications, so as not to spread or transmit more resistant viruses.

Although HIV transmission has been curtailed among individuals who are undetectable and barebacking may be considered safe in some situations, there is still the prevalence of Hepatitis C, syphilis and resistant staph infection. SSF is common and more the rule than the exception. On the other hand, HIV-positive persons in stable relationships with HIV-negatives, or individuals who understand the importance of adherence to HIV treatment while getting frequent STD (sexually transmitted disease) screening, may provide effective harm reduction. Still, condoms should always be considered when sexually interacting with unknown partners.

Dr. Daniel Berger is a leading HIV specialist in the U.S. and is assistant professor of medicine at the University of Illinois at Chicago and medical director and founder of Northstar Medical Center, the largest private HIV treatment and research center in the Greater Chicago area. He has published extensively in such prestigious journals as the Lancet and the New England Journal of Medicine and serves on the board of the AIDS Foundation of Chicago and Illinois ADAP. Dr. Berger has been honored by Test Positive Aware Network with the Charles E Clifton Leadership Award.

Daniel S. Berger, MD, is medical director of Chicago’s largest private HIV treatment and research center, Northstar Healthcare, and clinical assistant professor of medicine at the University of Illinois at Chicago. Dr. Berger has been the principle investigator in more than 100 HIV/AIDS clinical research trials and has published extensively in peer-reviewed medical journals and national and international conferences. He serves on the medical issues committee for the state of Illinois and on the board of directors for the AIDS Foundation of Chicago. He can be reached at DSBergerMD@aol.com or 773-296-2400.