New Study Shows Some Risk is Not No Risk

by Shaun Knittel

EDGE Media Network Contributor

Monday April 9, 2012

A study of 101 gay men at the Fenway Health HIV clinic in Boston, Mass., found that a quarter of men with undetectable viral loads in their blood nonetheless had detectable HIV in their semen.

The results also found that although seminal viral load in these men was low researchers suggest that this is still enough to be one of the explanations for ongoing transmission in gay men despite a high proportion being on antiretroviral therapy.

Importantly, the study findings show a very strong association with detectable HIV in semen and having a current sexually transmitted infection (STI). Six of the eight men whose HIV were undetectable in blood but detectable in semen had a urethral STI. After adjusting for other factors the researchers concluded that men who had an STI and/or urethritis were 29 times more likely to have viral discordancy.

"Ultimately, this confirms the importance of offering both STI screening and HIV testing because of the strong association between having detectable HIV in semen and having a co-occurring sexually transmitted infection," Gay City Health Project Executive Director Fred Swanson told EDGE. Gay City provides gay, bisexual, and transgender men free HIV/STI testing in Seattle.

Swanson says that important part of the work they do is "helping our clients to understand the risks they may be taking and to make a plan to reduce the likelihood that HIV or another STI would be transmitted when they are having sex."

Although new breakthroughs can be exciting, this study points to the fact that no prevention strategy is foolproof.

"There are many great reasons to connect HIV-positive guys to treatment options, primarily for their own health," he said. "Although the potential prevention benefits are compelling, this study demonstrates that even achieving an undetectable viral load in your or your partner's blood doesn't necessarily prevent HIV from being transmitted during sex."

"Whether you're living with HIV or not, having a comprehensive risk reduction strategy that includes, among other things, regular screening for STIs, is very important if you are sexually active," said Swanson.

In the Boston study, participants were on average 43 years old and three-quarters were white. They had all been on antiretroviral therapy for more than three months and 80% for over a year.

Nearly three-quarters were judged as being at high risk of acquiring an STI because they had had unprotected sex in the last three months. Nine of the men were diagnosed with an STI (gonorrhea, syphilis, chlamydia or non-gonococci urethritis) and 24 had leukocytospermia or white cells from the immune system in the sperm, indicative of urethral inflammation.

Eighteen of the 101 men had a detectable viral load in their blood. Nine of these 18 men also had detectable HIV in their semen (50%).

Of the 83 men without detectable HIV in their blood, 21 (25%) had detectable HIV in their semen.

So a person could be HIV+ and have an undetectable viral load. The question here is: how infectious are they at that point?

"An equally important difference to understand is that between 'exposure' and 'infection,'" Eric Marlowe Garrison, a certified sex counselor and Diplomate of the London School of Hygiene & Tropical Medicine told EDGE. "I could go have unprotected anal intercourse tonight with an HIV-positive individual, be exposed to the virus, and not infected by it. Realize though, I cannot be infected unless I am exposed."

So the health question is this: how risky is unprotected sex between an HIV-negative person and an HIV-positive person with an undetectable viral load?

"PLWHA receiving 'effective' treatment -- meaning no detectable live virus in the blood -- are much less likely to pass their virus on than those not receiving 'effective' treatment," said Frank Oldham, CEO, National Asso

Condom Use Advised to Reduce Exposure Risk

"Many of us would still advise condoms -- for many reasons -- in these circumstances, and HIV infection would still be one of those reasons," he said. "Because sex with a condom feels different, I encourage all my cisgender males to masturbate with condoms. Then sex can feel the same as masturbating."

And for those who want to slide along the safety curriculum, realize that two goals here with HIV infection prevention are these: reduce or eliminate the amount of the contagion and/or reduce the amount of time exposed to the contagion.

"A condom can help with both," says Garrison.

So why then are some gay men still engaging in unsafe practices?

"Some young men who are suicidal, depressed, or have a personality disorder might engage in riskier sex. Some might lack comprehensive sex education," Garrison explains. "Some might be so far removed from all the funerals we all attended back in the '80s, that he doesn't 'remember' about HIV."

"And it can also be that sex feels absolutely amazing the way he enjoys it now," he said.

"My one take home message might be in all the above: think of an amazing future with you in it," continued Garrison. "Now think of all the wonderful things that you need to do, all the incredible experiences you need to have, and all the strength and health you need to possess to get there. Then find the people and the resources, the information and the encouragement to make all those things happen for yourself."

Researchers point out that a low viral load has rarely been associated with transmission in heterosexual studies, some infections have occurred and animal models suggest that HIV is five times more transmissible via anal than vaginal sex -- so a median viral load of 200 would imply a low but definite risk of transmission.

One interesting aspect of this study was the higher risk of seminal viral load associated with unprotected insertive sex. The researchers suggest that urethritis in these HIV-positive gay men could be caused by infections with fecal bacteria acquired during sex or even that the virus detected could be passively carried virus from other HIV-positive gay men. Either way, this would tend to increase the infectiousness of HIV-positive men if they have insertive sex with negative men.

"We are excited about the potential of treatment-as-prevention. Recent studies show that People Living with HIV/AIDS (PLWHA) receiving 'effective' treatment -- meaning no detectable live virus in the blood -- are much less likely to pass their virus on than PLWHA who are not receiving 'effective' treatment," said Frank Oldham, president and CEO, National Association of People with AIDS. "We believe that broader testing and early treatment can reduce the number of new infections and help turn the tide in the HIV/AIDS epidemic."

"But that's for whole populations," he said. "Individuals still have to practice safe sex."

"Not only do a small minority of men in 'effective' treatment still have live virus in their semen, but roughly three-quarters of Americans living with HIV/AIDS aren't receiving 'effective' treatment," he continued. "Too many don't even know they are infected. That needs to change. We all need to get tested regularly, to protect our own health and avoid infecting others."

"And there is always the risk of other STIs, which can be devastating to people with compromised immune systems," concluded Oldham. "There is a new strain of gonorrhea, for example, that so far is resistant to all available antibiotics. So we say to all Americans: Get tested, and if you test positive, start treatment -- but continue regular, proper use of condoms."

Shaun Knittel is an openly gay journalist and public affairs specialist living in Seattle. His work as a photographer, columnist, and reporter has appeared in newspapers and magazines throughout the Pacific Northwest. In addition to writing for EDGE, Knittel is the current Associate Editor for Seattle Gay News.