How often have you heard or said, "I have an undetectable viral load and so the risk of getting HIV from me is very small even without using a condom." It's a seductive message, even more so because there is some truth in it, but there are serious complications. As Dr Ulrich Marcus of the Robert Koch Institute in Berlin said, "There are simple truths and complex truths. People like simple truths - complex truths are often inconvenient, because they require people to realize that what they do – even if they act with best intentions – may have unintended consequences." Continue reading for the complex truth and more...
A new campaign has just started in France Campagne Sérophobie 2012. They have a website here. It's tackling phobia of people with HIV. Fair enough. On that page they give reasons why it's possible to like people with HIV. The fifth is
"Parce qu’ ... avec une personne séropositive qui prend un traitement, a une charge virale indétectable et pas d’IST, le risque de transmission du VIH est presque nul."
which translates to
"With a HIV+ person undergoing treatment and with an undetectable viral load and no STIs, the risk of HIV transmission is almost nil."
Queer,de (a leading German online gay news site) have translated that as "Das Risiko einer HIV-Übertragung beim Sex mit Positiven unter wirksamer Therapie ist nahezu Null." (here)
"The risk of getting HIV from sex with an HIV+ person on effective treatment is virtually nil." Oops - they missed out the bit about not having any other Sexually Transmitted Infections (STIs).
They also both did not say:
1) If the HIV- person has another STI they are more likely to get HIV.
2) The basic science is based on the Swiss Statement issued in January 2008. The statement was based on a study of heterosexual couples in monogamous relationship.
3) More recent studies show that the amount of HIV virus in semen and arse mucus is often significant even when the person has undetectable viral load.
Simple truths and complex truths: So the claim is barely relevant to men who have sex with lots of other men.
When I read the French website and the German press announcement, I decided to investigate! I interviewed with Dr Ulrich Marcus of the Robert Koch Institute in Berlin. The Koch institute researches the general health of the German population and Dr Marcus is in a team of about 30 who specialise in sexually transmitted infections and those transmitted by sharing blood.
First I asked him if there are any studies, similar to the Swiss Statement study, but about gay men instead of heterosexuals. He says there are not. There is one European wide study underway but they are having difficulty recruiting people who are willing to disclose enough details of their own sex lives. If you think you can help go to www.partnerstudy.eu.
He also commented on the Aidsmap result that "Many men with undetectable HIV in blood still have low levels in their semen" published April 2012. He was not surprised and added that the mucus that lines the gut (and the arsehole) can also contain higher levels of the virus.
HIV Infection Rates Decreasing
In Germany in the last couple of years the rate of new HIV infections is somewhat levelling off (as reported by the Koch institute). I wondered if this might be evidence that increased prevalence of effective HIV therapy was making people less infectious, which might explain the reduced infection rate. He confirmed that an increasing number of people diagnosed with HIV going on treatment is the most likely explanation for the levelling off, but he also cautioned that as of 2010 in Germany just about 50% of gay men with HIV were on treatment. The other 50% either don't know or have not started treatment. Therefore, still a lot of virus is around. And he said that the rate of new infections would almost certainly be lower were it not for the increase in other STIs such as syphilis and gonorrhoea. People with HIV are twice as likely to have other STIs as people not infected with HIV, and it makes them more likely to pass on HIV if they have a detectable viral load. Paradoxically, this higher risk for other STIs is a consequence of actions intending to restrict the risk of transmission to HIV negative people – particularly the preference for sex partners who are also infected with HIV. This results in a higher accumulation of STIs in the group of men infected with HIV (because when having sex with each other, many men infected with HIV don’t feel it’s necessary to use condoms).
Two Sexy Men
My next question was going to be "Given two sexy men with similar sexual histories, which one would you prefer to have sex with: The one with HIV and on effective treatment or the one who has never been tested for HIV". I had established that Dr Marcus (picture) is gay but he is a serious man and I was nervous that his answer to that would be "Do you think I'm stupid? I wouldn't touch either of them. Get out of here and never speak to me again." So I changed the question a bit and asked "Given two sexy men with similar sexual histories, which one would you be less likely to get HIV from: The one with HIV and on effective treatment or the one who has never been tested for HIV". He was quite clear that the one with HIV and on effective treatment was the better gamble.
On the subject of over the counter HIV self-test kits, which have just become available in the USA Dr Marcus said that there were risks attached. Some of these were
1) By detaching testing from the medical system people who test positive may not get counselling or treatment.
2) Self testers may misinterpret the result and be unduly panicked or complacent.
3) There is a time delay between the moment of infection and when it becomes detectable. It is about 4-8 weeks. If self testers are not aware of that, then they might have unprotected sex one night, do the test the next day, get a negative result and think they were OK. In that example the test proves no such thing.
But in general he thought that self testing was a good idea because it lowered the barriers to testing. He expects that a discussion about it will evolve in Germany as well as other European countries, and that as a result of this discussion the current ban on self tests eventually may fall.
Where are the Condoms in Berlin Sex Clubs?
My final question was on one of my favourite topics: Why don't medical insurance companies or the government pay for condoms in German sex clubs? Each new HIV infection costs about £500,000 to treat over the patient's lifetime. Surely for medical insurers it's a no brainer? They just have to prevent one case of HIV and they are in the money. The answer was apathy really. Dr Marcus said that there had been discussions about making it a legal requirement that sex clubs must provide condoms and lubricant. These had fallen by the wayside partly because of enforcement difficulties and cost. For the insurance companies he opined that it was difficult to prove that they would really save money.
I'd like to thank Dr Marcus for giving me his time even though I was half an hour late due an unfortunate incident on the S-Bahn. And whilst we support the French campaign against "Sérophobie", they are being a little bit misleading.