Undetectable...
Dear Dr. Dick,
I've been sprung ever since I met my partner Johnson last month----this man is off the chain! Anyway, he recently got his levels checked and the doc told him he's "undetectable." To be honest, I'm not exactly sure what "undetectable" means, but I was too shy to ask him. We used condoms at first, but haven't since we had the conversation about his viral load. Just for my info, what exactly does undetectable mean, and can you tell me how likely I am to get HIV?
- Dick in Downtown Seattle
Dear Dick,
Kudos to both of you for having these important, and sometimes difficult conversations. And hats off to Johnson: sounds like he's doing a fantastic job taking his HIV medications and caring for his health.
The CDC (Centers for Disease Control and Prevention) recommends HIV medication for ALL people living with HIV--no matter how recent the infection or a person's CD4 Count (the number of healthy white blood cells in a cubic millimeter of blood). There are many benefits to taking HIV medications, including a longer and healthier life; increased CD4 count; a healthier immune system; less chance of giving HIV to a partner, and a greatly reduced viral load.
Viral load is the number of virus particles in a milliliter of blood. These virus particles are called "copies." When a person who has HIV gets a viral load test, and the test doesn't show any HIV in their blood, the test result is "undetectable." Different tests are different, and current tests are better than the ones used years ago, so the meaning of undetectable has varied over time and can be different depending on where a person gets their medical care. Most tests that are widely used define a person as being undetectable if they have fewer than 40-50 copies of the virus per milliliter in their blood. The person still has HIV in their body, but their HIV medications have done a great job keeping the virus from replicating (making copies of itself). If someone who's undetectable stops taking their medications, the virus will reappear in their blood.
Studies show that when people take their HIV medications consistently and correctly, their chances of transmitting HIV to a partner are very small. Consistently and correctly means that a persons is taking the medication at the same time each day and is following the instructions given to them by their medical providers and pharmacist (for example, some medications should be taken on an empty stomach).
To answer your question, I can't precisely estimate your likelihood of getting infected with HIV from someone with an undetectable viral load. A study presented last year followed several hundred men who have sex with men who are in HIV discordant partnerships (one man had HIV and the other did not). In all of the partnerships, the HIV positive man was taking HIV medications, and the study found no incidences of HIV transmission. That finding is very consistent with studies of heterosexuals in Africa, which have found that taking HIV medications reduces the risk of transmitting HIV by over 90%.
With all of that said, if you are going to make important health decisions based on a partner's HIV treatment status, there are some important issues to consider.
OTHER STDs
Having an STD can increase your chances of getting infected with another STD, because your immune system is under stress. In addition, STDs that produce open sores, like syphilis and herpes, create entryways that make it easier for HIV and other STDs to get in the body.
• Get regular STD tests with your partner(s), and if you test positive for an STD, connect with your medical provider right away for treatment. Treatment will help restore your immune system's infection-fighting power.
ARE YOU CONFIDENT YOUR PARTNER IS GIVING YOU ACCURATE INFORMATION?
If you're going to make important health decisions based on what a partner tells you, you need to be confident that the information you're getting is right. Some people may believe they are undetectable, but actually aren't. If a person stops taking their HIV medications, they rapidly become detectable and can transmit HIV. Also, some people are not entirely truthful with their partners. I'm not saying that your partner is not being truthful or that lots of people lie about being undetectable, but some people are not entirely honest. You really need to trust someone if you're going to take a significant risk based on what they tell you. At least to me, it's one thing to trust someone you know and care about. It's quite another thing to wager your health on what someone you've never met before says on their online profile.
HAVE YOU CONSIDERED PRE-EXPOSURE PROPHYLAXIS, or PrEP?
You may know PrEP as a hot-button subject in the gay community. PrEP is for people who don't have HIV, but are at a higher risk of getting infected. PrEP involves taking a daily HIV medication to prevent getting infected with the virus.
PrEP works best at preventing HIV infection when it's taken consistently and correctly. PrEP doesn't protect against other STDs, like chlamydia, gonorrhea, herpes, human papillomavirus and syphilis--so medical providers also recommend using condoms and getting regular STD tests. For more information on PrEP, check out my article: That Little Pill.
IS METH IN THE MIX?
Crystal can add a layer of complexity when it comes to preventing HIV. Here's why:
• Prolonged, rougher crystal-sex can create tiny tears in the delicate tissue of the anus and throat. These tears create more entryways for infection to get into the body. Use lots of water-based lube during anal sex to reduce friction.
• Crystal can damage the teeth and gums, causing an increased risk of transmitting HIV and STDs during oral sex. I recommend trying out dams, oral sex condoms, and tongue condoms during oral sex. Check out Project NEON's Meth and Your Mouth Brochure for more info.
• Crystal can make it harder to take HIV medications consistently and correctly, which can lead to a higher viral load, and medication resistance. I recommend that guys who use crystal visit their primary care or HIV doc to discuss medication and their ability to take it as prescribed.
RUBBERS
For some people, "Always use a condom" plays like a broken record. At the same time, the truth is that gay men use condoms way more than heterosexuals do. In fact, the vast majority of men who have sex with men in Seattle use condoms at least some of the time, and lots of men have successfully protected themselves for decades by consistently using condoms. Condoms are safe, cheap, easy to use, and unlike PrEP, they help protect you from all the STDs, not just from HIV. Condoms are still a very important part of protecting yourself. Even if you don't currently use condoms all they time, they might come in handy in certain situations, like if for instance, you're having rough crystal sex, or your partner stops or changes his HIV meds, or you're having sex with a guy you don't know very well.
Thank you, Dick, for your great question, and for taking charge of your health. Don't hesitate to write again if something comes up.
In health,
-Dr. Dick