Serodiscordant Relationships: What You Need To Know

Viral Suppression, Risk, and Serodiscordant Relationships: Should Serodiscordant couples practice safer sex practices? What's the real-life risk of HIV transmission? 

Remember seroconversion from your HIV 101: the physiological conversion from being HIV negative to becoming HIV positive. HIV statuses are reported in terms of positive and negative. Thus, Serodiscordant couples, also referred to as Magnetic Relationships, are those couples where one partner is HIV – and the other partner is HIV +.

As we enter the fourth generation of HIV, we are surviving the disease and living longer lives than those in previous generations. Along with this amazing gift of survival, HIV positive men and women are faced with a myriad of new issues including mixed-status dating and relationships, creating a number of Serodiscordant couples. Serodiscordant couples are presented with a unique set of circumstances to circumvent in order to have an open relationship and a healthy, safe sex life. 

In a 2013 article, John Sovec discusses how Serodiscordant couples are faced with more anxiety and fear than many relationships due to the fear of unintentional HIV transmission: often both the positive partner fears transmitting HIV and the negative partner fears becoming infected. Other challenges include worries regarding HIV care if the positive partner becomes sick, finding psychosocial support for both partners (more services available for the negative partner in a Serodiscordant relationship are needed), and issues of disclosure (who do you tell that your partner is positive?) to name a few. Creating an open dialogue is crucial for any healthy long-lasting relationship; however, it may be more crucial for Serodiscordant couples due to the health risks involved in keeping secrets and lack of communication. "These worries can create a barrier to true intimacy and leave each partner feeling unfulfilled. This is a time when each partner must risk talking about his or her needs, what forms of sexual contact feel safest, likes and dislikes, and how the couple can find ways to keep their sex life active and intriguing."

Are safer sex practices necessary in a Serodiscordant relationship if the HIV positive partner is in treatment, seen regularly by a doctor, and is undetectable? 

 Serodiscordant couples persist with a silent goal in mind: to keep the HIV negative partner negative and to keep the HIV positive partner healthy and undetectable. The goal of becoming undetectable, or viral suppression, is two-fold. One, viral suppression is key in HIV positive people to maintain a healthy CD-4 count, an undetectable HIV viral load, and long-term survival. Second, viral suppression is integral to HIV Prevention due to the fact that having an undetectable viral load carries a low to no risk of HIV transmission depending upon the research. 

Research conducted and reported upon over the last several years regarding Serodiscordant couples and HIV transmission, when the HIV positive partner is undetectable, cumulatively suggest that the real life transmission of HIV between mixed-status partners is extremely low to none. Most recently, the PARTNER study (a study on HIV transmission among Serodiscordant couples where viral suppression is reached in the HIV positive partner) reported on their findings after the first 2-year mark (the full report will be expected in 2017 after the final phase of the study is complete). The findings are remarkable and may offer astounding news about preventing HIV transmission with or without condom use. The unique thing about this study in regard to many earlier studies is that both heterosexual and homosexual couples and sex are included in this study: data from over one thousand mixed-status couples and thirty thousand sexual encounters were collected. Two years into the study, not one instance of HIV has been transmitted regardless of condom use, regardless of whether the couples engaged in anal or vaginal sex. The study also reports that the maximum chance of HIV transmission during viral suppression is 1% for anal sex (insertive or receptive) and 4% for anal sex with ejaculation (with a receptive negative partner). "When asked what the study tells us about the chance of someone with an undetectable viral load transmitting HIV, presenter Alison Rodger said: Our best estimate is it's zero." 

Does this mean that those of us in Serodiscordant relationships can toss out the condoms? Not necessarily; however, this is extremely optimistic and viral suppression may be one of our greatest weapons in the arsenal to contain HIV and move closer to the goal of an AIDS-free generation. It is imperative to remember that open and honest communication regarding condoms, unprotected sex, and risk associated with various sexual acts, etc. is necessary for Serodiscordant couples to make their own decisions based on facts and personal decisions. Ultimately, it is up to the individuals within the couple and centers on the HIV positive partner's adherence history and viral load.

Personally, my partner and I have been together for nearly 8 years. We began dating less than a year following my HIV diagnosis. To this day my partner is HIV negative. I become livid when it is assumed that he is HIV positive simply because I am and we are in a relationship. I do not become upset out of shame or fear, but because of the ignorance in that assumption: it is impossible for two mixed-status individuals to have a healthy, 'normal' long-term sexual relationship without both ending up HIV positive. Yet, this assumption is partly to blame for why we see young gay men seek out HIV infection; why some HIV – allow themselves to seroconvert (become HIV +); and why PrEP is being peddled to Serodiscordant couples. 

Hopefully research will continue to support the findings of low to no risk of HIV infection with ART therapy & viral suppression and HIV concerns will no longer be a part of the equation for love and healthy relationships. 

For further reading: 

Should HIV Serodiscordant Couples Always Take Preventative Measures? Experts Debate

Undetectable Viral Load Essentially Eliminates HIV Transmission Risk in Straight Couples 


Bryan C. Heitz
Risk Reduction Specialist
Community Counseling Center  

What Does HIV Prevention Really Mean?

 

 

 

HIV prevention is more than basic HIV education (e.g. infectious fluids, transmission routes, risky behaviors, condom use, etc.), it includes Risk Reduction and, the controversial strategy of, Harm Reduction. What does HIV prevention mean, and what is the difference between risk and harm reduction.

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HIV Prevention focuses on the prevention of new HIV infections with education and risk/harm reduction strategies. HIV transmission occurs through sexual and non-sexual behaviors with varying levels of risk. Sexually, HIV is transmitted through unsafe/unprotected oral, vaginal, anal, or any form of sexual play that involves exposure to HIV infected fluids (blood, semen, vaginal fluids, breast milk, or any bodily fluid that contains HIV-infected blood). Non-sexually, HIV is transmitted through blood-to-blood contact (shared needles used by an HIV-infected individual and, extremely rare, contaminated blood products) and mother-to-child transmission (during pregnancy, delivery, or breastfeeding).

Preventing sexual transmission of HIV involves a number of strategies including safer sex practices, testing, treating STIs, and treatment as prevention. Safer sex practices include limiting the number of sexual partners and unprotected sexual encounters; knowing the risk-level involved in oral, vaginal, and anal sex; and, correct use of condoms from erection to ejaculation. Condom use includes both external (male) and internal (female) condoms (never to be used together), and it is important to note that internal condoms can be used for vaginal sex by women and for anal sex by both women and men.

Regular HIV and STI testing is key in preventing new HIV infections. It was not too long ago that we were advised to get an HIV test once a year. Now, frequency of HIV testing depends upon the quantity of sexual encounters & partners an individual has had; thus, a sexually-active individual not in an honest, monogamous relationship (regardless of age, gender, or sexual identity) should test once every 3 to 6 months.

Treatment as prevention consists of two strategies using antiretroviral therapy (ART) to prevent HIV transmission: PEP and PrEP. PEP, or Post-Exposure Prophylactics, is utilized after an individual has potentially been exposed to HIV in an exposure situation (sexual or non-sexual). PEP is a 4-week daily dose of ART that potentially stops HIV infection and should be started within 72 hours after HIV exposure. PrEP, or Pre-Exposure Prophylactics, is utilized before an individual is potentially exposed to HIV. PrEP is being targeted to at-risk HIV-negative men who have sex with men (MSM). More about this controversial topic shall be addressed in a later blog.

Preventing HIV transmission through blood focuses on screening blood products; reducing the instances of accidental needle sticks in medical settings; and, most importantly, decreasing the sharing of used needles in injection drug use (IDU).

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Risk Reduction is concerned with reducing the actual risk an individual has of acquiring HIV through sexual and non-sexual behaviors. For example, knowing that receptive (bottoming) anal sex (regardless of sexual identity) carries the greatest risk for sexual transmission of HIV, whereas, oral sex (regardless of sexual identity) carries the least risk for sexual transmission of HIV emphasizes risk reduction.

Risk reduction among People living with HIV/AIDS (PLWHA) focuses on treatment and adherence to HART. The goal of HART for PLWHA is to decrease an individual’s viral load (how many copies of HIV replications per ml of blood) as low as possible, hopefully, until it becomes undetectable (also known as viral suppression). This is an example of using Treatment as prevention and risk reduction.

Although having an undetectable viral load does not mean that HIV is no longer transmittable, it does mean that it is less likely to transmit HIV than an individual without viral suppression. In 2014, the Conference on Retroviruses and Opportunistic Infections stated that researchers “calculated that the average real-world risk reduction as a result of an undetectable viral load would be 95 percent."

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Harm Reduction, historically, is concerned with reducing the harms associated with injection drug users (IDU).  The number one non-sexual behavior that carries the most risk for HIV transmission is sharing needles, most commonly, for injection drug use. However, other forms of drug use (smoking, snorting, drinking, etc.) also contribute to the transmission and spread of HIV. Alcohol, marijuana, methamphetamines, and other recreational drugs often impair one’s decision-making skills, decreases inhibitions, and increase the opportunity to engage in sexual or non-sexual risky behaviors that put the individual at risk for HIV transmission and other STIs.

Harm reduction, in terms of reducing non-sexual HIV transmission, should include availability to clean needles and works for IDU. It is more likely that an IDU would use clean needles/works if they are available than an IDU would simply quit injecting drugs.

Harm reduction strategies need to be applied to sexual risks as well. Harm reduction, in terms of sexual HIV transmission, may include getting an individual to move from never using condoms to using condoms for the most risky sexual behaviors (anal and vaginal sex).

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Today we, the diligent community of HIV professional in all areas of the fight, have a myriad of HIV prevention strategies of which we should not take advantage. It is equally important to acknowledge that many of these prevention strategies were not available in the beginning of the aids era more than thirty years ago. Finally, regardless of the prevention, risk reduction, or harm reduction strategy used, one must implement said strategy without judgment, prejudice, or blame.

 

-Bryan Heitz

Risk Reduction Specialist
CCCofSN