This article by Gus Cairns first appeared on aidsmap.com here.
About 40% of men who answered a community survey for HIV-positive gay men in the Netherlands said they took their viral load into consideration in deciding whether or not to use condoms. This represents about two-thirds of those who actually did have unprotected sex.
This published paper adds new data to this study’s original conference presentation at the AIDS Impact conference in 2011.
The survey found that consideration of viral load was almost as common when having sex with partners who also had HIV as when having sex with partners of negative or unknown status. Disclosure and discussion of viral load was far more common with HIV-positive partners, whereas viral load was rarely discussed with partners assumed to be HIV negative, remaining purely part of a unilateral decision.
The study also found that this group of HIV-positive men, who, as part of a community consultation panel providing advice to the Netherlands HIV Association (NHA), might be assumed to be well informed on HIV prevention matters, were as a group by no means convinced that undetectable viral load protected them from transmitting HIV to partners. Not surprisingly, the more confident individuals were that this was the case, the more likely they were to take it into account as part of a decision to have condomless sex.
The NHA’s Open Online Panel consists of 517 women and men living with HIV who are contacted on a regular basis by email to ask their opinion on important topics in HIV. In this case just the 212 gay men on the panel were asked to complete an online survey about unprotected sex and consideration of viral load.
This paper only looked at the answers from the 177 men (85%) who said they had an undetectable viral load. Of these, all but two were on antiretroviral therapy.
Results: unprotected sex
One hundred and twenty (68%) of the 177 had ever had unprotected anal sex since their HIV diagnosis and of these 73 (61%, or 41% of the whole group) did it without a condom the last time they had anal sex.
The researchers asked respondents if their last sex had been with a casual or a regular partner and of the 73 who’d had unprotected sex last time, 43 (59%) said it was with a casual partner and 30 (41%) with a regular one.
The 73 were also asked the HIV status of the most recent partner and 38 (52%) said they were HIV negative or status unknown and 35 (48%) that they were HIV positive. Unprotected sex partners were more likely to be ‘buddies’ if they were HIV positive (15 casual, 20 buddies) and more likely to be casual meets if they were HIV negative or status unknown (28 casual, 10 buddies); this is what one would expect, as HIV status is usually not discussed until people have reached a level of trust.
Results: considering viral load
Of the 120 who had ever had unprotected sex since diagnosis, 75 (63%) said that their viral load was something they had taken into account when deciding to use condoms.
Interestingly, more said they had taken viral load into consideration with HIV positive partners (44% of the 120) than with men who were HIV negative or of unknown status (38% – some men considered it with both positive and negative partners).
Participants were asked to estimate the perceived protective value of having an undetectable viral load on a scale of one (“absolutely no risk”) to seven (“absolute risk”). The average score was three (low-to-moderate risk) when considering sex with HIV-negative partners and two (no-to-low risk) when considering sex with HIV-positive partners (where the perceived risk was presumably superinfection). Not surprisingly, men who thought the risk was lower were more likely to have unprotected sex and to consider viral load as one of the reasons involved in doing so.
When having unprotected sex with HIV-positive partners, men said they were more likely to consider viral load with buddies (over half the partners) than with casual partners (only one in five). Conversely, when having unprotected sex with HIV-negative partners, nearly 60% said they considered their viral load with a casual partner but only 40% with a buddy.
With positive partners, all but one of the 14 men who said they had considered viral load had explicitly discussed it with their partner before sex. Conversely, only three of the 20 men who had considered viral load when having unprotected sex with an HIV negative partner had discussed the subject.
It looks as if there are two different phenomena going on. With HIV-negative partners, men who considered their viral load are doing so in the main as part of a unilateral process of considering how liable they are to transmit HIV. In the case of HIV-positive partners, the researchers comment that “further qualitative studies are needed to shed light on the perceived added value of considering viral load”, but speculate that it may take place within the context of broader discussions about HIV superinfection and STIs.
This is a small study of quite a specific group: HIV-positive gay men who were already engaged and informed enough to join a community consultation group. They could therefore be ‘early adopters’ of viral load as a factor to take into account when considering sexual risk.
As the researchers comment, “future investigations should include the perspectives of HIV-negative MSM in the communication around undetectable viral load and unprotected anal intercourse”, and a wider consultation with less-engaged HIV-positive men would be interesting too.
They also comment that further investigations are needed to establish the risk of transmitting HIV via anal sex with an undetectable plasma viral load.
They comment: “HIV prevention campaigners need such evidence to take an informed stance in the debate around viral load considerations and urgently so, in light of their already frequent use by MSM.”
Van den Boom W et al. Undetectable viral load and the decision to engage in unprotected anal intercourse among HIV-positive MSM. AIDS and Behavior, e-publication ahead of print: DOI 10.1007/s10461-013-0453-9, 2013.