Can “HIV-Suppressed” Persons Toss Condoms to the Wind?

May 10, 2013

To suggest today that condoms are “obsolete” sounds heretical and like a topic ripe for heated debate. Here, HIV/AIDS blogger Dr Rodger MacArthur lays out the science for your review.

Much has been made about HIV-infected persons being able to live a “normal” life once they are receiving antiretroviral therapy. In fact, a 26-year-old living in North America or Western Europe who gets infected with HIV today is expected to live at least another 40 years.1 Of course, 40 additional years of life is only about 80% of the life expectancy of a similar individual not infected with HIV, but the point is that once HIV is controlled (suppressed) as a result of 100% adherence to antiretroviral therapy, both the life expectancy and quality of life approximate those of HIV-negative persons. Consequently, young HIV-infected individuals increasingly are entering into stable, monogamous relationships, and many are considering having children. An HIV-infected woman who is taking combination antiretroviral therapy (cART) and whose HIV RNA level (viral load) is “undetectable” (less than, say, 200 copies/mL of blood) is extremely unlikely to transmit HIV in utero or at the time of delivery.

But do these data suggest that the same individual has a negligible risk of transmitting the virus to a partner not infected with HIV after months or years of an ongoing sexual relationship without the use of barrier protection (ie, condoms)? The answer appears to be "Yes."  

In 2008, the Swiss Federal Commission for HIV/AIDS stated that “after review of the medical literature and extensive discussion, [we] resolve that an HIV-infected person on antiretroviral therapy with completely suppressed viraemia (“effective ART”) is not sexually infectious, ie, cannot transmit HIV through sexual contact.”2 Some of the data reviewed by the Swiss Commission included the article by Tom Quinn and colleaques3 that looked at risk of heterosexual transmission of HIV among 415 discordant Ugandan couples (one partner positive, the other negative). They found no instances of transmission if the HIV RNA level in the blood was less than 1500 copies/mL. Similar results were found in a group of 393 Spanish couples reported by Castilla and colleagues.4

The Swiss statement and the data behind the statement may seem like “old news” to many. So why spend time reintroducing the topic today? 

One reason is that another approach to reduce risk of transmission of HIV to women, pre-exposure prophylaxis, or PrEP, was shown this year not to work. In a study reported at the recently completed Conference on Retroviruses and Opportunistic Infections (CROI) in Atlanta,5 5000 young (average age of 25 years), primarily single (79%) African women were followed for about 2 years. Women randomized to take oral or vaginal antiretroviral agents (PrEP) were as likely to get infected with HIV as were those women in the study randomized to no PrEP, largely because the women in the PrEP arms did not reliably take their PrEP, despite the fact that average self-reported adherence was 90%.5 In other words, the best documented method to prevent HIV transmission is for the HIV-infected person (rather than the HIV-negative person) to take antiretroviral therapy to maximally suppress the virus.

Getting back to the issue posed earlier: should health care providers suggest or even encourage their HIV-infected patients who are in a stable, monogamous, discordant relationship to “throw away” their condoms? 

On the one hand, HIV-negative couples in a similar situation typically do not use condoms. On the other hand, wearing condoms never “hurt” anyone, and condoms do prevent the transmission of other sexually transmitted diseases. In any case, the advice by health care providers to HIV-infected persons to always wear condoms is so well-established that to suggest that condoms are “obsolete” in this setting often is treated as heresy and is quite likely to lead to a heated and vocal argument.

The Swiss Commission anticipated much of this. They stated “[we realize] that medical and biologic data available today do not permit proof that HIV infection during effective antiretroviral therapy is impossible, because the non-occurrence of an improbable event cannot be proven. If no transmission events were observed among 100 couples followed for 2 years, for instance, there might still be some such events if 10,000 couples are followed for 10 years. The situation is analogous to 1986, when the statement ‘HIV cannot be transmitted by kissing’ was publicized. This statement has not been proven, but after 20 years’ experience, its accuracy appears highly plausible.”2

My personal experience with this issue is that health care providers who are aware of the data have a very difficult time accepting the logical extension of the data, which is to conclude that condoms in the setting of undetectable HIV RNA levels are unnecessary to prevent transmission of HIV. Nevertheless, conveying this information to patients can be reassuring, empowering, and useful in many situations, such as when an HIV-negative partner is considering conceiving a child. 

As health care providers, we have an obligation to discuss these data with our patients, even when the implications of the data contradict “traditional” medical beliefs.

1. The Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries; a collaborative analysis of 14 cohort studies. Lancet. 2008;372:293-299.
2. Vernazza P, Hirschelb B, Bernasconic E, Fleppd M. Les personnes sropositives ne souffrant d’aucune autre MST et suivant un traitment antirtroviral efficace ne transmettent pas le VIH par voie sexuelle. Bull des Mdecins Suisses. 2008;89:165-169.
3. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342:921-929.
4. Castilla J, Del Romero J, Hernando V, et al. Effectiveness of highly active antiretroviral therapy in reducing heterosexual transmission of HIV. J Acquir Immune DeficSyndr. 2005;40:96-101.
5. Marrazzo J, Ramjee G, Nair G, et al. Pre-exposure prophylaxis for HIV in women: daily oral tenofovir, oral tenofovir/emtricitabine or vaginal tenofovir gel in the VOICE study (MTN 003). 20th Conference on Retroviruses and Opportunistic Infections; March 3-6, 2013; Atlanta. Abstract 26LB.