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Ask the Doc: Sexual Roulette

by Howard L. Scheiner, MD/AAHIVS

EDGE Media Network Contributor

Friday September 19, 2014

Dr. Howard Scheiner, MD/AAHIVS
Dr. Howard Scheiner, MD/AAHIVS  (Source:Courtesy of Dr. Scheiner)

In this week's edition of Ask the Doc, Dr. Howard Scheiner answers a tricky question about serosorting. If you think it's safer to have unprotected sex with an HIV-positive person whose viral load is undetectable rather than with someone who doesn't know their status, you may be right... or you may be wrong.

It's a Russian roulette you're playing with your health, says the doc. Those who are undetectable may have viral blips where detectable virus can't be measured. Or, they may be missing doses or taking their meds irregularly, degrading this 'undetectable' status. And even if you dodge the bullet for HIV, you may be at risk for other STDs like Hep C or HPV.

He'll also tell you exactly how often you should get tested for HIV.

Non-Detectable Partners Less Risky?

Q. Dear Doc, My friend is HIV-negative, but he only has sex with HIV-positive guys taking their meds. He says they're safer than guys who might be negative, but don't really know their status. Is this true?

A. I have heard of this type of serosorting as well, but only in the context of barebacking. If condoms are being used it (serosorting to choose your partner) wouldn't normally matter. Contracting HIV or any other sexually transmitted disease in the context of "safer" implies sex always carries a risk of disease.

Treatment as prevention was validated in the 2011 HPTN 052 trial, which showed that the risk of transmitting HIV to an uninfected partner was reduced by 96 percent. Now the caveats! Almost all the study couples were heterosexual, given condoms and counseled on risk reduction. Definitive conclusions can't be made about men who have sex with men (MSM) from this study.

Another study from China involving 38,000 couples, not part of an intensive study, showed only a 26 percent reduced risk of transmission. The assumption your friend makes is that guys on meds have an undetectable viral load, which means a lower risk of HIV transmission. Unfortunately, even those on meds who have been undetectable may have viral blips where detectable virus can be measured. Moreover, it is not that uncommon for people to miss doses or take their meds irregularly.

Imagine the game of Russian roulette using guns with six chambers, some having bullets, some having blanks and some empty. There are several guns on the table with a varying assortment of chamber mixes. So, it depends which gun you happen to pick up and what each chamber is filled with in that particular gun in order to come up with a risk assessment. But no matter the gun, the more you play the game, the greater the risk. To complete the analogy, the chambers with bullets carry HIV, the chambers with blanks carry other sexually transmitted diseases like Hep C or HPV, and the empty chambers carry nothing.

So, just as you don't know which bullet is in which chamber in the gun you picked, you don't know which partner really has an undetectable viral load when you are having sex or if they have other diseases they may transmit to you.

There is always some disease risk with sex. Even in a monogamous relationship with condom use, there is risk. Risk that your partner wasn't who you thought they were can be the wild card in a sexual game of chance.

There are too many variables and confounding variables to give an across the board answer to a provocative question. The best answer to your question is "it depends." If you choose an HIV-positive partner who is taking his meds, who indeed has an undetectable viral load, then he may well be "safer" if he has no other transmissible disease. If he takes his meds haphazardly, or is unreliable or has other diseases then he is not "safer." And, if he is sociopathic and lies about everything, who knows what risks there are?

Shooting blanks from an empty chamber may not be quite so "hot," so, if you choose to serosort on this basis, my advice is to take PrEP as your bullet-proof vest -- although it's not foolproof if you put the gun to your head.

How Often Should I Get Tested?
Get tested, in a clinic or at home  (Source: Orasure)

How Often Should I Get Tested?

Q. My doctor tells me I should get tested for HIV every three months. But come on, I have a life! How often do you really need to get tested for HIV?

A. If you are on PrEP, then every three months is recommended. If you should convert to HIV-positive status, continuing on PrEP would be a mistake as the Truvada would need to be changed to a fully-effective combination antiretroviral therapy (cART). If you are sexually active but using condoms, getting tested once a year with your annual physical should suffice.

Called "more than a doctor, a trusted friend" by his patients, Dr. Howard Scheiner is a true native New Yorker. He was born in the Bronx, he attended the esteemed Bronx High School of Science and City University of New York before receiving his medical education at The Mount Sinai School of Medicine. Truly a Renaissance man, in addition to his lifelong service to the medical profession, Dr. Scheiner is a published author, playwright and musical composer. Combining all his loves, he is perhaps most proud of founding "The Brent Varner Project, Inc." a charity that provides free HIV services to those in need through the Actors Fund of America.

Ask the Doc

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