At least once a week, I am asked by one of my HIV-infected patients whether they need to continue to practice safe sex if they are in a monogamous (one mate only) relationship with an HIV-infected partner. Put another way, since both partners already have HIV, what's the harm of unprotected sex? Actually, this is not an easy question to answer fully. My belief, however, is that the best approach is to provide as much information as possible; emphasizing what is known versus what is uncertain. Such a complete disclosure is the only way I can remain credible while allowing the patient to make a fully informed decision.
My response to this question generally begins by telling the patient what is known about the risks of unsafe (unprotected) sex between HIV-infected partners. First of all, we know that in this situation, the spread of other sexually transmitted diseases (STDs), such as gonorrhea, chlamydia, syphilis, and herpes remains a risk, as usual. What's more, these so-called traditional STDs are well known to be associated with serious complications.
Both gonorrhea and chlamydia initially can cause infections of the urethra (urethritis) and anus, or rectum (proctitis). Subsequently, these infections can progress to serious complications in these areas and even spread to other parts of the body. In addition, in women, gonorrhea and chlamydia are associated with increased risks of infertility and ectopic pregnancy, which at times can be life-threatening. (An ectopic pregnancy occurs when the fertilized egg implants outside of the uterus; for example, in the tubes.)
Viewed from another perspective, however, in a monogamous relationship between HIV-infected partners, with good diagnostic screening, the problems of gonorrhea and chlamydia are usually not insurmountable. Thus, when diagnosed, these diseases are generally curable. The same holds true for syphilis, except that it can be difficult to treat. Finally, herpes disease, although manageable, is never cured, and once acquired, results in life-long infection.
Other sexually transmitted infections can cause serious diseases that may be difficult or impossible to cure. For example, hepatitis B and C both can be transmitted sexually and may be difficult to cure. Remember, however, that hepatitis B is preventable by vaccination. While hepatitis C is more frequently spread by exposure to blood (for example, during intravenous drug abuse), transmission can occur from sexual exposure. Moreover, when hepatitis C infection occurs, about 85% of cases result in a chronic (long duration) infection that may be difficult to treat and can lead to liver failure and/or liver cancer.
The human papilloma virus (HPV) is also sexually transmitted and cannot be eliminated. It is associated with cervical cancer in women and anal cancer in both men and women. Additionally, HPV is associated with an even greater frequency of these cancers in individuals co-infected by HIV.
The human herpes virus 8 (HHV-8) has been strongly linked to Kaposi's sarcoma (a skin cancer in patients with HIV disease). Therefore, HHV-8 is clearly an infection worth avoiding if at all possible. However, it is not known just how the spread of HHV-8 occurs and how it can be prevented. It may very well be transmitted sexually. At this time, however, there is no readily available way of determining whether an individual is infected with this virus.
Another concern that frequently arises during our discussions on the risks of unsafe sex between HIV-infected partners is the possibility of acquiring another strain of HIV, in particular one that might be more aggressive (virulent) or perhaps one that is resistant to antiretroviral drugs. While this possibility often is the greatest worry among the patients, we unfortunately have limited information regarding the actual risk.
I always inform my HIV patients that we are on firm ground regarding our understanding of the risks of acquiring the traditional STDs, hepatitis B, HPV, and probably hepatitis C. The data are less clear for HHV-8 and regarding the possibility of HIV super-infection (infection by another strain of HIV on top of the one the person already has). It is worth noting that there have been increasing reports of cases of suspected superinfection. Although the data remains limited it suggests that when superinfection occurs it may be associated with CD4 decline and possible disease progression. Based upon this emerging data I believe it is important for people to be aware of this potential risk while this area of research continues to evolve.
In summary, individuals need to know the currently available facts regarding the risks of unsafe sex between HIV-infected partners. If they choose to assume the known and potential risks, they should be screened for the sexually transmitted diseases and treated when possible. Finally, the clinicians and patients must maintain an open dialogue regarding evolving issues and new information as it becomes available. Although one of the greatest challenges in HIV medicine is dealing with uncertainty, honest and open discussions between patients and their healthcare providers are always the best place to start.
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