I am HIV negative. I have a girlfriend who is unfortunately HIV positive. She is now on HIV medication (Atripla I'm told) and for the past few blood tests she has been told she has an undetectable viral load. I do not live with her but she tells me she is very careful about taking her pills. I know she has a daily alarm set on her mobile phone to remind her to take the pill so she always takes it at the same time each day and tells me she never misses a dose. She is generally in good health although she does suffer from fatigue and finds she needs more rest than the average person. I understand this is likely to be a side effect of the medication?

My question relates to the sexual transmission risk from her to me as I do not live near her and have not attended any of her check up appointments and so rely in information she passes on to me.

I have read up on things and I have established there is no risk to me from kissing her or from her sucking my penis.

My concerns thus relate to 2 things,

1. Me giving her oral sex. I have not done this to her since her diagnosis but it would be something we would both enjoy.What would be your assessment of the risk to me from performing cunnilingus on her given that she has an undetectable viral load? Obviously I would not do this if I had any open cuts in or around my mouth, but if my mouth was healthy? What I am trying to avoid is a situation where I would need to be re-tested for HIV as I found the testing quite traumatic. I accept few things in life carry no risk at all (I drive a car every day for example) but would you consider the risk from cunnilingus on her to be so incidental as to be not worth worrrying about or would you still recommend I should be tested if I were to engage in it?

2. Protected sexual intercourse. I understand that intercourse with a condom is a virtual zero risk activity regardless of a persons HIV status (as long as the condom stays on and doesn't break of course). I have had quite gentle protected intercourse with her 3 or 4 times but I have found I have not yet been able to fully let go and enjoy it as I am regularly stopping to check the condom is intact. The worst case scenario would obviously be a split condom during an act of sexual intercourse. I would like to know what your assessment of the risk to me in that situation would be? I have read the general risk of transmission from a single act of heterosexual intercourse is maybe 1 in 1,000, or perhaps slightly lower than that for the male insertive partner. Would I be right in assuming that if the female had an undetectable viral load that the risk to me would be a lot lower than even than that statistic, and thus a very low risk event in the unlikely and unfortunate event that it happened?

I am trying to establish a safe balance between risk and enjoyment that enables us both to have a fulfilling sex life. I'm not trying to have zero risk because I go out every day and accept risks like being struck by lightning or mowed down by a drunk driver! But sexually I don't want to really accept risks that are a lot greater than that and thus would require me to need testing.

[Dr Sean]

Good Morning

Thank you for your questions.

Firstly, the fatigue your partner suffers is likely due to the fact that 1) she has a chronic ie longlasting illness and this is likely to cause fatigue and also 2) the medications may well cause additional fatigue.

1. Me giving her oral sex. I have not done this to her since her diagnosis but it would be something we would both enjoy.What would be your assessment of the risk to me from performing cunnilingus on her given that she has an undetectable viral load? Obviously I would not do this if I had any open cuts in or around my mouth, but if my mouth was healthy? What I am trying to avoid is a situation where I would need to be re-tested for HIV as I found the testing quite traumatic. I accept few things in life carry no risk at all (I drive a car every day for example) but would you consider the risk from cunnilingus on her to be so incidental as to be not worth worrrying about or would you still recommend I should be tested if I were to engage in it?

Hello, the available evidence suggests that there is a colossal reduction in risk of HIV transfer in serodiscordant (different HIV status) heterosexual couples when the affected person takes effective HIV suppressing medications and is otherwise well. It sounds in this case that your partner is well controlled and with an undetectable viral load there should be little or no risk - there will be some risk but it is thought to be miniscule and generally not of relevance. Obviously as you realise the ultimate decision is yours to make. You can make things even safer by considering using PrEP = Pre exposure prophylaxis - this is the concept of the HIV negative person taking a dose of an anti HIV medication to prevent infection - this does have merit but clearly you need to decide on whether you wish to take a medication to deal with an already low risk threat.

2. Protected sexual intercourse. I understand that intercourse with a condom is a virtual zero risk activity regardless of a persons HIV status (as long as the condom stays on and doesn't break of course).correct I have had quite gentle protected intercourse with her 3 or 4 times but I have found I have not yet been able to fully let go and enjoy it as I am regularly stopping to check the condom is intact. The worst case scenario would obviously be a split condom during an act of sexual intercourse. I would like to know what your assessment of the risk to me in that situation would be? I have read the general risk of transmission from a single act of heterosexual intercourse is maybe 1 in 1,000, or perhaps slightly lower than that for the male insertive partner. Would I be right in assuming that if the female had an undetectable viral load that the risk to me would be a lot lower than even than that statistic, and thus a very low risk event in the unlikely and unfortunate event that it happened?YES you are correct - the risk will be hugely lower than that - obviously higher than having sex with an HIV negative partner because there would not be any risk at all but we think the transfer rate is reduced by approximately 99% in the scenario you have described. If you were to have a condom break then taking POST EXPOSURE PROPHYLAXIS - PEPwill further reduce any transfer risk - you can obtain emergency pep from major A+E units around the UK or if needed then you could take your partner's atripla as an emergency stop gap until you saw a doctor

I am trying to establish a safe balance between risk and enjoyment that enables us both to have a fulfilling sex life. I'm not trying to have zero risk because I go out every day and accept risks like being struck by lightning or mowed down by a drunk driver! But sexually I don't want to really accept risks that are a lot greater than that and thus would require me to need testing. well - I think in your circumstance periodic testing - say every year or so would be in order - I do have patients in your situation where they do not use condoms and they seem to prove the points made above that the risk of acquisition is low - there are a number of things whihc need discussion before you embark on that path and those are outside the scope of this Forum and best dealt with in a face to face consult

very best, Sean

Dear Dr Sean

Many thanks for your time and advice. That is very helpful.

Kind regards