HEALTH: Safe Sex With HIV - and Without a Condom?

MEXICO CITY, Aug 13 , 2008 (Tierramérica) - The Swiss Federal Commission for HIV/AIDS set off a small firestorm of debate by asserting that people living with the virus can have sexual relations without a condom and without endangering their uninfected partners, under certain conditions.

People living with HIV who are free of other sexually transmitted diseases and are under effective antiretroviral therapy do not transmit HIV, the AIDS virus, through sexual contact, says the Swiss governmental entity in a text signed by four renowned experts, professors Pietro Vernazza (chairman of the Commission) and Bernard Hirschel, and doctors Enos Bernasconi and Markus Flepp.

To achieve these conditions, an HIV-positive individual must follow antiretroviral therapy to the letter, remain under regular medical testing, and have no other sexually transmitted diseases, and his or her viral load must be undetectable (less than 40 copies of the virus per millilitre of blood) for more than six months.

Because of the risks posed by additional sexually transmitted diseases, the couple should understand the need to define rules about sexual contact outside the stable relationship, states the text in a sidebar about the advice that doctors should provide their patients and the patients' partners.

Furthermore, the decision to stop using a condom should be made by the partner who is free of HIV.

Under these conditions, the risk of becoming infected with AIDS is less than one in 100,000, say the Swiss experts in their statement, published in January by the Bulletin des Médicins Suisses.

This proposal became a hot topic at the XVII International AIDS Conference, held Aug. 3-8 in Mexico City.

The Swiss statement upset some in the community dedicated to fighting AIDS, who are concerned about a new threat: the decline of prevention measures, like condom use.

"They are important and interesting conclusions, but they take place within a very controlled context and are not necessarily applicable in all countries," César Núñez, director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for Latin America and the Caribbean, told Tierramérica.

Rick Jones, coordinator of the Global Network of People Living with HIV/AIDS, said his group had not yet had the opportunity to discuss the new findings with its membership.

For Nikos Dedes, of the non-governmental European AIDS Treatment Group, the report is good news, which will help people with HIV to overcome constant fear and to learn to enjoy their sex lives.

The recommendations of the Commission were based on epidemiological and biological data from 26 international studies.

One of the studies, conducted in Spain with 393 heterosexual couples in which one partner was living with HIV, found that there were no transmissions of the virus to the uninfected partners of people undergoing antiretroviral therapy for 14 years, while the percentage of transmission in couples without ARV treatment was 8.6 percent.

"The evidence is quite sound, but it is, in a way, indirect. There are practical, political and ethical difficulties for doing this type of study," one of the authors, Professor Hirschel of the Geneva University Hospital's infectious disease division, told Tierramérica.

It is a situation comparable to that of 1986 when the affirmation that "kissing does not transmit HIV" was published and disseminated, despite the fact that it was not scientifically proven at the time, although it has been upheld by 20 years of experience, say the Swiss experts.

Although ARV therapy considerably reduces the risk of transmission of HIV, many believe the Swiss pronouncement could undermine the AIDS prevention campaigns that are based on condom use.

Furthermore, said the president-elect of the International AIDS Society, Julio Montaner, it shifts attention away from the core issue: universal coverage of ARV treatment, which can save lives and prevent infection.

In a Tierramérica interview, Montaner, an Argentine physician working in Canada, noted that it is a difficult message to manage for the general public.

"You have to explain to people all of the details. Also, if antiretroviral treatment stops working in the infected individual because it generates resistance, that person is going to start to transmit the virus," he warned.

"And if your spouse cheats on you? How are you going to know? Is he going to tell you, 'Honey, I have to confess that I cheated, and now I'm going to use a condom'?" Montaner said with a note of irony.

"In Latin America not all health services are equally advanced, and not all people living with HIV are undergoing treatment or undergo constant monitoring of their viral load," said UNAIDS's Núñez.

"We are not disqualifying the declaration, but the buzzword at the conference is combined prevention," which consists of ARV therapy, condom use, male circumcision and awareness-raising campaigns, he said.

Condom use should not stop, because "the susceptibility of each person to HIV is different," 25-year-old Panamanian activist José Rafael Olmedo, a member of the Global Youth Coalition on HIV/AIDS, told Tierramérica.

"I don't see it as being very feasible in Latin America," said Olmedo, agreeing with Spanish activist Carmen Tarrades of the International Community of Women Living with HIV/AIDS, who believes the ideal scenario put forth by the Swiss experts is a long way from the reality of regions like Africa.

The Swiss health authorities laid out the repercussions of the resolution for their country's legal system, whose penal code punishes the intent to spread a serious infectious disease. People with HIV who meet the indicated conditions cannot be accused of that crime, they said.

In other countries, this aspect would require action in the political sphere, said Tarrades. To implement the Swiss policy, each country would have to reform legislation that otherwise treats people who transmit the virus as criminals, she said.

(*Originally published by Latin American newspapers that are part of the Tierramérica network. Tierramérica is a specialised news service produced by IPS with the backing of the United Nations Development Programme, United Nations Environment Programme and the World Bank.) (END)

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