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Love is love: It’s a lesson the United States continues to learn. In small steps, the country as a whole has become more accepting of different couples, from mixed-race couples to homosexual couples. Although they don’t get as much attention, serodiscordant couples—couples in which one partner has human immunodeficiency virus (HIV), and the other does not—are also facing better conditions than they ever have before. Serodiscordant relationships were once considered off-limits or impossible, but HIV/AIDS education and medical advancements have changed the landscape for these couples.
Serodiscordant couples face their own set of challenges, including the risk of transmission for the HIV-negative partner. HIV can spread not just through sexual transmission, but this specific risk factor used to lay a heavy burden on couples—so much so that at one point, “serosorting” (choosing not to date someone due to their HIV status) was not uncommon. But we now know much more about HIV infection, treatment, and prevention, including which behaviors are high-risk and how to account for them in the prevention of HIV.
HIV is a virus that affects your immune system by targeting a type of white blood cell called CD4 cells. These cells—which are also sometimes referred to as T-cells, T-lymphocytes, or helper cells—play a central role in immunity. The attack on these cells damages the immune system, which in turn increases the risk of serious infections (and even some types of cancer). HIV also goes through three stages of infection: acute infection, chronic infection, and AIDS (HIV.gov, n.d.).
Though HIV is sexually transmitted through body fluids such as semen and vaginal and anal excretions, sexual activity isn’t the only way it’s spread. The virus is also spread through blood, so people who need blood transfusions or those who share needles have a high risk of HIV transmission. HIV can also pass to children during pregnancy, birth, or through breast milk while breastfeeding, so children of mothers with HIV are also at risk.
9 things you need to know about HIV
Steps to take when your partner is HIV positive
Couples are partners, which means there are steps both people need to take to ensure the best possible health for both parties in the HIV serodiscordant couple. In some cases, that means methods for HIV prevention for the partner who is HIV-negative. In other cases, it’s steps that need to be taken to ensure the ongoing good health of the HIV-positive partner. In some cases, these things overlap. Here are the steps that can be taken to help keep both people in the couple in good health.
Consider PrEP (pre-exposure prophylaxis)
One type of medicine that can help people who are HIV-negative avoid becoming infected is called pre-exposure prophylaxis (PrEP). PrEP is a pill that is taken daily and is currently available under the brand names Truvada and Descovy. Each of these medicines contains a different mixture of antiretroviral drugs. People are considered good candidates for PrEP if they don’t know the HIV status of their partner, have a partner with known HIV risk factors or are having condomless sex. But it’s also suggested for people whose partners are HIV positive and have a detectable viral load. You can get PrEP from your healthcare provider through a prescription (CDC-e, 2019).
Help make sure your partner is getting treatment
Known as antiretroviral therapy (ART), HIV treatment can lower the amounts of virus, called the viral load, in the body when taken as prescribed. But it also does something else: It can help prevent HIV infection in HIV-negative partners. This was discovered in a famous study referred to as HPTN 052 (Cohen, 2011). In some people, levels of the virus may get low enough on ART that HIV testing cannot detect them, at which point they’re considered “undetectable.” Research shows that when somebody has an undetectable viral load, he or she has “effectively no risk” of transmitting HIV to their sexual partners (CDC, 2020). The risk is so low, in fact, that a campaign was launched to promote the knowledge that “U = U” or “Undetectable = Untransmittable.” Taking ART with a secondary goal of preventing transmission to a partner is called “treatment as prevention.”
ART is also important for serodiscordant heterosexual couples in which the female partner has HIV who are considering having a baby. Antiretroviral therapy treatment, if taken daily throughout pregnancy, labor, and delivery, is also an extremely effective risk reduction for child transmission of the virus. The risk of passing HIV to your baby, if antiretroviral treatment is taken correctly, can be 1% or less (CDC-b, 2019). Other prevention strategies, such as in vitro fertilization, need to be taken for serodiscordant heterosexual couples in which the male partner is HIV positive. Sperm washing, a process in which the individual sperm are separated from the seminal fluid (which can spread HIV), is means of insemination that can decrease the risk of transmission of HIV to the uninfected partner (Zafer, 2016).
PrEP’s role in reducing HIV transmission rates
And make sure they’re taking it regularly
ART is truly what transformed HIV from a debilitating health condition into one that’s chronic and manageable. When taken as intended, ART can even prevent HIV from ever developing into AIDS. But people on ART need to take it daily, and studies show that isn’t happening. Past studies that have looked at adherence show varying numbers between 27 and 80%, according to one review of the literature—and that simply isn’t high enough (Iacob, 2017). Skipped doses allows the virus a chance to multiply rapidly. Taking the medicine daily is key to driving down the viral load to undetectable levels, which is the best thing someone with HIV can do to stay healthy (HIV.gov, 2019).
Use condoms regularly
Despite countless campaigns aimed to prove otherwise, condoms seem insignificant when they’re anything but. Condom use is extremely effective at preventing HIV transmission, according to the Centers for Disease Control and Prevention (CDC), as long as they’re used correctly and consistently. Since HIV is spread through body fluids, condoms can protect against transmission by preventing their exchange (CDC, 2013). Although transmission rates are different between vaginal, anal, and oral sex, condoms should be used for all of these sexual activities.
Receptive vaginal sex and receptive anal sex both have a higher transmission rate than their penetrative equivalents, so condom use is especially important for the “recipient.” In fact, your risk is 13 times higher with receptive anal sex than it is with insertive anal intercourse (CDC-b, 2019). Though the CDC considers oral sex a low-risk behavior in terms of HIV transmission risk (CDC-c, 2019), condoms can still prevent the spread of other diseases and should be used.
HIV testing: development, accuracy, and types of tests
Get regular HIV testing
This is suggested for both partners. People who are HIV positive should know how their levels of CD4 cells are doing and where their viral load stands. Preventative methods help slash the risk of HIV transmission, but they aren’t perfect, so the HIV-negative partner should get tested once a year to see if their status has changed, according to the CDC (CDC-a, 2019).
- Centers for Disease Control and Prevention (CDC). (2013, March 5). Condom Fact Sheet for Public Health Personnel. Retrieved from https://www.cdc.gov/condomeffectiveness/latex.html
- Centers for Disease Control and Prevention (CDC-a). (2019, December 3). Testing. Retrieved from https://www.cdc.gov/hiv/basics/testing.html
- Centers for Disease Control and Prevention (CDC-b). (2019, November 12). HIV and Gay and Bisexual Men. Retrieved from https://www.cdc.gov/hiv/group/msm/index.html
- Centers for Disease Control and Prevention (CDC-c). (2019, November 13). HIV Risk Behaviors. Retrieved from https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html
- Centers for Disease Control and Prevention (CDC). (2020, March 3). HIV Treatment as Prevention. Retrieved from https://www.cdc.gov/hiv/risk/art/index.html
- Centers for Disease Control and Prevention (CDC-d). (2019, November 12). Pregnant Women, Infants, and Children. Retrieved from https://www.cdc.gov/hiv/group/gender/pregnantwomen/index.html
- Centers for Disease Control and Prevention (CDC-e). (2019, December 3). PrEP. Retrieved from https://www.cdc.gov/hiv/basics/prep.html#consider-taking-PrEP
- Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., et al. (2011). Prevention of HIV-1 Infection with Early Antiretroviral Therapy. The New England Journal of Medicine, 365, 493–505. doi: 10.1056/NEJMoa1105243. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21767103
- Iacob, S. A., Iacob, D. G., & Jugulete, G. (2017). Improving the Adherence to Antiretroviral Therapy, a Difficult but Essential Task for a Successful HIV Treatment—Clinical Points of View and Practical Considerations. Frontiers in Pharmacology, 8. doi: 10.3389/fphar.2017.00831. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703840/
- Taking Your HIV Medication Every Day. (2019, January 9). Retrieved from https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treatment/taking-your-hiv-medications-every-day
- Zafer, M., Horvath, H., Mmeje, O., Poel, S. V. D., Semprini, A. E., Rutherford, G., & Brown, J. (2016). Effectiveness of semen washing to prevent human immunodeficiency virus (HIV) transmission and assist pregnancy in HIV-discordant couples: a systematic review and meta-analysis. Fertility and Sterility, 105(3). doi: 10.1016/j.fertnstert.2015.11.028. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26688556
Dr. Mike is a licensed physician and the Director, Medical Content & Education at Ro.