Welcome to the HIV forum. Congratulations on a level headed approach and for your apparent love and commitment to your partner. A lot of people would have panicked and bailed out.
The following advice should be considered just a starting point. Every couple in your situation should rely primarily on the advice of the infected person's doctor or clinic. If you have not done so, you should attend an upcoming doctor visit with your partner and ask all these questions there. Please look at the following comments as preliminary, not the final word -- and follow that person's advice if it differs from mine.
Recent research has confirmed what was long suspected: that HIV transmission risks are very low when the infected person is on antiretroviral therapy (ART) and has an undetectable viral load. As long as he continues his treatment and his viral load remains low or undectable, the chance you will catch HIV is low. You should still use condoms consistently for vaginal or anal sex -- but the risk is low enough that in the event you and your partner decide you want children, you probably can safely stop the condoms periodically when you want to conceive. To the specific questions:
1) A condom that is worn throughout anal (or vaginal) sex, and that remains intact, is virtually 100% protective against HIV. The risk is primarily in breakage; HIV cannot pass through intact latex or polyurethane. In the event there is a break, the transmission risk in your situation would be far less than 1 in 100. That statistic applies to unprotected sex and no treatment (with usually high viral loads) in the infected partner, and it presumes ejaculation in the rectum. Even without a condom, given your partner's undetectable viral load, the chance of transmission with ejaculation into the rectum (or vagina) probably is well under 1 in 1,000, maybe much lower than that. Nobody can say the risk is zero, but it may actually be zero.
2) Oral sex is very safe. Even without ART, the transmission risk from an infected penile partner to the oral partner has been estimated at 1 in 10,000. If your partner continues ART with excellent suppression of his viral load, probably the risk is zero or close to it. Although presumably higher with ejaculation in the mouth than without it, this may not actually make an important difference. While I cannot take the responsibility to say that you don't need to use condoms, many couples in your position would not use condoms for oral sex.
I hope this helps. But please do confirm this advice with your partner's HIV doctor or clinic. Best wishes to you and your partner.
Good luck-- HHH, MD
Thank you so much for your prompt and thoughtful response. I had a couple of followup questions.
1. Does any of this advice regarding risk level change given the fact that we're both men (I noticed you had a comment regarding conceiving children)?
2. I noticed you didn't mention Post-Exposure Prophylaxis. Is the risk of a broken condom + the low viral load not enough to warrant possibly keeping a dose of PEP on hand 'just-in-case'? Do you believe PEP would be warranted in a situation where anal sex was occurring and there was a condom rupture (with or without ejaculate)?
Thank you so much again
You're right: I thought you were female. I guess my own (heterocentric?) biases were in play. Shame on me!
But no, none of this advice changes on that basis.
As for PEP, to my understanding the guidelines promulgated by most experts (e.g., the Infectious Diseases Society of America, CDC, and others) have not yet incorporated the evolving data on transmission risk as related to ART and viral load. My personal judgment is that you would not need PEP in the event of a condom failure during anal sex, with or without intra-rectal ejaculation. But I'm not confident all experts would agree. This is also something for discussion with your partner's doctor or clinic.
Thanks so much for your quick response!
I suppose this last question may be one just meant to smooth the anxiety level before we speak with his physician.
Basically, my last question before I leave you alone: the evolving data on viral load and transmission risk, would you say that it's scientifically and statistically reliable? As I know you've heard many times on this site, there are a bunch of statistics regarding HIV/AIDS that may not give the whole picture (the San Francisco oral sex study, for instance, which causes many people confusion. Similarly, I, for one, didn't know until I spoke to you that the estimates given out were based on high-viral load, untreated encounters.).
I know this research is probably in an entirely different league. Basically I just want to know if you feel that this new research is reliable based on your professional medical opinion.
I cannot thank you enough for this service Doctor - it's given me a great starting point and peace of mind.
Yes, I believe the data on viral load and transmission risk are reliable. But I am just echoing the views of most HIV/STD prevention experts. This is now the garden-variety, middle-of-the-road understanding. A couple years ago, the Swiss government's HIV/AIDS prevention unit used such data to support the astounding policy that HIV infected people on ART no longer need to use condoms regularly for casual sexual encounters. All other experts believed then, and still believe, that that advice was far too cavalier and potentially dangerous -- but it does illustrate how strong the data are. (I don't know if the Swiss prevention policy remains the same.)
Don't misunderstand my statement about older transmission risk estimates "based on high-viral load, untreated encounters". The older data were without any knowledge at all about viral load. However, they were collected at a time when few people were on ART, so it can be assumed that many (not all) infected people in the population had high viral loads.
Thanks for the thanks about the forum.