Sexual relationships between people with different HIV statuses were once widely considered off-limits. Now there are many resources available to mixed-status couples.

To reduce the risk of HIV transmission, it’s important for both partners in mixed-status couples to take preventive measures. Antiretroviral therapy, pre-exposure prophylaxis (PrEP), and condoms can help both partners manage and maintain their health. Expert consultation can also help them understand their options for having children.

HIV can’t be transmitted from one person to another through simple skin-to-skin contact or kissing. Instead, the virus is transmitted through bodily fluids. These include blood, semen, and vaginal and rectal excretions.

According to the Centers for Disease Control and Prevention (CDC), having anal sex without a condom is more likely to result in a man or woman contracting HIV than any other sexual behavior. People are 13 times more likely to contract HIV during anal sex if they’re the “bottom partner” or the one who’s penetrated. It’s also possible for men and women to contract HIV during vaginal sex. The risk of transmission during oral sex is lower.

When people have high levels of HIV in their blood, it’s easier for them to transmit HIV to their sexual partners. Antiretroviral medications can be used to lower the amount of HIV in the blood. With these medications, HIV-positive people may be able to achieve and maintain an undetectable viral load. An undetectable viral load occurs when an HIV-positive person has so little of the virus in their blood that it can’t be detected by tests.

People with an undetectable viral load aren’t at risk of transmitting HIV to their sexual partners, reports the CDC.

Condom usage, as well as preventive medication for the partner without HIV, can also decrease the risk of transmission.

“Treatment as prevention” (TasP) is a term that describes the use of antiretroviral therapy to prevent transmission of HIV.

AIDSinfo, a service of the U.S. Department of Health and Human Services, recommends that all people diagnosed with HIV receive antiretroviral therapy. It’s important to begin antiretroviral therapy as soon as possible after a diagnosis. Early treatment can lower a person’s risk of transmitting HIV, as well as reduce their chances of developing stage 3 HIV, commonly known as AIDS.

HPTN 052 study

In 2011, the New England Journal of Medicine published an international study known as HPTN 052. It found that antiretroviral therapy does more than stop the replication of the virus in HIV-positive people. It also lowers their risk of transmitting the virus to others.

The study looked at more than 1,700 couples, mostly heterosexual. Almost all study participants reported using condoms during sex and all received counseling.

Some of the HIV-positive participants began antiretroviral therapy early, when they had comparatively high counts of CD4 cells. CD4 cells are a type of white blood cell.

Other HIV-positive participants had their treatment delayed until their CD4 counts fell to lower levels.

In couples where the HIV-positive partner received early therapy, risk of HIV transmission was reduced by 96 percent.

Undetectable = untransmittable

Other research has confirmed that maintaining an undetectable viral load is key to preventing transmission. In 2017, the CDC reported that transmission is impossible when antiretroviral therapy suppresses HIV levels to undetectable levels. Undetectable levels were defined as less than 200 copies per milliliter (copies/mL) of blood.

These findings serve as the foundation for the Prevention Access Campaign’s Undetectable = Untransmittable campaign. This campaign is also known as U = U.

People without HIV can protect themselves from contracting it by using pre-exposure prophylaxis (PrEP). PrEP is currently available in pill form and sold under the name Truvada. It contains two antiretroviral drugs: tenofovir disoproxil fumarate and emtricitabine.

Effectiveness

PrEP is most effective when taken daily and on a consistent basis. According to the CDC, studies have found that daily PrEP can lower a person’s risk of contracting HIV from sex by more than 90 percent. It reduces transmission risk by more than 70 percent for people who use injected drugs.

If PrEP isn’t taken consistently, it’s much less effective. For example, at the end of the iPrEx study, 51 percent of participants had detectable levels of PrEP in their blood. Those with detectable levels in their blood had a 95 percent reduction in risk of HIV acquisition.

More recent research, such as the PROUD study, has reinforced the connection between adherence to PrEP and its effectiveness.

Best candidates for PrEP

If a person is planning to have sex with an HIV-positive partner, they may want to consider asking a healthcare provider about PrEP. PrEP may also benefit people who have sex without condoms and:

  • don’t know the HIV status of their partners
  • have partners with a known risk factor of HIV
  • have multiple sexual partners

Obtaining PrEP

Many health insurance plans cover PrEP. Individuals may want to try contacting their health insurance provider for more information. Some people might also be eligible for a commercial medication assistance program run by the manufacturer of Truvada.

Before having sex without condoms, it’s best to get tested for HIV and other STIs. Consider asking partners if they’ve been tested recently.

If either member of a couple has tested positive for HIV or another STI, they can protect each other by getting treatment. They can also ask their healthcare provider for tips on how to reduce the risk of transmission.

Condoms

Condoms can help stop the transmission of HIV and many other STIs. They’re most effective when used every time a person has sex. It’s also important to use them according to the package directions and discard expired, used, or torn condoms.

Antiretroviral therapy combined with PrEP

If a person is in a monogamous mixed-status relationship, their healthcare provider will likely encourage them and their partner to combine condoms with antiretroviral therapy. This combination helps to lower the risk of HIV transmission. If the HIV-positive partner has a detectable viral load, then the partner without HIV can use PrEP to prevent transmission.

Consider asking a healthcare provider for more information about PrEP and other prevention strategies.

Thanks to advances in medical science, there are many options available to mixed-status couples who want to have children. AIDSinfo encourages mixed-status couples to seek expert consultation before trying to conceive. A healthcare provider can inform them about their options for healthy conception and delivery.

If a female member of a mixed-status relationship is HIV-positive, AIDSinfo recommends using assisted insemination to try to conceive. This approach involves a lower risk of HIV transmission when compared to conventional sex without condoms.

If a male member of a mixed-status relationship is HIV-positive, AIDSinfo advises using sperm from an HIV-negative donor to conceive. If this isn’t an option, men can have their sperm “washed” in a laboratory to remove HIV. However, AIDSinfo notes that this procedure hasn’t been proven completely effective. It’s also expensive, generally costing several hundred dollars.

Because it involves sex without condoms, natural conception can put people without HIV at risk of contracting it. However, there are steps a couple can take to lower the risk of transmission.

Before attempting natural conception, AIDSinfo suggests that the HIV-positive partner try to suppress their viral load as much as possible. In many cases, they may be able to use antiretroviral therapy to achieve and maintain an undetectable viral load. If they can’t do so, their partner can try PrEP.

AIDSinfo also advises mixed-status couples to limit sex without condoms to periods of peak fertility. Peak fertility may occur in the two to three days before ovulation and on the day of ovulation. Using condoms for the rest of the month can help lower the risk of HIV transmission.

It’s possible for pregnant women with HIV to transmit it through blood and breast milk. But taking certain precautions can reduce the risk.

To lower the risk of HIV transmission during pregnancy, AIDSinfo encourages prospective mothers to:

  • undergo antiretroviral therapy before, during, and after conception, pregnancy, and delivery
  • consent to have their child treated with antiretroviral medications for four to six weeks after birth
  • avoid breastfeeding and use baby formula instead
  • speak to their healthcare providers about the potential benefits of cesarean delivery, which is primarily recommended for women with relatively high or unknown HIV levels

AIDSinfo notes that, if a woman and her baby take their HIV medications as prescribed, it can lower the baby’s risk of contracting HIV to 2 percent or less.

Treatment options have made it possible for many to live long and healthy lives with HIV. Stunning medical advances have also been made in the field of HIV prevention, which has increased the possibilities for mixed-status couples.

Moreover, anti-stigma campaigns have developed educational resources to help address misconceptions and discriminatory attitudes about people living with HIV. While more work need to be done, a study published in the Journal of the International AIDS Society shows that progress is being made.

Before having sex with someone who has a different HIV status, consider making an appointment with a healthcare provider. They can help develop a plan to prevent HIV transmission.

Many mixed-status couples have satisfying sexual relationships and even conceive children without concern that the partner without HIV will contract the virus.