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 kissing or simple skin-to-skin contact, such as hugging or shaking hands. Instead, the virus is transmitted through certain bodily fluids. These include blood, semen, and vaginal and rectal excretions — but not saliva.

According to the Centers for Disease Control and Prevention (CDC), having anal sex without a condom is more likely to result in a person 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 people 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 stop HIV from replicating, or making copies of itself, 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 have “effectively no risk” of transmitting HIV to their sexual partners, according to 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 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 mixed-status 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. A CD4 cell is 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 there is “effectively no risk” of transmission 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 the virus by using medication known as pre-exposure prophylaxis (PrEP). PrEP is currently available in pill form under the brand names Truvada and Descovy.

Truvada contains two antiretroviral drugs: tenofovir disoproxil fumarate and emtricitabine. Descovy contains the antiretroviral drugs tenofovir alafenamide and emtricitabine.


PrEP is most effective when taken daily and consistently.

According to the CDC, studies have found that daily PrEP can lower a person’s risk of contracting HIV from sex by about 99 percent. Daily PrEP reduces transmission risk by more than 74 percent for people who use injected drugs.

If PrEP isn’t taken daily and consistently, it’s much less effective. Recent research, such as the PROUD study, has reinforced the connection between adherence to PrEP and its effectiveness.

Best candidates for PrEP

Any person planning to have sex with an HIV-positive partner 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 for HIV

Obtaining PrEP

Many health insurance plans cover PrEP now, and even more will after the US Preventive Services Task Force (USPSTF) recommended PrEP for all individuals with known risk factors for HIV. Contact your health insurance provider for more information.

Some people might also be eligible for a medication assistance program run by Gilead, the manufacturer of Truvada and Descovy.

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, getting treatment will help prevent transmission. They can also ask their healthcare provider for tips on how to reduce the risk of transmission.


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, the partner without HIV can use PrEP to prevent contracting HIV.

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 cisgender 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 cisgender 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 2 to 3 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. 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 4 to 6 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 from their mother to 1 percent or less.

Treatment options have made it possible for many to live long and healthy lives with HIV. Important 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 needs 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.