Swiss Say Condoms Not Necessary...Sometimes

The Swiss Federal Commission for HIV/AIDS released a remarkable statement a few weeks ago that opened the door to the possibility of sex without condoms for people with HIV.

Citing their review of a long string of studies measuring HIV transmission from people with HIV to HIV-negative partners, the Commission concluded that sex without condoms is possible for some people with HIV under certain conditions. Those conditions are specific: the person must currently be on anti-retroviral therapy, have had an undetectable viral load for six months and not have other active sexually transmitted infections.

The commission estimated the risk of transmission, under the cited circumstances, at less than one in 100,000. That's six times the risk of getting hit by lightning (according to the National Oceanic and Atmospheric Administration's risk estimate of one in 600,000), but it is remote enough for the Swiss commission to declare such persons not sexually infectious and state they cannot propagate HIV through sexual contact.

This unambiguous declaration was authored by four of Switzerland's foremost HIV experts: Prof. Pietro Vernazza, of the Cantonal Hospital in St. Gallen, and President of the Swiss Federal Commission for HIV/AIDS, Prof. Bernard Hirschel from Geneva University Hospital, Dr. Enos Bernasconi of the Lugano Regional Hospital (and former President of the Swiss Federal Commission for HIV/AIDS), and Dr. Markus Flepp, president of the Swiss Federal Office of Public Health's Sub-committee on the clinical and therapeutic aspects of HIV/AIDS.

Interpreting the Swiss statement as "permission" to stop using condoms would be a mistake. So too would dismissing it altogether or denying its powerful message of hope.

There are important considerations which were not addressed by the Swiss statement. The research they reviewed was based on heterosexual couples; undetectable viral loads sometimes suddenly spike; and there is a difference between viral load in sperm and viral load in blood. Each must be better understood before foregoing condoms.

Those caveats and concerns not withstanding, this is still an earth-shaking development for people with HIV. Possible liberation from the most burdensome and intrusive restraint on sexual intimacy offers powerful hope for more meaningful, pleasurable sex, without shame or fear.

Perhaps more surprising than the substance of the Swiss statement is its assumption of what has been largely unacknowledged: anti-retroviral therapy is an effective risk reduction and HIV-prevention strategy, at least on a community basis, even though not always medically appropriate on an individual basis.

The most common response from public health officials and HIV prevention experts to the Swiss statement, so far, has been either to ignore it or to point out its limitations while reflexively reaffirming the traditional message to "use a condom every time". There is little popular support for speaking out in favor of expanding the sexual safety zone for people with HIV.

But just as it is a mistake to consider the Swiss guidelines completely risk-free, so too is it a mistake to think condoms are risk-free. The "condom code", which orders their use every time one has sex, generally ignores the risk of breakage (between 1% and 7%, depending on the study) and does not take viral load into consideration.

The Swiss findings suggest the tantalizing--and as-yet unproven--prospect that careful adherence to their guidelines may actually present less risk of HIV transmission than a sole focus on using condoms without consideration of viral load. (Using both--the "belt and suspenders" approach--would reduce risk even further.)

The wiser response to the Swiss statement would be an urgent call to scientific, medical and epidemiological experts, community members and behavioral scientists to pool their collective wisdom and develop detailed new safer sex guidelines that recognize viral load as an important factor in reducing risk.

The HIV prevention establishment is concerned about sending the wrong message about what is safe and unsafe. Yet their reluctance to engage the communities they serve in an honest and open discussion about risk reduction strategies, or the possibility of sex without condoms, is at the heart of what is wrong with HIV prevention efforts.

A response to the Swiss report from the World Health Organization and UNAIDS dismissed it with "more research is needed" and virtually ignored the substance of the report, saying that "A comprehensive HIV prevention package includes, but is not limited to, delaying sexual debut, mutual fidelity, reduction of the number of sexual partners, avoidance of penetration, safer sex including correct and consistent male and female condom use, and early and effective treatment for sexually transmitted infections."

The WHO and UNAIDS did not acknowledge the risk/benefit negotiation inherent in discussion and disclosure of one's HIV status. Nor did they mention other widely-used risk reduction strategies, like withdrawal before ejaculation, or sero-sorting (choosing sexual partners of the same HIV status as oneself) and sero-positioning (choosing sexual positions that present less risk to the HIV negative partner) or pre- and post-exposure prophylaxis.

Failing to fully engage with the community perpetuates the problem public health authorities ought to combat. Stigmatization, prejudice and disempowerment thrive on ignorance. So does HIV transmission. Instead of dismissal, the Swiss statement should be embraced as an opportunity to raise levels of HIV prevention literacy.

Understanding how antiretroviral treatment reduces one's risk of transmission may incent some people to get tested or to commence treatment. The health of at-risk communities--and especially of people with HIV--has depended on having facts and finding hope where it exists. The Swiss statement advances both objectives.

Early in the epidemic, fear of HIV was so great it was necessary to hold press conferences to announce that kissing people with HIV was safe. There are cases where kissing was identified or suspected as the means of transmission, yet they are so rare and only in such extraordinary circumstances that no one has suggested amending the "kissing is safe" message.

In fact, the Swiss statement points out that there is more scientific foundation for their new guidelines than there was for the 1986 announcement that HIV could not be transmitted through kissing.

The question of HIV transmission via oral sex, of any kind, has also had an important evolution. For most of the 1980s, the message was to always use condoms for oral sex. Not many people were willing to do so. A few gave up oral sex but most chose to accept the relatively small risk it posed.

The science and prevention establishment eventually caught up with popular practice. AIDS service organizations and public health officials that once insisted on the necessity to "use a condom every time" for oral sex now routinely categorize oral sex as low-risk or relatively safe.

While risk cannot be quantified precisely, the extremes of "high (unacceptable) risk" and "low (acceptable) risk" are recognized, including that they differ by individual. The Swiss have rightly brought viral load into the risk calculus, revolutionizing the paradigm of HIV prevention, and placing condoms in their proper place, as one tool among many to be utilized to prevent HIV transmission.

HIV prevention efforts in the US would do well to heed the leadership of the Swiss by focusing on the efficacy of risk-reduction strategies, rather than the misleading, unattainable but political expedient holy grail of supposed "risk elimination".

The focus of public health officials and many HIV prevention experts is on controlling, restricting and regulating the sexual behavior of people with HIV rather than informing them with the facts they need--including the truth about relative risks and harm reduction strategies--to make safe choices, take care of themselves and protect others.

Failing to embrace the opportunity presented by the Swiss statement--to stimulate community discussion, improve the ability of individuals to accurately assess risk and encourage more research--is irresponsible.

Sadly, it is emblematic of a continued disempowerment of people with HIV and a failure to acknowledge our profound interest in understanding risk in order to reduce HIV transmission. We are treated like pariahs, our right to intimate sexual relationships denigrated and denied, instead of as vital partners in a shared commitment to end the epidemic.