Rethinking Unprotected Sex for HIV-Positive Men

By Mina Kim

The public health message around unprotected sex for those with HIV has always been the same: Don’t do it. Even with huge strides in medical science that’s changed HIV from a death sentence to a chronic but manageable disease, that directive has not changed.

Now, a new program based in San Francisco is challenging this long-held campaign, and helping HIV-positive men have babies -- the conventional way. The program run by San Francisco General Hospital, called PRO Men, teaches men about a range of reproductive options, from adoption to in vitro fertilization -- where an egg is fertilized in a lab dish -- to carefully timed intercourse.

“I would say as an HIV provider community, we have really failed these men,” says UCSF professor Deborah Cohan, who runs the hospital's Bay Area Perinatal AIDS Center or BAPAC. “We really have not created programs to help them realize those goals and do so safely.”

With the discovery of drugs to treat the virus, Cohan said people with HIV are living long, healthy lives. And for those who want to start families, having “safe” sex, Cohan said, can mean foregoing condoms when a female partner is ovulating. Women can also take HIV drugs, which some studies show can protect against the virus. (BAPAC has helped HIV-positive women who adhere to their medications have healthy babies for years.)

“We know that if the person who is positive takes antiretrovirals and their viral load is suppressed, meaning the medication is working at killing all the HIV in the blood, that the likelihood of them passing HIV to a sexual partner is essentially zero,” Cohan said.

“Essentially zero” but not absolutely zero, Cohan says, because there’s some concern the virus can be in genital fluid even when it’s not detected in blood.

Despite this concern, couples are forging ahead with their family plans. Deon, 32, who thought his life was over when he tested HIV positive when he was in jail four years ago. Now he is about to welcome a baby girl with his fiancée Caroline. (Both Deon and Caroline preferred to go by their first names only.)

The couple became pregnant through unprotected sexual intercourse. Caroline does not have HIV, so the baby does not either. And she said she’s really not too concerned about getting HIV from her partner.

“He’s on his meds, and it’s a really, really, really low chance of me getting it,” she said. “And I just, like I love him, it’s not a big issue.”

BREAKING STIGMA

Though it may not be a big issue for Caroline, being HIV positive and having unprotected sex runs counter to just about every public health message that’s been put out for decades. Both state public health officials and officials with the Centers for Disease Control declined to comment for this story. The latest ethics report from the research and advocacy group American Society for Reproductive Medicine called the practice, “unsafe” and “not recommended.”

The San Francisco program is thought to be the first of its kind, and David Evans with the AIDS activist group Project Inform said it may stay that way for a while.

“I think stigma is still very, very strong in society about HIV in general.”

Evans, who has been following HIV medical science for decades and pushes for policy changes, said that in some states, doctors have refused to help those with HIV have kids altogether. Until about two years ago, health officials in Mississippi required people who tested positive for the virus to sign a form saying they would never have children. Evans said a program that affirms the right of people with HIV to have kids, and let go of condoms, could be revolutionary.

“I think this really changes things in a quite dramatic way,” Evan said. “And it is one of the last big remaining hurdles that I think many heterosexual men and women have to what they would consider living a normal, ordinary life.”

Case in point, as a typical father-to-be, Deon worries more about raising a daughter than he does about his HIV.

“It's like 'Oh my god,’” he said. “I definitely want her to know all kinds of self-defense. I envision her to be a black belt in karate.”

Caroline said she's confident they'll be good parents.

“We just have a really good relationship, like we really talk about everything,” she said. “He says I can make the decisions, but we make decisions together really, and things are just better when we're together.”

The hospital treats about 500 straight men with HIV. The PRO Men program plans to launch a monthly support group in March that will also be open to men living outside San Francisco.

Listen to Mina Kim's story: