Unprotected sex

Safety first

Condoms are one of the most effective and reliable ways of preventing the spread of HIV (and many other STIs) when you have sex. There are other ways of reducing the risk of HIV being passed on if you don't use condoms; some of them are more effective than others. We have sorted the fact from the fiction so you can be aware of the risks you are taking if you don't use a condom.

What is viral load and how does it impact risk?

• Viral load refers to the amount of HIV a person has in their blood, cum and anal mucus 

• The lower the viral load, the less infectious the HIV-positive person will be 

• People who have been diagnosed with HIV are encouraged to have regular blood tests

• Looking at viral load in the blood helps doctors monitor someone’s progress, e.g. to see if the drugs are working for him

• If HIV treatment is successful, someone's viral load will become so low that it will be undetectable. 

What is HIV-undetectable? (U=U)

• Modern anti-HIV drugs mean that most people with HIV on treatment have a very low or undetectable viral load

• Someone with an undetectable viral load cannot infect their sexual partners

• Someone with an undetectable viral load still has HIV and if they stop taking treatment their viral load will become detectable again (and the risk of transmission will increase)

Does being undetectable mean safer sex?

The most recenty study (PARTNER2) recruited and monitored gay couples between 2010-18, where one was HIV-undetectable and the other HIV-negative. There were 782 couples eligble for the study who had condomless anal sex 76,000 times and the study found no transmission of HIV between the couples.

The first PARTNER Study (2010-2014) monitored condomless sex between over 1,000 gay and straight couples where one was HIV-undetectable and the other HIV-negative. After these couples had condomless sex over 58,000 times the study found no transmission of HIV between the couples.

All studies suggest that someone who is undetectable on effective treatment is not infectious. 

The PARTNER study found no cases of HIV transmission from an HIV-positive partner on treatment whose viral load was low enough to be considered undetectable. This remained the case even when other STIs were present.

Researchers are cautious about saying that any prevention method is 100% effective however the weight of evidence that undetectable means uninfectious (U=U) is growing. 

People do not become undetectable immediately when they go on treatment and their viral load may fluctuate, particularly early on. For this reason, the recommendation is that someone should be undetectable for six months before expecting this to mean uninfectious.

Being HIV-undetectable for HIV does not mean that someone won’t pass on other STIs. Using condoms and lube will prevent transmission of a wide range of infections.

What if I have sex less?

It's true that the less you have sex without condoms, the smaller the chance you will catch HIV. Some kinds of sex carry no risk of HIV transmission (wanking, rimming) and some are pretty low risk (blowjobs, especially if cum doesn't get in your mouth).

What if I only have sex without condoms with someone the same HIV status as me?

• There are no visual signs or sexual behaviours which guarantee someone will be HIV-positive or negative 

• There are many reasons why someone may not want to tell you their HIV status and lots of men don't know their HIV status, or believe it to be different from what it actually is

• Around 5% of HIV-positive men don’t know that they have HIV [2]

• If you are HIV-negative you cannot safely or reliably find partners who are also negative if you have just met in a bar or through internet sites/apps.

Having condomless sex will also expose you to other sexually transmitted infections (e.g. hepatitis, syphilis, chlamydia, gonorrhoea and herpes) which can be harder to treat in men with a compromised immune system.

What if I want to stop using condoms with my partner?

If you've slept with someone a few times, or you're starting a relationship, condoms might not seem as important. However, there are a few things you should consider.

• Roughly a third of recently-infected gay men said they got it from having unprotected sex with a regular partner [4]

• If you want to stop using condoms with a partner and want to avoid HIV from entering your relationship, you could come up with a plan to avoid HIV
• PrEP, the HIV prevention drug, could be for you. It is now available on the NHS and it stops the transmission of HIV.

• You need to be sure that you are both HIV-negative and if either of you has never tested, or if you have taken any sexual risks since your last test, you should have an HIV test to avoid any doubt about your status.

If you both test negative it is important that you are both happy with the decision to not use condoms, without either of you feeling under pressure. A healthy relationship is based on mutual trust and respect and carries a level of responsibility on both sides, so you should agree whether or not you are both going to be monogamous. 

Many men stick to their agreement with their boyfriend and some don't. Think about how you might cope if you or your boyfriend made a mistake. If you talk with each other about how you will address it before you ditch the condoms, it will make it a lot easier to own up and get back on track if one of you does fuck someone else without condoms. 

If you have any sex with other people, even if it is always with condoms, you should continue to get tested for HIV and other STIs on a regular basis. You can also look into PrEP as a way to prevent HIV. 

Remember, if you are not sure about ditching the condoms, don't do it. If you ever feel uncertain about anything, you can always go back to using condoms.

What if I go for regular check-ups?

STIs can make HIV-positive men more infectious and HIV-negative men more vulnerable to infection. You can have an STI without knowing it and without any noticeable symptoms. Fortunately most STIs can be treated if they are detected soon enough. An STI check-up every three to six months is enough for most gay men but if you do have symptoms, you should get checked out straight away. Getting tested regularly for HIV will not stop you from becoming infected; it will only tell you if you have become infected.

What about pulling out before cumming?

• Pulling out before cumming will reduce the chance of HIV transmission for the active (top) partner, but not for the person who is  the receptive (bottom) partner. 

• There is more HIV in cum than there is in pre-cum, both in the quantity of the body fluid and the concentration of HIV in that liquid. However, it is still possible to get infected from pre-cum, although it is less likely than if the the active (top) partner cums inside the arse

• Even when withdrawing before cumming, both partners still run the risk of catching other STIs. 

Does it make a difference if you are the top or the bottom?

• Gay men are more likely to catch HIV from being passive (or bottom) than from active (or being top) [6]

• People who do not have HIV have less chance of becoming infected if they are tops and if you have HIV there is less chance of you passing it on to your partner if he fucks you. However, even when topping, you can still get HIV from the anal mucus of an HIV positive bottom guy getting into your urethra. This is how many tops get infected with HIV

• Having sex without a condom or using PrEP is riskier than giving someone a blowjob, even if they cum in your mouth.

What about hard sex and fisting?

• If the lining of your arse is damaged, and you get fucked without a condom, there is more chance of HIV being transmitted

• The lining of the arse is very delicate and can be damaged easily. If this happens, the body's defences will spring into action, and these are the cells that HIV infects. Therefore, fucking someone who has just been fisted, or had sex toys shoved up his arse, makes it easier for HIV to enter his bloodstream

• Gently playing with his arse could reduce the damage of the lining of his arse

• The lining of the arse could be damaged even if you don’t see any blood.

What about poppers?

Poppers (amyl nitrite) have been linked with an increased risk of HIV transmission when used by guys whilst fucking without condoms. In one study, 80% of men who had recently become infected with HIV had used poppers compared with 58% of those who remained HIV-negative [7]. Some researchers think that this is because poppers can cause the blood vessels in your arse to dilate, giving the virus easier access to the bloodstream. It may also be linked to the fact that poppers can relax the arse muscles making it easier for some men to get fucked for longer.

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