How to Have Safe Sex When You or Your Partner Have HIV

HIV medicine, called antiretroviral therapy (ART), stops the virus from making copies of itself. Over time, the amount of virus in the blood can drop so low that standard tests can't find it. This is called an undetectable viral load.

"When you get undetectable and stay undetectable, you cannot sexually transmit HIV to your partners," Zajesky said. "Not 'probably won't' or 'the risk is very small.' You will not sexually transmit HIV."

That's the idea behind U=U, or Undetectable = Untransmittable, and science backs it up. A 2023 review in The Lancet looked at eight studies of more than 7,700 couples where one partner had HIV and the other did not. Researchers found only two possible transmissions when the partner with HIV had fewer than 1,000 copies of the virus per milliliter of blood. In both cases, that partner's last viral load test was at least 50 days old, so their levels may have risen since.

Zajesky said most of her patients become undetectable four to eight weeks after starting treatment. Even so, her team advises patients to use condoms or skip sex for the first six months on medication to make sure their viral load stays low.

Note that U=U does not protect against other sexually transmitted infections (STIs) or pregnancy, so other forms of protection such as condoms are still important to keep partners safe.

If you have HIV, sharing your status with your partner can feel scary, but it doesn't have to feel like a confession. Zajesky suggested picking a private, relaxed moment before sex. Here's language she offers to help bring up the subject:

"Before we take this any further, there's something important I want you to know. I’m HIV positive. I’m on treatment, and my viral load is undetectable, which means I cannot transmit HIV sexually. I’m healthy and I’m happy to answer whatever questions you have."

Then give your partner time to take the information in. "HIV is a medical condition, not a reflection on your character, your sexuality or your worth," Zajesky said.

Partners often ask Zajesky what happens if a treatment dose is missed. The virus doesn't bounce back right away, she said, but daily meds and regular lab tests are what keep U=U working. Couples also often ask her about having children. When the partner with HIV stays undetectable, federal guidelines say couples can conceive without condoms and without passing HIV to the partner or baby.

If you don't have HIV but your partner does, two kinds of medicine can protect you. The difference is timing.

PrEP (pre-exposure prophylaxis) is taken before sex. It comes as a daily pill, a shot every two months or a shot just twice a year. In a large study of more than 2,100 young women in South Africa and Uganda, none who got the twice-yearly shot got HIV. A second study that included U.S. sites found similar results in men and gender-diverse people: 99.9% stayed HIV-free.

PEP (post-exposure prophylaxis) is taken after a possible exposure, like a broken condom. You take PEP every day for 28 days, and you must start the treatment within 72 hours of the exposure, although it’s best to start within 24 hours. You can get PEP at an emergency room, then follow up with your clinician or an infectious disease specialist.

If your partner stays undetectable, you don't medically need PrEP. But Zajesky said that some people take it anyway as an extra level of reassurance.

Read: PrEP and PEP: Prevention for HIV >>

The tissue in the vagina and anus is thin and tears easily during sex. Tiny tears make it easier for viruses and bacteria to reach the bloodstream. “Once torn, it is much easier for bacteria and viruses to reach the bloodstream and infect you,” Zajesky explained. Lubrication cuts down on friction and helps keep condoms from breaking or slipping.

Zajesky recommends using water-based or silicone-based lube. Silicone lasts longer, which makes it a good pick for anal sex. Skip lube with nonoxynol-9 (N-9), a spermicide. It can irritate vaginal and rectal tissue and may actually raise your chances of getting HIV. Also avoid oils like coconut oil or Vaseline, which can weaken latex condoms.

If you or your partner is not undetectable yet, or you just want to take things slow, intimacy doesn't have to stop. Sex can mean a lot more than intercourse. "Mutual masturbation or other forms of self-fulfillment can also be healthy outlets for sexual gratification," Zajesky said.

Touching, kissing and oral sex carry extremely low to no risk of passing HIV. And the virus doesn't spread through saliva, so kissing is safe.

Here are some ideas you and your partner can try:

• Kissing, cuddling and massage. These activities let you feel close to your partner with no HIV risk.
• Mutual masturbation. This means touching yourselves while you're together. This is a completely risk-free way to share pleasure safely. If you touch your partner's genitals, wash your hands before touching your own body, mouth or eyes.
• Body rubbing with clothes on (also called dry humping and grinding). Keeping clothes on keeps body fluids apart.
• Sex toys. Wash sex toys with soap and water before they touch another person, or cover them with a condom and switch to a fresh condom between partners.
• Oral sex. Oral sex carries a much lower risk of spreading HIV than vaginal or anal sex, but the risk isn't zero. A condom or dental dam lowers the risk more. Bleeding gums or mouth sores can raise the risk, so skip oral sex if either of you has them.
  

Money and access matter when it comes to staying undetectable. "If a patient can't afford their meds, they can't take them," Zajesky said. Without insurance, transportation or stable housing, keeping up with appointments and lab tests gets hard. Zajesky has seen recent Medicare and Medicaid cuts hurt her patients, especially prevention services. “Once [patients] are no longer virally suppressed, the HIV begins to weaken their immune system, putting them at risk of opportunistic infections and increasing the risk of transmission.”

While funding challenges affect access, there are still programs available to help. The AIDS Drug Assistance Program (ADAP) provides HIV medicines to people with low incomes who have little or no insurance coverage. Each state runs its own ADAP, and some also help with insurance premiums or copays. You'll usually need to show proof of your HIV status, income and where you live to qualify. To apply, ask your HIV clinic for a case manager or contact your state health department.

For people who want PrEP, most private health plans must cover PrEP at no cost under the Affordable Care Act. If you're uninsured, many states have a PrEP Assistance Program (PrEP-AP) that may pay for PrEP medicine, lab tests or clinic visits. Some state programs, like New York's, cover visits and labs while the medicine comes through drug makers' assistance programs. Find your state's program in NASTAD's national directory.

"Loving someone with HIV is no different than loving someone without," Zajesky said. Many of her patients living with HIV have loving, fulfilling relationships with partners who don't have HIV. The tools to keep everyone safe are available. The key is using them and staying consistent.

NASTAD State PrEP and PEP Assistance Programs Directory

NASTAD PrEP Assistance Programs