My new boyfriend and I are both positive. He wants sex without protection, but I worry about catching a second form of HIV (superinfection) or a urinary tract infection. What are the odds?

—Super Worried

Dear Worried,
I get so many questions about this. Let’s face it: Sex without a condom can be more pleasurable and intimate. The desire to have unprotected sex is common in couples, whether or not they know their status.

While there is evidence of superinfection, it’s very limited, and doctors haven’t seen many cases in patients who’ve had unprotected sex with their positive partners. Many HIVers in relationships have had unprotected sex without their disease worsening. This doesn’t mean it can’t happen. Without a large superinfection clinical study it’s difficult to pinpoint your risk—but it’s considered quite low.

However, there may be a greater risk for superinfection when another sexually transmitted infection (STI) is present. Gonorrhea, syphilis, chlamydia, herpes and urinary tract infections can lower CD4 counts. These are difficult for HIVers to fight, and open sores or lesions from STIs make HIV transmission easier. You can avoid other STIs by being monogamous.

Superinfection can pose long-term treatment problems because mutated virus may not respond to some meds. While mutations naturally occur, poor pill adherence can also contribute. If you or your partner aren’t adherent and are having unprotected sex together, you’re more likely to swap mutations. If possible, get on the same dosing schedule and take your meds correctly and consistently.

If you decide to have unprotected sex, agree on what risks each of you is willing to take. As long as you are clear of other STIs, are in a caring and monogamous relationship and are med-adherent, there’s little evidence that condomless sex is harmful.

+ Perry N. Halkitis, PhD, is a professor at New York University and director of the Center for Health, Identity, Behavior & Prevention Studies.

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