Are Lesbians Safe From HIV?

Confirmed case of HIV sparks fear and speculation

Lesbian couple on bed

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The risk of HIV among lesbians (also referred to as women who have sex with women) has long been considered low. But as recent as 2014, there have been cases of sexual transmission between two women where no other possible route of infection.

Does this mean that the woman-to-woman sexual transmission of HIV can no longer be considered rare? Or are there specific factors that increase that potential for infection that might inform prevention strategies moving forward?

Women Who Have Sex With Women

Women who have sex with women (WSW) is a term used to categorize females who engage in sexual activity with other females, regardless of how they identify themselves. The term was created in the 1990s by epidemiologists as a surveillance tool to better identify the route of HIV transmission and the spread of the disease through female-female sexual activity.

Prior to this, researchers were limited by the identity-based analyses, wherein women who identified as lesbian or bisexual weren't necessarily sexually active, while those who identified as straight might be sexually active with other women.

The term WSW instead focuses on behavior rather than cultural or personal self-identification, thereby providing a clearer picture of HIV prevalence and, in turn, a better perspective of the strategies needed to prevent HIV.

Infection Rates

In the course of the history of HIV, much of the public health focus has been placed on HIV transmission among men who have sex with men (MSM), still considered among the highest risk category in most countries. By contrast, HIV among WSW has garnered far less attention, with the common belief that, as a group, they are of the negligible risk of infection.

Statistics largely support that belief. According to the U.S. Centers for Disease Control and Prevention (CDC), of the 246,461 American women infected with HIV in 2004, only 534 reported having sex exclusively with women.

Of these, 91 percent had at least one other key risk factor, typically injecting drug use. A similar study found that, of a million female blood donors, not one identified as HIV-positive reported sex with another woman as their sole risk factor.

Many of the investigated cases were not among women who exclusively had sex women but among those who were infected through other high-risk activities, such as sex with a bisexual male partner.

A 2008 report from the CDC concluded that, among 3,139 HIV-positive women, 14 percent of white women, 6 percent of black women, and 6 percent of Hispanic women acknowledged having sex with a bisexual partner.

Additionally, injecting drug use among HIV-infected women was seen to be the primary route of infection in between 24 percent to 33 percent of cases.

Cases of Transmission

To date, there have been only six cases of HIV transmission among WSW in which other high-risk factors were not readily identified.

In 2003, an African American woman reportedly acquired HIV from her female partner after vigorous sex using shared sex toys. Genotypic testing confirmed a genetic match with the partner's virus. Both women had reported that their relationship was monogamous and that neither had sex with a man. As there was no evidence of injecting drug use, it was concluded that the vigorous use of sex toys resulted in transmission through blood-tinged body fluids.

Because the HIV-positive partner was on antiretroviral therapy (ART), the women believed that the risk of transmission was unlikely and did not consider using protective barriers such as dental dams or condoms.

In March 2014, a similar case was reported by the CDC in which a 46-year-old Texas woman had "likely acquired" HIV through sex with her 43-year-old, HIV-positive female partner. Genetic testing showed a 98 percent match to that of her partner's virus, while a number of risk factors that could have contributed to infection were excluded.

As with the earlier, both women stated that they rarely used protective barriers during sex and that their sexual contact was "rough to the point of inducing bleeding." Furthermore, the partners were said to have had unprotected sex during menses.

However, unlike the 2003 case, the HIV-positive partner had stopped receiving ART nearly two years earlier, suggesting that her elevated viral load potentiated a greater likelihood of HIV transmission. Moreover, at the start of therapy, the woman had severe weight loss and esophageal candidiasis, the latter of which is one of the CDC's definitions of AIDS.

When looking at these factors in their totality, it's clear that the combined factors created something of a "perfect storm" for infection, wherein torn or damaged mucosal tissues could provide easy access for HIV.

HIV Prevention Tips

While current evidence suggests that the risk of transmission is extremely low in WSW with no other risk factors, prevention is nevertheless considered vital. This is especially true in women who are either having sex with an HIV-positive female partner or are uncertain about the partner's status.

Potential risk factors include:

  • Sharing of sex toys
  • Fisting, particularly if there is blood exposure
  • Oral sex

To ensure minimal risk, the use of condoms, fem-dom and dental dams is recommended, particularly during menstruation.

Additionally, an elevated viral load in the HIV-infected partner, whether treated or untreated, correlates to potentially higher risk. Therefore, the need for early testing and treatment is considered key to prevention. This is especially important for serodiscordant couples, in which one partner is HIV-positive and the other is HIV-negative.

Current research has shown that achieving and maintaining an undetectable viral load eliminates your risk of transmitting HIV to an uninfected partner, a strategy known as treatment as prevention (TasP).

The PARTNER1 and PARTNER2 studies, which ran from 2010 to 2018, reported not one incidence of HIV transmission among 1,770 gay and heterosexual mixed-status couples who engaged in condomless sex. This indicates that the risk of HIV transmission when the viral load is fully suppressed is effectively zero for anal, vaginal, and oral sex.

With that being said, HIV is not the only disease that can be sexually transmitted. Safer sex should be adhered to if you have multiple sexual partners. The screening of sexually transmitted infection is also recommended, especially for chlamydia and gonorrhea, if you are sexually active,

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