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Safer sex for HIV positive people

Sex is an important part of our lives, regardless of HIV status. Safer sex practices reduces the risk of getting or spreading sexually transmitted infections including HIV.

There are different risks associated with transmission of different infections by different sexual activities. HIV is transmitted when body fluids containing HIV virus is passed on from one person to another. The greatest risk is when blood or sexual fluids (semen, vaginal secretions) touches the soft, moist areas (mucous membrane) inside the rectum, vagina, mouth, nose, or the tip of the penis. These can be damaged easily and provides a way for HIV to get into the body. Risks are increased if you or your partner has cuts, sores, or bleeding gums in the body. To be safe, assume your partners are infected with HIV until proven otherwise.

Sexually Transmitted Infections:

There are many bacterial and viral infections that are commonly transmitted through sex. These are commonly called sexually transmitted infections (STIs) or sexually transmitted diseases (STDs).

Common bacterial STIs include Gonorrhea, Chlamydia and Syphilis. Untreated gonorrhea and Chlamydia can lead to infertility and damage to internal organs. Untreated syphilis can cause damage to internal organs including the brain. Gonorrhea and Chlamydia can be treated and cured the same way in all people but syphilis may be more difficult to treat in HIV positive people and may require longer and more aggressive treatments. Increasingly, there are more reports of an aggressive form of Chlamydia called LGV (lymphogranuloma vernerum) which often causes bleeding in the rectum.

Common viral STIs include genital herpes and warts. These viral infections are generally not curable, even in HIV negative people. They tend to recur and are harder to treat in people with a damaged immune system. Genital herpes cause painful ulcers on the skin. Genital warts are linked to increase risk of cervical and anal cancers. Genital ulcers caused by herpes and syphilis can increase the risk of HIV transmission.

The liver viruses hepatitis A, B & C, can also be transmitted sexually. Having HIV and hepatitis together may also increase symptoms and the risk of progression of both diseases, and make treatments for both conditions more difficult. There are vaccines for hepatitis A and B and all HIV positive people are advised to get these vaccinations.

In addition, some HIV related opportunistic infections, can be transmitted sexually as well. These include:

1. Kaposi Sarcoma which is linked to transmission through a form of herpes virus.
2. Bowel infections such as Giardia, amoeba, cryptosporidium and microsporidium, can be transmitted through oral-anal contact or any activity that lead to contamination of feces getting into the mouth. These infections can cause severe diarrhea and dehydration especially in people with very weak immune system.
   
   Having other STIs increases the amount of HIV in your genital fluids, therefore increases the risk of transmission to others and also the progression of the infection in yourself.

Anal & Vaginal Intercourse:

Unprotected vaginal and anal intercourse is very unsafe because these acts tend to cause small tears in the mucous membranes. Both the insertive partner and the receptive partner can be infected, though the risk is higher for the receptive partner. Some men mistakenly believe that if they pull out before orgasm (ejaculation) it would not cause infection. This is untrue because HIV can be present in the fluid (pre-cum) that comes out of the penis before orgasm.
Using a male or female condom during intercourse will reduce the risk of transmission of HIV and STIs. Lubricants reduces the trauma and tears in the mucous membranes and can increase sexual stimulation. However, oil-based lubricants (e.g. Vaseline, oils) can damage latex condoms so make sure you use water-based lubricants (e.g. KY, Wet etc.) if you use latex condoms. Spermicides with nonoxynol-9 should be avoided because they cause irritation to the mucous membranes and may increase risk of STI transmission.

Oral Sex:

Oral sex has some risk of transmitting HIV and can transmit all common STIs. Using condoms over the penis and latex barriers (e.g. dental dam) over the vagina as barriers during oral sex will reduce risk of transmission.

Safe Activities:

Safe activities have no risk for spreading HIV or STIs. These include kissing, masturbation, fantasy, sex talk, non-sexual massage and any acts that do not involve contact with blood or sexual fluids.

Disclosure issues:

Disclosure of your HIV status to your sex partner is a very sensitive issue and can be very difficult for some people. Talk to your doctor, nurse or counselor to get more information on safer sex practices, how to effectively protect yourself and your partner, and how to deal with disclosure issues.
However, it is important to be aware that in some countries, including Canada, there have been legal cases where someone with HIV has been charged for knowingly infecting his/her partners through unprotected sexual activities without telling them about their own HIV status.
For further details on the most updated legal information on disclosure, please consult the website of the Canadian HIV/AIDS Legal Network: www.aidslaw.ca (in English and French)

Sex with HIV negative people and those whose HIV status are unknown:
If you are HIV positive, using condoms during sex with people who are HIV negative or are unsure of their HIV status will protect them against HIV and protect both of you from STIs.
Even with you are taking anti-HIV medications and your blood viral load is undetectable, you can still have enough virus in your body fluids to pass on HIV.

Sex with other HIV positive people:
If you are HIV positive and having sex with another person who is also HIV positive, it is still advisable to use condom for protection for several reasons:

1. Unprotected sex between men and women can lead to pregnancy and there may be a risk of transmission of HIV to the baby
2. You may be infected with a new and different strain/type of HIV virus, which may make your infection more aggressive or resistant to anti HIV medications. This can lead to treatment failure.
3. Unprotected sex will put you at risk for other sexually transmitted infections some of which are hard to treat in PHAs.

If you are sexually active, it is advisable for you to talk to your doctor or nurse about your sexual activities, and to have check up to screen for sexually transmitted infections at least every six months.