BRENT ALLAN explains there are numerous strategies that positive people can employ to reduce risk to their partners — and themselves.
“HIV-infected persons who remain sexually active should be reminded that the only certain means for preventing transmission to noninfected persons is to restrict sex to partners known to be already infected with HIV and that they have a responsibility for disclosure of HIV serostatus to prospective sex partners.” — CDC Morbidity and Mortality Weekly Report, July 18.
New guidelines, issued by the Centres for Disease Control and Prevention (CDC) have told US doctors to “incorporate HIV prevention messages into the medical care” of their HIV-positive patients. These guidelines signal a change in emphasis that could be interpreted as making positive people solely responsible for HIV transmission and moving away from the principle of shared responsibility.
While that hasn’t happened here (yet), there are signs that, with increases in HIV infection rates in several states, claims of “safe sex complacency” and calls for urgent action, positive people need to claim ownership of sophisticated and effective safe sex strategies and reaffirm their position as a group united against AIDS and fighting to prevent HIV transmission.
Safe sex has always been about reducing — not eliminating — the risk of HIV transmission. Both HIV-positive and negative people have been encouraged to ‘play safe’ from the early days of HIV/AIDS, even before we knew for sure that HIV was sexually transmitted. But what constitutes ‘safe’ is changing as we learn more about HIV, how it is transmitted and the increasingly sophisticated options available to us to reduce the risk of transmission.
In those early days, when we had only limited understanding of the transmission of HIV, people were encouraged to either put a latex barrier between them and their partner or abstain from sex altogether — especially if they were unsure about their partners’ (or their own) HIV status. This extended to all forms of fucking, sucking, rimming and even fingering (perhaps only a few of us will remember finger cots?)
With only minimal information available to us to make safe sex choices, we were told to avoid almost all contact with anyone else’s body fluids. “Safe Sex is Hot Sex,” we were informed, and many of us dutifully went along to workshops where “hot” techniques in mutual masturbation and tickling with feathers were taught.
After the HIV test came along in 1985, options for other safe sex strategies were introduced (or in most cases simply figured out by people as they went about their sexual business) such as negotiated safety (“Talk-Test-Test- Trust”) and withdrawal before ejaculation (first for oral sex and then for fucking in certain circumstances).
As we learn more about the biology of HIV transmission, we have been able to create more safe sex strategies. Providing options to people is far more persuasive than dogma, which tends to lose credibility as it loses touch with everyday experience.
‘Safe’ sex means different things to different people in different circumstances, but safe sex has always been about options. Every sexual encounter is different and for each there is a safe sex option — in some cases there are many options.
So what are some of the options when it comes to safe sex for people living with HIV?
For us, there are two primary and equally important considerations: we need to limit the possibility of transmitting HIV (or another sexually transmissible infection) to our partners and we need to reduce the likelihood of acquiring an infection that will negatively affect our own health.
To reduce the risk of transmitting HIV to another person, condoms are the best of all choices when it comes to fucking, whether vaginal or anal. They have proven highly effective in limiting the spread of HIV, regardless of what their detractors may say. The evidence of the success of condom use is overwhelming and, when used properly, condoms have the added benefit of providing protection against a number of other sexually transmitted infections. On the other hand, many people find that they are awkward to use, a barrier to intimacy and most people say they would prefer not to use them if they didn’t have to.
Choosing to use a condom in certain circumstances may be the best option, but not necessarily the only option.
Some HIV-positive people choose to not use condoms when there is limited or no risk of transmitting HIV, such as when having sex with a positive partner. The risk can also be also reduced by maintaining a low viral load or if the positive partner assumes the receptive (bottom) position.
The table below shows the relative risk of a variety of sexual acts. The riskiest is where an HIV-negative person takes the receptive role in anal sex — if that act is rated as 100, the relative risk of other acts has been estimated as shown in the table.
This table, based on data from the CDC, doesn’t show the actual probability of transmitting HIV, but it does illustrate the different levels of risk depending on the sex act and the position of the HIV-negative partner.
These strategies, like condom use, reduce the risk of transmitting HIV — they do not eliminate the risk of HIV transmission.
Some HIV positive people choose different risk reduction practices based on their partner’s HIV status. Social and behavioural research clearly indicates that an overwhelming majority of HIV-positive people choose to use condoms with a sexual partner who is HIV-negative; but in situations where both partners are HIV-positive, many positive people choose not to use condoms at all.
Assuming the passive, receptive or ‘bottom’ role in sex — ‘strategic positioning’ — is another strategy that some positive people are using to reduce the risk of transmission of HIV to their sexual partner. This is based upon the fact that your partner is much less likely to be infected with HIV when taking the insertive role, as the table shows. This can be an effective strategy, although it’s far from perfect and may be more effective when combined with keeping your viral load low and avoiding other infections.
Having these different strategies available to use and applying them on the basis of our sexual partner’s HIV status enables us to reduce risks and to maximise enjoyment. Of course, they do not eliminate risk completely — we still don’t know enough about the risk of superinfection and there is always the risk of acquiring another sexually transmitted infection (STI) such as gonorrhoea or syphilis.
Keeping your viral load low by using HIV antiretrovirals means there is less virus in your body and it does reduce the likelihood of transmitting HIV — we know that. With more HIV-positive people in Australia than ever before and increasing rates of unprotected casual anal intercourse being reported, the importance of maintaining low viral load is emphasised.
If HIV treatments were more effective and easier to take, the effect of low viral load levels across the community on transmission rates could be quite dramatic. In the meantime, however, many of us are finding the tolerability and effectiveness of treatments lacking. This suggests another risk reduction strategy: if you’re taking a break from treatments for any reason or if your viral load is high, condoms really are the only way to go.
Even with undetectable viral load, the risk of transmitting HIV increases if you have any other infection (especially an undiagnosed and untreated sexually transmitted infection). Positive people who choose not to use condoms owe it to themselves and their partners to have regular sexual health checkups and keep health to ensure they avoid this situation. Or use condoms.
The second important consideration for people living with HIV is the impact that acquiring another sexually transmissible infection on top of HIV may have on their own health. Many sexually transmissible infections can be more aggressive and more difficult to treat in people with HIV. Syphilis is still on the rise in Australia, and positive gay men make up more than half of reported cases.
Condom use, although effective as a barrier with regard to HIV transmission does not eliminate all sexually transmitted infections and this is an important consideration for HIV positive people to factor into their decision making both with regard to the transmission and acquisition of an STI.
Safe sex is more an art than a science — and it always has been. Even the most hard-line condom advocates acknowledge that condoms, and human beings, are not perfect. Thankfully condom use is an effective barrier to HIV transmission and many other sexually transmitted infections such as gonorrhoea and chlamydia, unfortunately they do not protect against all sexually transmitted infections. Employing risk reduction strategies requires thoughtful consideration, attention to one’s own health status, the confidence and ability to disclose your HIV status and the skills to make healthy choices for yourself and thus your sexual partners.
*Brent Allan* is NAPWA’s national education portfolio co-convenor; the views expressed in this article are his own and do not necessarily represent the views of NAPWA.
