8. Positive Prevention
Managing your health: a guide for people living with HIV
8. Positive Prevention
Positive prevention, or poz prevention, is a way of reducing HIV transmission by involving HIV-positive people in prevention strategies and prevention work. It builds on years of thought and attention that people living with HIV have given to HIV prevention. This section is an introduction to positive prevention and a step toward making it useful in practical ways for those of us living with HIV.
What is positive prevention?
Positive prevention, or “poz prevention,” is a way of reducing HIV transmission specifically designed by and for people living with HIV. For many years, HIV prevention campaigns were directed mainly at HIV-negative people, focusing on how they could protect themselves from getting HIV. This neglected to consider how people with HIV can contribute to HIV prevention.
Positive prevention is a set of ideas about how people with HIV can contribute to the shared responsibility of reducing HIV in our communities. In practical terms, it is about taking better care of ourselves and the people we connect with. It is also about having the necessary services and environment to support us to do this over our lifetimes.
Positive prevention aims to:
- empower people with HIV and the people with whom we have sex;
- promote healthy relations with sexual partners;
- improve the conditions that contribute to strengthening the sexual health and well-being of people with HIV;
- reduce the possibility of new HIV infections and other sexually transmitted infections.
Why is positive prevention important?
All new HIV infections come from people who already have HIV. Research tells us two important things in this regard: firstly, that the vast majority of us have no desire to pass on HIV and that, even if we slip up, we still carry a standard of caring for people and our communities. Secondly, we know that just over one-quarter of people who are infected with HIV in Canada are unaware of their HIV status.
Taking responsibility for preventing HIV transmission is not as simple as knowing about safer sex, or not sharing needles. It involves thinking deeply about how we make risk decisions and taking the step to know our HIV status by testing.
Beyond knowing our own HIV status, being committed to preventing HIV transmission involves a deep and personal understanding of why we might consider taking risks with our own and others’ health. We need to understand the value we place on sexual pleasure, the role that addictions play in our personal lives, the reasons we might be led to place ourselves or another person in a vulnerable situation, our fears about rejection, our need to be accepted, our insecurities about our attractiveness to others, and so forth. We also need to look directly at what we truly value when we increase risk. This could be about deep connection, heightened sexual charge or a sense of holding on to a really important part of who we are.
If we are able to find ways to use this self-knowledge to lessen the risk to our partners and ourselves, then we become part of the solution. In practice, this may mean changing an inner decision of “I’m willing to take this risk” to actually asking our partner, “What risks are you all right with taking?”
Principles of positive prevention
The following principles of positive prevention are a starting place for managing our health and risk. They also call on us to respect our sexual partners. Strategies for putting these principles into practice are also included.
Shared responsibility
It takes two for an HIV infection to move from one person to another. Shared responsibility means that preventing HIV transmission is not solely up to the HIV-positive person or the HIV-negative person. We do have a responsibility to share decisions that may result in the virus moving from one of us to another.
Behaviour change
Behaviour change is easier when we know why we want to change. The biggest change in behaviour has to do with communication, particularly with yourself (self-talk). A good time for self-talk is either before you find yourself in a situation where risk may happen or after you have taken a risk and want to make sense of it.
The self-talk might consist of visualizing a situation where you meet someone you want to have sex with and you talk to them about HIV and the risks they are willing to take. Think about how you would introduce the topic. Imagine the questions that the person might have and how you would react. Imagine how you would react to different things that this person might say about HIV and risk. In this way, you can practice and perfect the words you’ll say and the things you’ll do when the opportunity arises.
Alternatively, you might try reviewing a situation where you took risks that you didn’t want to and imagine what you could have done or said so that things happened differently.
Taking care of your health and reducing harm
Reducing harm means making decisions to lessen some of the potential harms from sex to yourself and others. Preventing HIV transmission is about developing self-respect and confidence. If risky behaviour is the thing you want to change and it is a challenge, you can always start with practising a change in another behaviour that you care about and that is more manageable, perhaps something that is not even directly related to sex. For example, you might simply make a plan to clean your apartment weekly or start going to an exercise class at your local gym. Success with small changes begins to rewire our ability to take charge.
Disclosure
Telling another person that you are HIV-positive is a brave act. It is especially tough if you believe it might result in rejection. However, the law requires people with HIV to disclose their status before having sex that could pose a “significant risk” to their partners. This certainly includes unprotected anal and vaginal sex. Disclosure may even be required in some cases of protected sex (see Chapter 21, Legal issues for a discussion of this complicated topic).
Some things to think about
Twenty-five years ago when AIDS first appeared, many people began to think about and discuss their sexuality in ways they never had before. Since that time, the ways in which we think about sex and how we have sex have changed greatly.
Desire for unprotected sex
Many people wish they could have unprotected sex more often. This is a natural and normal desire. In the gay community, unprotected anal sex is often called barebacking. It is a controversial issue that has received a lot of attention. Sex workers are sometimes offered additional payment to have unsafe sex with their customers—creating a difficult dilemma. Some mixed-status heterosexual couples choose to have unprotected sex so they can become pregnant.
Serosorting
Often, the choice to have unprotected sex is combined with other strategies that are meant to reduce risk. Some people choose sex partners of the same HIV status—HIV-positive people with HIV-positive partners, HIV-negative with HIV-negative—with the intent to avoid a new HIV infection. This is known as serosorting.
Serosorting does not necessarily mean having unprotected sex. However, for many people, the two go together. Serosorting allows two HIV-positive people to have unprotected sex without infecting an HIV-negative person. What is absolutely vital in serosorting is knowledge and communication. For HIV-positive people, it is vital you get to know the other person’s HIV status; do NOT assume your partner’s status. Many new HIV infections happen because of misunderstandings and assumptions about the other person’s HIV status. If you are not sure, ask.
Two HIV-positive people who decide to have unprotected sex must also consider the risks of re-infection and other sexually transmitted infections, including hepatitis C. See Chapter 7, Your sexual health, for a more detailed discussion of these risks.
Life changes
A major stress in our lives—an addiction, a breakup, health problems, loss of a job or friendship—can lead us to agree to do things we normally would not. If you find this is happening to you, then it is time to seek help to understand the feelings you may have about taking risks or the stress you are feeling. Talk to a friend or go to an AIDS service organization or other mental health professional. You are worth it.
Stimulants, recreational drugs and addictions
Alcohol and recreational drugs can be fun, but they can also affect our safer sex decisions and the way we look after our own health. If you feel that partying is not getting in the way of your maintaining your health, always take condoms and lube with you when you go out. But if partying is affecting your ability to make good sexual decisions and you find yourself having unprotected sex without being in charge, get help from a counsellor at an AIDS service organization or from another mental health professional. See Chapter 4, Healthy living, for more on drugs and harm reduction.
Preventive treatments
You may have heard about using anti-HIV drugs to prevent transmission. This is a relatively new field of research and we are just beginning to learn what role these drugs may play in HIV prevention.
Some studies appear to show that people with HIV who maintain a sustained undetectable viral load as a result of adhering to their anti-HIV drugs may reduce the chances of transmitting HIV to partners when having unprotected sex. Not everyone agrees with this research and this research has not been done on gay men. More importantly, studies have shown that even with an undetectable viral load, it is possible to transmit HIV through unprotected sex. For decision-making between individuals, lowering viral load is not a completely reliable way to make sex safe.
Post-exposure prophylaxis (or PEP for short), means a temporary course of anti-HIV drugs for an HIV-negative person, starting immediately after he or she has been exposed to HIV. If you think you may have exposed your sexual partner to HIV, you can take your partner to the emergency room of your local hospital. PEP may be available there, although payment will probably be an issue. PEP should be started within 72 hours after exposure to HIV.
Pre-exposure prophylaxis, or PrEP, is a similar idea, in which an HIV-negative person may take anti-HIV drugs before being exposed to HIV. The idea is that this may reduce the chance of becoming infected. Currently there has not been enough research to determine whether or not PrEP will work.
Resources
Safer Sex for the HIV positive – Collection of positive prevention articles and resources
Pozitively Healthy: a gay man’s guide to sex and health - Booklet on sexual health for gay men living with HIV from the Poz Prevention Working Group of the Ontario Gay Men’s Sexual Health Alliance
Poz Prevention: knowledge and practice guidance for providing sexual health services to gay men – Practical manual for service providers who work with gay men
Most of these and many other relevant resources can be accessed through the CATIE Ordering Centre or by calling CATIE at 1-800-263-1638.
About the author
David Hoe’s work on HIV/AIDS over the last 20 years includes work in the community and being an advisor to governments. David is a person living with HIV and is a personal life coach in Ottawa. His HIV work now focuses on advocating for new ways to engage people with HIV in HIV prevention. As part of this work, David is currently working with the Positive Prevention Working Group of the Ontario Gay Men’s Sexual Health Alliance.
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