Wednesday 29 June, 2016 13.00 EDT
Managing your health: a guide for people living with HIV
7. Your sexual health
Sexuality and sexual practices are incredibly diverse. Although we may think we know what we mean when we refer to “gay sexuality” or “what straight people do,” as often as not we realize that we were thinking in limited or even stereotypical ways. The diversity of sexuality and the variety of sexual practices present challenges in writing clearly and completely about sexual health and HIV. Hopefully, this chapter meets the challenges of clearly explaining the relationship between HIV disease and sexual health for all people with HIV and their partners, because HIV disease has important consequences for all of us. The chapter covers important information for people living with HIV about what we can do to ensure that our sexual lives are as healthy and as fulfilling as possible.
What is sexual health?
Taking care of your health includes taking steps to ensure that your sex life is as healthy as possible. Sexual health means more than the absence of sexually transmitted infections, or the absence of other medical conditions that might prevent you from having a fulfilling sex life. Sexual health is not just the lack of such ailments or conditions, but the presence of a satisfying, respectful and beneficial sexual part of your life.
To be sexually healthy means enjoying a fulfilling and respectful approach to sexuality and sexual relationships. Signs of sexual health include the ability to have pleasurable and safe sexual experiences that are consensual and free from discrimination and violence. To achieve and maintain sexual health, the sexual rights of all persons must be protected, respected and fulfilled.
But in the context of HIV, it’s important to think about more than just your own individual sexual health. Since sex is, for the most part, a social act that takes place between or among people, your own sexual health is inescapably linked to the sexual health of your partners. The idea that you need to be thinking about yourself and your partner(s) may seem obvious at first, but not thinking this idea through can put you in situations of risk for transmission of HIV.
A note about language: this chapter has been written so that the information contained in it is applicable to all people with HIV disease: men, women and trans people, gay, lesbian and straight.
About safer sex
A very important aspect of sexual health is the ability to have safer sex. For people with HIV, safer sex involves learning and practising behaviours that reduce the chances of transmitting HIV or other sexually transmitted infections (as well as hepatitis A, B and C and parasites) to our partners and reduce the chances we will get re-infected with HIV or get a sexually transmitted infection from them.
Because having safer sex reduces—but does not entirely prevent—the possibility of transmitting HIV or a sexually transmitted infection, safer sex is always about the negotiation of risk between you and your partners. You try to negotiate risk or arrive at an agreement between the level of risk that is acceptable to you and the level of risk that is acceptable to your partner.
The Canadian AIDS Society publication HIV Transmission: Guidelines for Assessing Risk is an excellent starting point to learn about safer sex. This publication is available from the CATIE Ordering Centre.
However, we are learning a lot about other factors that affect our risk for getting or transmitting HIV—things like co-infections, the presence of other sexually transmitted infections, the health of our mucous membranes, even our age. With this knowledge, questions (as yet unanswered) continue to emerge about the complex relationship between sexual health, safer sex and HIV.
If you’re having intercourse (meaning putting a penis into a vagina or an anus), it is very important always to use a latex condom. Polyurethane (plastic) condoms protect against HIV, sexually transmitted infections and pregnancy, but break more easily than latex ones. Natural (lambskin) condoms do not provide protection against HIV. It doesn’t matter whether your penis is going inside someone else or his penis is entering you. HIV and other sexually transmitted infections go both ways.
Use a water-based lubricant (lube) with condoms. There are many brands available. Some AIDS service organizations provide free packages of lube as well as condoms. Never use oil-based skin lotions, cooking oil, Vaseline, Crisco, butter or anything oily as these can cause condoms to break. Drugs used to treat problems in your anus or vagina, such as suppositories for fungal infections or creams for hemorrhoids, can also damage condoms.
All condom packages should carry an expiry date. Throw them away if the date has passed. Never store condoms in direct sunlight or in places that are very hot or cold.
Condoms for men should be placed on the penis before starting intercourse or penetration. HIV can be transmitted through pre-cum and vaginal and anal secretions at any time during intercourse. Put a drop of lube inside the tip of the condom before you put it on. Place the condom on the penis with the tip sticking out. Squeeze the tip so that there are no air bubbles in it. Unroll the condom to the base of the penis. If you’re having anal sex (putting a penis in your partner’s anus), make sure the condom is always slicked up with lots of water-based lube. If you want to be really careful, use an extra-strong condom. If one partner is allergic to latex, use both a natural (lambskin) condom and a latex one, keeping the natural one next to the skin of the allergic person. You can also use a polyurethane condom instead of a natural condom.
When you’re finished having sex, take the condom off while the penis is still hard. Hold the open end of the condom while the penis comes out to prevent any semen (cum) from leaking out. Throw the condom out. Never use a condom more than once.
Never use latex condoms that are lubricated with nonoxynol-9 (a spermicide), as this can cause irritation, increasing the risk of HIV transmission. Women who have sex with men can protect themselves from pregnancy with contraceptives (birth control pills, spermicides, for example), but until recently had no way of protecting themselves against sexually transmitted infections and HIV except by convincing their sexual partners to wear condoms.
A condom for women (made of polyurethane, and sometimes called a “female condom”) is available, and it gives women another option for protection. It’s shaped like a large condom and has two flexible rings, one on the top and one on the bottom (where it’s open). The top ring is inserted into your vagina and covers your cervix (much like a diaphragm). The bottom ring remains outside your vagina. It can be inserted minutes or hours before intercourse.
Never douche before or after anal or vaginal intercourse (even if the condom breaks). Douching may irritate your mucous membranes (the skin lining your vagina or rectum) and increase the risk of HIV transmission.
There is evidence that people with HIV may be at increased risk for getting infected with the hepatitis C virus if they have unprotected sex. Although the exact way this happens is unknown, co-infection with HIV and the hepatitis C virus is a very serious health situation.
Oral sex (contact between the mouth and genitals) without using a latex barrier is considered a low-risk activity for HIV transmission. If you are HIV-positive and you perform oral sex on your partner, the chances of you transmitting HIV to your partner are extremely low. If your partner is performing oral sex on you, it is considered low risk. This means that HIV transmission can happen, but the chances are much smaller than the risks associated with anal or vaginal intercourse without a condom. The main risk in oral sex is getting or passing on sexually transmitted infections other than HIV, as well as hepatitis and parasites. The risk of HIV transmission increases, however, if your partner has cuts or sores on or inside the mouth. The same is true if your partner’s gums bleed.
If you want to have oral sex as safely as possible, you or your partner should put a condom on the penis or cover the labia (the outer lips of the vulva) or anus with a dental dam (one of the little rubber squares that your dentist uses) or plastic wrap (use the non-microwaveable kind). Or, instead of a dental dam, use a condom in the following way: first cut the top off, then cut the condom lengthwise and open it up. Safer sex guidelines suggest using a non-lubricated condom for oral sex. If you don’t use a condom, dental dam or plastic wrap for oral sex, neither you nor your partner should perform oral sex for at least two hours after brushing or flossing your teeth, since brushing or flossing can cause tiny cuts in the lining of your mouth. If you or your partner smoke or have nutritional problems, your gums can take up to two hours to heal after these activities.
Dildoes and other sex toys can be a fun part of safer sex. You just have to make sure that you keep them clean and don’t share them with sexual partners. Wash them with soap and water before and after you use them. Better yet, use warm water and a little bit of bleach and then rinse them really well. Or, if you don’t want to bother with all that, use condoms on your toys, or wrap them in non-microwaveable plastic wrap. Don’t use your sex toy in one person’s body and then put it into someone else’s without changing the condom or plastic. Ideally, everyone should have his or her own set of toys that are never used inside anyone else. Everyone living with HIV, and people with the bleeding disorder hemophilia, in particular, should be cautious of anything going into the body that might lead to heavy bleeding.
You can get more information on safer sex and sexually transmitted infections from your nearest AIDS service organization or public health office. You (or you and your partner or partners) may also want to talk about sex with a counsellor. Counsellors are available at many AIDS service organizations.
Safer sex when both of you are HIV-positive
Some HIV-positive people choose not to use condoms with other HIV-positive sexual partners. However, there are still risks that go with unprotected sex, even between HIV-positive people. So, while you may still choose to make this decision, it has to be made with some care.
First of all, it’s important to be certain your sexual partners are also HIV-positive before deciding not to use condoms. People may make assumptions about each other’s HIV status that could be wrong. Don’t assume you know your partner’s status; find out for sure.
All of the sexually transmitted infections we will talk about later in this chapter can be passed between HIV-positive people. In fact, people with HIV may be more vulnerable to getting infected with sexually transmitted infections. Hepatitis C can also be transmitted through unprotected sex.
Even HIV itself can sometimes be passed on from one HIV-positive person to another. (This is called reinfection or superinfection.) You may wonder, what’s the problem with getting HIV if you already have it? The danger lies in the fact that not all HIV is the same. It’s possible to be reinfected with a strain that could make you sicker than the one you already have, or one that’s resistant to the anti-HIV drugs you’re taking.
Safer sex and disclosing your HIV status
Sometimes people are afraid to talk about (or disclose) their HIV status or the issue of safer sex because of how other people may react. This fear can make a lot of sense, especially if you’re worried about rejection or violence.
Discussing your HIV status with someone you’re planning to have sex with is very different from telling a healthcare provider or a support worker. When thinking about disclosing your HIV status to sexual partners, there are many factors to consider. Do you tell someone as soon as you meet him or her, or do you wait until you are going to have sex? Does it make a difference whether this is a one-night stand or an ongoing relationship? What if sex work is how you make your living?
There have been an increasing number of legal cases in which people who knew they were HIV-positive have been taken to court for placing another person at risk for HIV infection through unsafe sex. Some people have been charged even though they disclosed that they were HIV-positive before having unsafe sex. If you need advice on how to get your partner(s) to have safer sex, or if you have fears about your relationship(s), safety or legal issues, contact someone at your nearest AIDS service organization. For more information about disclosure of your HIV status, see Chapter 6, Your emotional health and Chapter 21, Legal issues.
Building on the foundation of safer sex
In addition to practising safer sex, there are other strategies that you can use to reduce the risk of transmitting HIV to your partners and to keep yourself healthy. However, we don’t know how effective these strategies are yet. They include keeping your viral load as low as possible through effective anti-HIV treatment and adherence, and making efforts to prevent and treat sexually transmitted infections in both you and your partner(s).
Your viral load is a measure of the amount of HIV in your blood (see Chapter 9, Monitoring your health). Many people wonder if having a low or undetectable viral load makes them less infectious. This isn’t necessarily the case. That’s because virus is always present in your body, even if levels in your blood are too low to measure. And, even if viral load levels in your blood are undetectable, levels of HIV may be higher in other body fluids like semen or vaginal or rectal fluids.
Research into the different biological factors (such as viral load, the presence of genital sores, the presence of sexually transmitted infections and type of intercourse) that affect the risk of HIV transmission during sex is ongoing. The picture that appears to be emerging is that HIV risk is changeable. Over the course of time, people with HIV may experience periods of heightened infectivity, while at other times their infectivity may be quite low. Likewise, susceptibility of people who are HIV-negative can vary over time. Having a better understanding of how HIV is transmitted can help us make decisions about safer sex. Unfortunately, we don’t yet know all of the factors involved in accurately predicting transmission risk.
Preventing and treating sexually transmitted infections in both partners
A sexually transmitted infection is an infection that can be transferred from one person to another through sexual contact. Sexual contact is more than just vaginal or anal sexual intercourse. Sexual contact also includes oral sex and the use of sexual toys such as vibrators. HIV is considered a sexually transmitted infection. Others include chlamydia, gonorrhea, syphilis, genital herpes, genital warts, hepatitis A, B and C and parasites.
Some sexually transmitted infections, such as herpes, genital warts and syphilis, can be more easily transmitted than HIV, and condoms may not be as effective at preventing infection.
Many sexually transmitted infections can be transmitted to babies during pregnancy or delivery. Syphilis, like HIV, can be passed on to the baby in the womb. Others, such as gonorrhea, chlamydia, hepatitis B and C and genital herpes, can be transmitted during delivery.
People living with HIV may get some sexually transmitted infections more easily than other people, and often have more serious symptoms. If you have a sexually transmitted infection that isn’t treated, this can increase your ability to pass on HIV to other sexual partners if you do not practice safer sex. You can reduce your chances of getting or passing on sexually transmitted infections by practising safer sex. If you’re sexually active, it is good idea to get tested for sexually transmitted infections regularly. Speak with your doctor about testing for sexually transmitted infections.
Chlamydia is one of the most common sexually transmitted infections. Symptoms of chlamydia include a burning feeling when you’re urinating, and a discharge from your penis, vagina or rectum (ass). Chlamydia can also infect your throat and eyes. Many people, especially women, won’t have any symptoms. If left untreated in women, chlamydia can cause a serious infection called pelvic inflammatory disease. In men, chlamydia can cause an inflammation of epididymis, the thin tube that connects the testes to the urethra (the tube you pee through). Chlamydia can be treated easily with antibiotics. If you have chlamydia, anyone you’re having sex with should be treated; otherwise, you and your partner(s) can get reinfected again and again. Chlamydia is transmitted easily through unprotected oral, vaginal or anal sex.
LGV stands for lymphogranuloma venereum and is caused by a type of chlamydia bacteria. LGV is common in Africa, Asia, South America and the Caribbean. There have also been outbreaks among gay men in Europe, the United States and Canada. Both men and women can be infected with LGV.
The infection has three major stages. In the first stage, three days to three weeks after getting infected, there may be a small, painless sore where the bacteria got into your body (mouth, anus, vagina or penis). Many people don’t get a sore or don’t notice it. You will be able to give LGV to others from this point. In the second stage, 10 to 30 days later (or even longer), your glands may become painfully swollen. You may feel ill and have a fever, and you may have discharge from your penis, vagina or anus. If left untreated, LGV can later go on to cause serious complications. This third stage of infection can happen years after the first infection. Hemorrhoid-like growths can appear around your anus. The genitals can swell massively and the rectum (inside your ass) can be seriously damaged; you may need to have surgery.
Most symptoms of the first two stages can be easily missed. As long as it’s treated before it gets to the third stage, LGV is quickly cured with three weeks of antibiotics and leaves no lasting damage. In women, LGV often shows no symptoms until the third stage.
Gonorrhea may cause a thick discharge from your penis, rectum or vagina, and sometimes a burning feeling while you’re urinating. In many people, especially women, there may be no symptoms. Gonorrhea can also occur in your throat if you have unprotected oral sex. It can develop into an ongoing, serious infection if it isn’t treated. It can spread through your blood to other parts of your body, and can lead to sterility, the inability to have children. In women, it can cause pelvic inflammatory disease. Gonorrhea is treated with antibiotics. If you have it, anyone you’re having sex with should be checked and treated if necessary.
If left untreated, syphilis goes through three stages, with different symptoms at each stage. In the first stage, a single chancre (painless sore) forms in or around your penis, vagina, rectum, mouth or throat. The chancre will disappear on its own in three to six weeks, without treatment. The second stage happens two to four weeks after the disappearance of the chancre. The symptoms of the second stage are sores and a rash that may appear over your entire body and/or on the palms of your hands and soles of your feet. You may feel like you have the flu, with headache and aches and pains in your joints or bones. In addition, you may experience hair loss and flat, wart-like growths inside your anus or vagina. Without treatment these symptoms may come and go. However, you are only infectious during the first year. Symptoms of the third stage can be very serious and can result in blindness, heart or brain damage and, in some cases, death. Third-stage syphilis may take many years to develop, but people with HIV seem to develop third-stage syphilis much faster than others.
Syphilis is diagnosed by a series of blood tests. The first test, called the VDRL, is a screening test. Usually, if this test is negative, you don’t have syphilis. However, people with HIV may have false-negative VDRL tests. (That is, the test says you don’t have syphilis, even though you actually do.) If you suspect you have been exposed to syphilis, you may want to ask your doctor to run two other tests, called the FTA-ABS and the MHA-TP.
The usual course of syphilis may be faster and harder to treat in people with HIV. Syphilis is treated with large doses of benzathine penicillin, given by injection into your butt cheeks over three consecutive weeks. Penicillin is the preferred treatment for syphilis. If you’re allergic to penicillin, your doctor may “desensitize” you to its effects. This is done by giving you tiny doses at first, and slowly building up the dosage until you can take the full amount.
Condoms can reduce, but do not eliminate, the risk of transmitting syphilis when used for anal, vaginal or oral sex. Syphilis can also be transmitted to a baby in the womb or during delivery.
In the past few years, there have been outbreaks of syphilis in several Canadian cities. Many of these infections have been among people living with HIV.
Genital herpes is caused by a virus known as herpes simplex 2, or HSV-2. (“Cold sores” around the mouth are usually caused by a related virus, HSV-1). Symptoms of genital herpes include itching or tingling around the infected area (such as the anus, vagina, penis or testicles), an outbreak of painful blisters or sores that later form scabs, and sometimes a mild flu-like illness. It may take two to three weeks for symptoms to go away. Doctors can often diagnose herpes simply by recognizing the symptoms, but infection can only be confirmed by swabbing the blisters and sending the fluid to the laboratory.
Herpes blisters may show up two days to three weeks after contact with an infected person, but can take months or years to appear. Once you are infected, the herpes virus stays in the body permanently, usually causing periodic outbreaks of blisters and symptoms. Some people have monthly outbreaks, some less frequently, and some people (about one in 10) never have another outbreak after the first. Between outbreaks, the virus stays in the body in an inactive state. Stress, menstruation, poor diet, lack of rest, illness, and exposure to extreme heat, cold or sunlight seem to trigger outbreaks for some people. Others don’t notice any special reason for an outbreak.
Condoms can reduce the risk of transmission, but they don’t eliminate it, since condoms do not always cover the infected area. The herpes virus can be passed on during skin-to-skin contact—mouth to genitals, genitals to genitals, genitals to ass and mouth to ass. It can be transmitted when there are no symptoms present, as well as by direct contact with a sore. As with all sexually transmitted infections, pregnant women can pass the virus to their babies during delivery.
There’s no cure for herpes infection, but treatment can reduce the symptoms and speed up recovery. The possibility of repeated outbreaks varies from person to person. In time, outbreaks may become less frequent or stop altogether. However, people with severely weakened immune systems (very low CD4+ cell counts) can experience more severe and more frequent outbreaks. Having herpes also makes it easier to transmit or be infected by HIV.
The human papillomavirus (HPV) can cause genital warts. These warts appear, often in large numbers, around the head of your penis, on your vulval lips, in your vagina, on your cervix, on your anus (your asshole), in your rectum (inside your ass) or around your groin area. The warts are ugly but generally painless. They may make sex less pleasant. The warts are usually removed with liquid nitrogen.
The human papillomavirus is associated with cervical dysplasia (abnormal cells of the cervix) and cervical cancer in women, and with anal dysplasia (abnormal cells of the anus) and anal cancer in both men and women.
Women who have HIV should have regular Pap tests. Men who have had the human papillomavirus should have regular rectal exams and possibly Pap tests of the rectum, where available. Condoms reduce but do not eliminate the risk of transmission. Vaccination can prevent some strains of papillomavirus infection. This may reduce the likelihood of getting warts or cancers. Vaccination may have a role to play for people living with HIV—especially if given before exposure to the papillomavirus strains targeted by the vaccine.
Hepatitis A, B and C
For more information on hepatitis A, B and C see Chapter 12, HIV-related infections and cancers.
Practising safer sex and keeping it sexy can be a challenge for everyone. Sexual dysfunction can be defined as any difficulty during sex that prevents the individual or couple from enjoying sexual activity. Living with HIV can increase the challenge, as certain anti-HIV drugs might cause problems in becoming or staying aroused. Using a condom can interrupt the moment, and make this even more difficult. It is important to talk to your doctor or other healthcare provider because, in many cases, sexual dysfunction can be treated and you can have a fulfilling and safe sexual life.
Beginning and maintaining a relationship can be challenging. Living with HIV can add a complication and may make a romantic or sexual relationship seem impossible. Still, many people with HIV are in fulfilling relationships, some with partners who are HIV-negative and others with partners who are also living with HIV. Some people with HIV choose not to focus on romantic or sexual relationships and are satisfied to focus on relationships with friends and family.
People in relationships may work to make decisions together, including decisions about sexual activities and sexual health. However, partners in relationships may find it hard to balance each other’s concerns, needs and influence. When one partner has more power and control than the other, it is important to talk about this imbalance. Power imbalances in relationships can develop for all sorts of reasons. For example, one partner might earn more money and the other is dependent on him or her for living expenses. Power imbalances can change: one partner might have power in one circumstance but not in another.
Be aware of the power you hold in your relationship. Make sure it doesn’t prevent you and your partner from talking about things that are important to each of you. Make sure that both you and your partner(s) are able to communicate freely.
Sometimes the use of unequal power, or the fear that it might be used, might make it difficult for you to insist on things that are important to you, such as condom use. If this is the case, talk to someone—a friend, supportive family member or a community organization.
The Positive Side– Health and wellness magazine contains articles about healthy living, such as:
- Sexual healing – Have you lost that loving feeling? 4 PHAs talk about life between the sheets; 8 experts offer tips on spicing it up
- Magnetic couples – Four serodivergent couples reveal how they keep love alive in the face of HIV
- Sex, Drugs and Viral Load - Does undetectable = uninfectious? CATIE weighs in on the latest controversy over the biology of HIV transmission
- The other “H” word – Herpes: The hidden epidemic
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
Fact Sheets on sexually transmitted infections - Comprehensive information for people living with HIV and their care providers
Sexuality and U – Information and education from the Society of Obstetricians and Gynaecologists of Canada
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.