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. 

Another challenge in writing about sexual health in the context of HIV is that we are grappling with the role of anti-HIV drugs, viral load and the role they play in the prevention of HIV transmission.  Using a condom for anal or vaginal sex is no longer essential to the prevention of HIV transmission.  But the prevention of other sexually transmitted infections is also an important part of sexual health, and anti-HIV drugs do not prevent these. Many people with HIV, and their sex partners, are doing a major personal rethink of the idea of sexual risk-taking

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?

To be sexually healthy means enjoying a fulfilling and respectful approach to sexuality and sexual relationships.

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 and/or other sexually transmitted infections (STIs).   

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.

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About safer sex

Safer sex is still about the negotiation of risk between you and your partners.

A very important aspect of sexual health is the ability to have safer sex. For people with HIV, safer sex involves

  • taking our anti-HIV drugs as prescribed in order to keep our viral load continuously undetectable, which prevents us from transmitting HIV;
  • 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.

Though research shows that taking HIV treatment and having a continuously undetectable viral load means that we cannot transmit HIV to our sexual partners, safer sex remains a 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 relationships among sexual health, safer sex and HIV are definitely complex and we continue to learn a lot about other factors that affect our sexual health, including getting and transmitting HIV.

For more information on the role of HIV, treatment in preventing sexual transmission read Undetectable viral load and HIV sexual transmission. Also check out CATIE’s Safer Sex Guide.

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Sex toys

You can get more information on safer sex and sexually transmitted infections from your nearest AIDS service organization or public health office.

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. 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 HIV 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.

Other kinds of safe and sexy fun

Learning how to bring yourself and your partner to orgasm through masturbation is very safe and very sexy. You can masturbate together while reading or looking at porn, you can have phone and cyber sex, you can tell each other your sexual fantasies while masturbating, you can have or give an erotic massage, as long as no sexual fluids are exchanged. Perhaps Tantric sex, which views sex as a path to greater self-awareness without concentrating on orgasm as the “goal,” has something to offer you.

If your definition of abstinence includes having great sex alone, try out porn and experiment with sex toys to please yourself with. Women-focussed sex stores can be found in some cities and they often offer workshops in masturbation for women who want to learn more about self-pleasure.

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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.

Don’t assume you know your partner’s status; find out for sure.

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.

HIV itself can sometimes be passed on from one HIV-positive person to another. (This is called reinfection or superinfection.) This cannot happen if you have a continuously undetectable viral load on treatment. But if you do not, it is possible to be reinfected with a different strain and this strain may be resistant to certain anti-HIV drugs, limiting your treatment options.  

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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.

When thinking about disclosing your HIV status to sexual partners, there are many factors to consider.

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 not disclosing their HIV status.

If you need advice on disclosure, on safer sex, or if you have fears about your relationship(s), safety or legal issues, contact someone at your nearest HIV organization. For more information about disclosure of your HIV status, see Chapter 6, Your emotional health and Chapter 21, Legal issues.

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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 are 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.

If you’re sexually active, it is good idea to get tested for sexually transmitted infections regularly.

People living with HIV may get some sexually transmitted infections more easily than other people, and may have more serious symptoms. 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.

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Chlamydia

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 oral, vaginal or anal sex without a condom.

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LGV

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.

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Gonorrhea

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.

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Syphilis

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.

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 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.

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Genital herpes

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.

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 can also make it easier to transmit or be infected by HIV.

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HPV and genital warts

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.

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Hepatitis A, B and C

For more information on hepatitis A, B and C see Chapter 12, HIV-related infections and cancers.

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Sexual dysfunction

Practising safer sex and keeping it sexy can be a challenge for everyone.

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.

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Relationship issues

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.  

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.

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Resources

Undetectable viral load and HIV sexual transmission – how to make it work for you

Safer Sex Guide – A guide that gives tips to prevent sexually transmitted infections (STIs) and explains how to make sex safer.

The Positive Side – Health and wellness magazine contains articles about healthy living.

Fact Sheets on sexually transmitted infections - Comprehensive information for people living with HIV and their care providers

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About the author

John MaxwellJohn Maxwell is executive director at AIDS Committee of Toronto (ACT). He has been working in the community-based HIV movement for more than 20 years. He has extensive experience in the area of HIV prevention/sexual health promotion, and has been an active participant in many community-based research projects. In addition to his work at ACT, he is a member of numerous local, provincial, national and international HIV working groups. 

In 2007, John was honoured at the Canadian Association for HIV Research conference with the Red Ribbon Award, which was presented to him for “outstanding service to the cause of research in Canada that will lead to increased understanding of the treatment and prevention of HIV/AIDS, while enhancing the quality of life for those living with this disease.”

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