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 is a way of reducing HIV transmission specifically designed by and for people living with HIV.

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 (STIs).

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Why is positive prevention important?

Just over one in five people who are infected with HIV in Canada are unaware of their HIV status.

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 in five 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?”

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Principles of positive prevention

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.

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.

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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.

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Taking care of your health and reducing harm

Preventing HIV transmission is about developing self-respect and confidence.

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.

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Telling another person that you are HIV-positive is a brave act.

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 “realistic possibility of transmitting HIV” to their partners. See Chapter 21, Legal issues for a discussion of this complicated topic.

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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 condomless sex

Many people wish they could have condomless sex more often. This is a natural and normal desire. In the gay community, condomless 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 condomless sex with their customers—creating a difficult dilemma. Some mixed-status heterosexual couples choose to have condomless sex so they can become pregnant.

Two HIV-positive people who decide to have condomless 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

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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.

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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 condomless 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.

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Preventive treatments

Treatment to help prevent HIV – Research has shown that taking antiretroviral drugs (also known as ART or HIV treatment) to maintain an undetectable viral load not only protects your health but it can also help prevent HIV transmission. When ART is used consistently and correctly, an undetectable viral load can significantly reduce the risk of sexually transmitting HIV.

In other words, if you are taking HIV medications consistently and viral load tests cannot detect HIV in your blood for several months (the virus is still there but at levels too low to be detected), you have a very low chance of passing HIV to others. If your viral load rises, due to poor adherence (missed doses), a sexually transmitted infection or treatment failure, this could increase the risk. But the evidence is clear: Effective HIV treatment can lower the amount of HIV in your body to undetectable levels and help prevent the sexual transmission of the virus.

Pre-exposure prophylaxis, or PrEP, involves an HIV-negative person taking certain HIV medications to help prevent HIV transmission. When a person who is at high risk for HIV takes the HIV medication Truvada consistently and correctly (every day as prescribed), it can significantly reduce the risk of getting HIV.

While taking PrEP, it’s important that a person see their healthcare provider every three months for adherence counselling (if necessary), to test for HIV and other STIs, and to screen for side effects.

To learn more about PrEP, check out the CATIE fact sheets on Truvada and pre-exposure prophylaxis (PrEP).

Post-exposure prophylaxis (or PEP for short), involves an HIV-negative person taking HIV drugs for 28 days, starting as soon as possible but definitely within 72 hours of being 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 may be an issue. These prescription drugs need to be taken every day, as prescribed, for four full weeks.

To learn more about PEP, check out the fact sheet on post-exposure prophylaxis (PEP).

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Some people choose sex partners of the same perceived 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 condomless sex. However, for many people, the two go together. Serosorting allows two HIV-positive people to have condomless 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.

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About the author

David HoeDavid 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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