Hi Dr.

Don't you think it's just a little bit irresponsible to reccommend an HIV bottom with a sore anus (obviously it's going to be sore when you sexually abuse it) switches to being a top? Tops are the ones in a position to infect more than anyone. So now you have reccommended an HIV positive man who would have likely never infected anyone else for the rest of his life, turn around (literally) and begin injecting others with his HIV "needle." Please think about this. The main thing keeping HIV from spreading in the united states the way it spreads in third world countries is circumcision: women and bottoms are much much less likely to transmit their virus to tops. So please, don't encourage bottoms to now become tops (especially after they have already contracted HIV). I know it comes down to their right to do what they want, but let's play the parent somewhat.

Thank you

R Cohn

I had imagined that my original answer would generate some controversy. The gentleman who wrote me was no longer able to use his bottom for sex because of extreme soreness. He was looking for an answer to a situation which he did not feel comfortable discussing with other health care providers. I shared with him the solution that several of my patients have found to be effective--- i.e. switching from bottom to top. It would be my strongest recommendation for him to use a condom when he's a top (in other words, sheathing that HIV needle, as you call it). Was I irresponsible?? I try not to be judgmental. It's not my place to tell an HIV positive patient not to top, though I , as well as most HIV providers, advocate safer sex.