Safer sex and prevention issues are too often targeted solely to HIV-negative audiences. Yet, the prevention of HIV and other infections remains an important issue for positive women. Whether your partner is HIV-positive or HIV-negative, female, male or transgendered, there are many reasons to be concerned about prevention. This article explores some of the most common sexual transmission concerns for women living with HIV.

What are the risks of transmitting HIV to my HIV-negative partner?

The concern of many positive women with negative partners revolves around transmitting HIV to their uninfected partner(s). While considerable evidence suggests that men transmit HIV more easily than women, women can still pass HIV to uninfected partners -- both male and female -- through sex. This is because HIV is present in blood (including menstrual blood), vaginal secretions, and in cells in the vaginal and anal walls. In fact, high levels of HIV can be found in these areas even if viral load (as indicated by a viral load test) is at very low levels in the blood.

HIV levels in vaginal secretions increase significantly in the presence of active gynecological (GYN) conditions (e.g. vaginal yeast infections, herpes, etc.) or vaginal inflammation. Several studies in test tubes have shown that certain common sexually transmitted diseases, such as chlamydia, increase HIV reproduction. Vaginal inflammation, a common symptom of such infections, causes tiny scrapes and cuts to gather on the delicate skin of the vaginal area, that can then harbor HIV. HIV levels can also increase temporarily after receiving treatment for some of these conditions.

In short, in the absence of practicing safer sex, there's no way to know when you're more or less likely to transmit HIV to your partner(s). Exposure to vaginal secretions with high levels of HIV increases the risk of transmission. The risk increases further when one's partner has an infection or inflammation. It's possible to have active GYN conditions or infection without having symptoms or knowing it. (Click here for general guidelines on safer sex practices).

Finally, a number of documented cases have shown transmission of multi-drug resistant HIV from people living with HIV to their partners. What this means is that the newly infected person has a form of the virus that is not affected by currently available anti-HIV drugs, leaving them with limited options to treat their infection.

What are my prevention needs?

Prevention isn't just about protecting someone from HIV infection; it's also about protecting yourself. The risks of unsafe sex to women living with HIV are numerous. Many sexually transmitted conditions can cause serious harm for people living with HIV. Cytomegalovirus (CMV) is such a condition. While many (but not all) adults are infected with CMV, it doesn't cause disease in healthy, HIV-negative people. However, once CMV becomes an active infection, it's the leading cause of blindness and among the major killers of people with AIDS. Precautions against infection with CMV include practicing safer sex.

Again, when CMV causes disease, it's most often the result of a CMV infection acquired previously (i.e. latent infection becoming active). CMV prevention issues are probably much more relevant to women than to men, particularly gay adult men. The prevalence of CMV infection among women is generally lower (40% among women living with HIV) than what's observed among gay adult men (80-90% of whom are already infected with CMV, regardless of HIV status). The bottom line is that if you're not already infected with CMV, safer sex remains a potent tool in preventing the potential for later developing CMV disease.

Like CMV, human papilloma virus (HPV) is another STD that requires concern. One of the major causes of cervical cancer, HPV is prevalent and difficult to treat among women living with HIV. Some types of HPV are more associated with the development of cancer than other types. While it appears that the types of HPV which cause cervical cancer are more prevalent among women who have sex with men, a recent study of women who have sex with women shows that women who have never had sex with men can transmit and get HPV. This again demonstrates the importance of practicing safer sex among women who have sex with women.

Hepatitis, cryptosporidiosis, parasites and other types of disease-causing pests can also be transmitted during sexual activity. Every condition described above can be deadly in women living with HIV, particularly when the immune system is suppressed. (Click here for more information on non-HIV-related infections and how to prevent them.) It's important for HIV-positive women to protect themselves from these unwanted and potentially dangerous pests during sex.

We're both positive. What are our concerns?

For women whose partner(s) are also living with HIV, prevention messages and reasons to practice safer sex sometimes become obscure. A common question among HIV-positive partners is: "If I'm already positive, and my partner is positive, why do we have to practice safer sex?" Simply put, safer sex remains important among positive partners. This is because, in addition to preventing infections as discussed above, other factors place HIV-positive sex partners at risk.

While the issue of re-infection with HIV remains unresolved, increasing evidence shows that it can and does happen. Re-infection could occur if you're taking anti-HIV therapies which you've become resistant to and then transmit the drug-resistant strain of HIV to your partner. Conversely, if your partner is taking anti-HIV therapy, you could become infected with drug-resistant strains of HIV. (Click here for more information on drug resistant virus.)

Finally, it's important to remember that your partner's viral load is not necessarily associated with the level of HIV in his semen or her vaginal secretions. Therefore, while viral levels may be below the limit of detection in the blood, they may be present in high or low levels elsewhere. (note: Standard viral load tests do not measure the amount of HIV in semen or vaginal secretions. Moreover, in studies, even when HIV levels in semen were "undetectable," HIV-infected cells in the semen could still be found. These cells are believed important for transmitting HIV from man to woman.)

In settings where both partners live with HIV, consider these points when negotiating safer sex practices:

• Infections like CMV, HPV, herpes, hepatitis (B and C) among others, remain major concerns. All these infections are potentially deadly in people living with HIV. They all can be prevented through safer sex practices.

• Re-infection with drug-resistant or more aggressive disease-causing strains of HIV remains a theoretical possibility. It must be weighed in the balance of negotiations regarding safer sex between positive partners.

The reality of safer sex

Negotiating safer sex and implementing risk reduction measures for transmission of HIV and other infections is not easy. In the absence of safe and affordable woman-initiated methods for HIV prevention, safer sex requires the participation of willing partners. For women living in a domestic violence setting, this can become virtually impossible. In this case, strides to seek family violence prevention services are probably the safest and smartest strategy.

You put yourself at risk through unprotected oral sex with a partner or other sex play or activities that expose you to your partner's blood, blood products, feces, semen or vaginal secretions. These risks include possible infections that may never harm your partner, but may be life-threatening to you should your immune system weaken as a consequence of HIV infection.

If your partner(s) is living with HIV as well, neither of you is immune to new infections. Be aware of both real and theoretical risks as you negotiate safer sex. Every sexual behavior or activity carries a risk. It's generally believed that some activities are less risky than others, but low risk obviously doesn't mean no risk.

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