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Pozitively Healthy: A Gay Man's Guide to Sex and Health in Canada

2009

Pozitively Healthy: A Gay Man's Guide to Sex and Health in Canada


This Guide Is for You

This guide was developed and written by gay men living with HIV in Ontario. We wrote it for gay men living with HIV whether you are a long-term survivor or have been diagnosed with HIV more recently. We talked with many gay men living with HIV, including guys from diverse ethnoracial communities, urban and rural guys, working guys and guys on disability assistance and young and older guys. Unfortunately we were not able to speak with gay or queer transmen living with HIV, even though these guys are part of the gay community.

This guide was developed and written by gay men living with HIV.

This guide is also for you if you are:

We hope this guide 'speaks' to all of you.


Your Sexual Health "Top 10"

Your life didn't stop when you were diagnosed with HIV. Your sex life doesn't have to stop either.

  1. Your life didn't stop when you were diagnosed with HIV. Your sex life doesn't have to stop either.
  2. Your sexual health is an important part of your health, so it may make sense for you to talk about your sex life with your doctor or the other people that help you take care of your health.
  3. All gay guys -- HIV positive, HIV negative and guys who don't know their HIV status -- can help prevent new HIV infections.
  4. You can pass HIV on to other guys through unprotected sex, especially fucking without condoms, whether you are the top or bottom.
  5. You can pass HIV on through unprotected sex even if your viral load is undetectable.
  6. Unfortunately, the criminal law can get involved in your sex life. If you are going to have sex with a guy and it will put him at a significant risk of being infected with HIV, you have a legal duty under the criminal law to tell him about your HIV status before sex.
  7. If you are sexually active get tested for sexually transmitted infections (STIs) on a regular basis. STIs can lead to more serious health problems if you do not treat them.
  8. You might decide to have sex with other HIV positive guys to stop new HIV infections and so you can fuck without condoms. But there are still health issues you may want to think about, like STIs and the possibility that you could be re-infected with a different strain of HIV.
  9. You might have challenges with your sex drive and sexual performance. Getting older, HIV, medications, party drugs and emotions can affect your sex drive and sexual performance. But you can do things to overcome these challenges.
  10. To be sexually healthy you will probably need to take care of your body, your mind and your emotions. It is important for gay men, including gay men living with HIV, to have the information we need to make informed decisions about our sexual health.


Pozitively Hot: Being an HIV Positive Gay Man

Sex Positive, HIV Positive

When we talked to gay men about living with HIV and having sex, many of them said HIV brings a lot of responsibility. There is no cure for HIV. So many of us will take HIV medications for the rest of our lives. And there is a risk that we will pass on HIV during sex. But your life didn't stop when you got your HIV diagnosis. Like many of us, you were probably shocked and stressed out for a while after you found out you had HIV. Maybe you even felt some shame or guilt. But you went on living. Your sex life can go on too.

What Is "Sexual Health"?

Sexual health means having sex and sexual relationships that are as hot and satisfying as possible. Sexual health also means taking care of your health and the health of your sex partner(s). To be sexually healthy you will probably need to take care of your body, your mind and your emotions. It is important for gay men, including gay men living with HIV, to have the information we need to make informed decisions about our sexual health.

Living Positively and Gay

Homophobia, AIDS-phobia and sex-phobia can affect how we think, feel and behave. Sometimes people direct their phobias and negative attitudes at us. At other times these phobias and negative attitudes might bubble up from inside us. No matter how thick-skinned or "out" we are, these negative attitudes can make us feel ashamed or guilty. Or can cause us to suffer from low self-esteem. Those of us from minority ethnic and racial communities may feel guilt, shame and low self-esteem more intensely. We may have experienced racism and hostility towards our culture on top of homophobia, AIDS-phobia and sex-phobia. Society also judges what it means to be a "normal" man or a "normal" woman. So guys who are effeminate or transmen are judged harshly and may have a hard time feeling good about themselves and their sexuality. You may not always realize how these negative attitudes and feelings affect your health and the decisions you make. But it is important to recognize and deal with the negative effects of homophobia, AIDS-phobia and sex-phobia. This can help you live a proud life and have a fulfilling emotional and sexual life.

HIV Positive People and HIV Prevention

We can reduce the spread of HIV in the gay community if all of us -- HIV negative, untested, and HIV positive -- take responsibility for our sexual health. Most HIV prevention messages are aimed at people who don't have HIV. But people living with HIV also play an important role in HIV prevention. Many of us know a lot about HIV. Many of us educate other people about HIV, including the guys we have sex with. You can take better care of your sexual health when you have useful information about sex, communicating with sex partners, and HIV and other sexually transmitted infections (STIs). We hope that the information in this guide will help you make decisions that are right for you. We hope that you can use the information to have a fulfilling emotional life and a hot and satisfying sex life. And to help reduce the spread of HIV and other STIs.


Your Sexual Health, From Top to Bottom

You might run into challenges in your sex life. But there are ways to overcome the challenges.

Your Sex Drive

Your sex drive is affected by your physical, mental and emotional health.

Sometimes you might not feel very interested in sex. That's not necessarily a problem. Your sex drive is affected by your physical, mental and emotional health. Many of us feel less interested in sex when we're stressed, tired, sick, or just dealing with other things in life. Here are some other things that can lower your sex drive:

If you are not interested in sex for a long time, and that bothers you, you may want to talk to your doctor. There are probably things you can do to get your sex drive back.

Hard-On, Not Hard Up

If your cock is not getting or staying hard you can do something about it. Prescription medications -- like Cialis, Levitra and Viagra -- can help you get a hard-on. Only a doctor can prescribe these erection drugs for you. They're pricey and your drug plan may not pay for them.

Be careful when you take erection drugs.

If you still get a hard-on in the morning, erection drugs are probably not the answer. Taking care of your emotional or psychological health may be the answer. You can start by finding a doctor, other health professional or counsellor you feel comfortable talking to about your sex life.

Coming Clean on Butt Play

For many gay guys it is important to have a clean ass when we have sex.

For many gay guys it is important to have a clean ass when we have sex. HIV might make that a challenge. HIV and HIV medications give some guys diarrhea. If you have diarrhea, here are some things you can do to stop it:

Diarrhea that comes on suddenly can be a sign of an infection. Go see your doctor. You may need medications to get rid of the infection.

Some guys clean their ass out with water -- called douching -- before ass play or getting fucked. Douching can make the inside of your ass more sensitive and easier to damage. So you may not want to douche, or douche too much. It's up to you to figure out what works best for your body.


An HIV Positive Guy's Guide to Safer Sex

Many of us worry about passing on HIV or becoming re-infected with a different strain of HIV. That worry might never go away completely. But you can have great sex without passing on HIV or becoming re-infected with HIV. Great safer sex starts with an understanding of the risks involved in sex.

Figuring Out the Risk of HIV Transmission

When experts figure out the risk of passing on HIV during sex, they ask two questions:

  1. Is there a potential that HIV can be transmitted from one person to another during a sex act?

    • An HIV positive man's blood, cum, pre-cum and ass fluids can contain enough virus to infect another person with HIV.
    • Blood, cum, pre-cum or ass fluids that contain HIV must get directly into the other guy's bloodstream.
    • Or the cells lining the inside of other guy's ass, piss hole or mouth must absorb blood, cum, pre-cum or ass fluids that contain HIV.
  2. Is there evidence that HIV has been transmitted from one person to another during that sex act?

Based on the answers to these two questions, experts have developed four different categories of HIV transmission risk for sex:

Condoms Can Prevent HIV Transmission

Great safer sex starts with an understanding of the risks involved in sex.

Some gay guys, no matter what their HIV status, are tired of hearing about condoms. But condoms work. When they are used properly, condoms are the single best way to prevent HIV transmission when guys have anal sex or oral sex. Condoms can also prevent you from becoming re-infected with a different strain of HIV. And condoms can protect you against many other sexually transmitted infections (STIs).

The HIV Risk Table for HIV Positive Guys

Use this table to figure out your risk of passing on HIV to a guy during sex. The information in this table is only about HIV. For information about other STIs, see Other STIs can increase the risk of passing on HIV. Most other STIs are spread more easily than HIV. Some of the information in the table will apply to you if you are a gay or queer transman. For more information about safer sex for gay and queer transmen read Primed: The Back Pocket Guide for Transmen & The Men Who Dig Them. For detailed information about your legal duty to disclose your HIV status, sex and the law, read HIV disclosure: a legal guide for gay men in Canada.

The sex Your risk of passing on HIV Some important details

You fuck him (anal sex) without a condom.
You are the top.

High risk

HIV can get into his body through the lining of his ass, even if the lining is not damaged HIV can get into his ass even if you don't shoot your cum inside him. Your pre-cum contains HIV, and you can leak small amounts of cum before you have an orgasm. So sticking your cock into the other guy's ass just a little, for just a short time (sometimes called "dipping") or pulling it out before cumming is high risk. Rough sex can damage his ass and your cock. This increases the risk of passing on HIV.

He fucks you (anal sex) without a condom
You are the bottom.

High risk

Inside your ass there are fluids that contain a lot of HIV. HIV can get into his body through tiny cuts or open sores on his cock, through his foreskin or through the lining of his piss hole (urethra). Rough sex can damage his cock and your ass. This increases the risk of passing on HIV.

You put a sex toy in him after it has been in you.

High risk

 

You fuck him (anal sex) or he fucks you with a condom on. If you are the top or the bottom.

Low risk

 

He sucks your cock without a condom on it.

Low risk

 The risk of passing on HIV is increased if he gets your cum or pre-cum in his mouth.

You suck his cock with or without a condom on it.

Negligible risk

 

He sucks your cock with a condom on it.

Negligible risk

 

You rim a guy's ass, he rims your ass, you finger his ass, he fingers your ass, you stick the head of your cock into his foreskin "docking", he sticks the head of his cock into your foreskin, cock and ball torture.

Negligible risk

 

You fist a guy's ass, or he fists your ass.

Negligible risk

 

You piss or shit in a guy's mouth or on his damaged skin.

Negligible risk

If there is blood in your shit or piss this can increase the risk of passing on HIV to him. Getting shit on open skin carries a high risk of bacterial infection and can lead to blood poisoning. This is true whether or not the shit comes from someone who has HIV.

You piss or shit on his skin that is not broken or damaged.

No risk

 

Kissing, jerking off each other, playing with sex toys without sharing them.

No risk

 

Your HIV Viral Load Can Make a Difference

You can still pass on HIV during sex even if your viral load is "undetectable."

If you are taking HIV medications and you have an "undetectable" viral load this means that your medications are doing a good job controlling the HIV in your body. But you can still pass on HIV during sex even if your viral load is "undetectable."

Most HIV experts and community groups believe HIV positive people who have undetectable viral loads should continue to use condoms when they fuck. Here are some medical and legal reasons why:

Other STIs Can Increase the Risk of Passing on HIV

If you have an untreated STI you are more likely to pass HIV on to another guy during unprotected sex. And if an HIV negative guy has an untreated STI, it is easier for him to get HIV during sex.

Cut or Uncut

Not many studies have looked at whether circumcision (having a cut cock) can protect gay men from getting HIV or reduce their risk of passing on HIV. The results from these studies don't provide any clear answer.

Slip-Ups, Mistakes and Condom Breaks

Condoms sometimes break or slip off when we are fucking. And some of us might fuck without a condom, even though we didn't intend to and afterwards we wish we hadn't.

An HIV negative guy who is exposed to HIV can take HIV medications to try to stay uninfected. This medical treatment is called PEP -- short for "post-exposure prophylaxis." Scientists believe that PEP reduces the risk that someone will become HIV positive after being exposed to HIV.

A doctor must prescribe PEP. Go to a hospital emergency department. But doctors and other staff at medical clinics and emergency rooms may not know about PEP. Or they may not have a clear policy on who can get PEP. If a guy has problems getting PEP he should insist on seeing an infectious disease specialist doctor.

If you're on HIV medications, you may think it is a good idea to give the guy some of your medications. That's not recommended. Your HIV medications may not be an effective PEP treatment. And it may leave you short on medications later on.


You and Him Talking About Sex and HIV

Many gay guys find it difficult to talk openly and honestly about sex. Living with HIV can make it more difficult to talk about sex. And research has found that some men of colour and transmen find it especially difficult to talk about sex and safer sex with guys they have sex with.

Finding Out if He Has HIV Too

When you think about having sex with another guy (or a group of guys), you might ask yourself:

You may find it difficult to ask him about his HIV status or to talk about condoms. It may be easier to avoid those subjects. Or you might just assume that he also has HIV. But unless you talk about it with him, you won't know for sure if he has HIV. And you won't know what he thinks about using condoms.

If you have assumed that he is HIV positive, and it turns out he is not, you could face criminal charges for not disclosing your status. And you could pass on HIV.

Deciding Whether to Tell Him You Have HIV

Deciding whether to tell the guy you have HIV may not be easy. But you might want to disclose your HIV status to a guy you are going to have sex with for reasons like these:

When Do You Have a Legal Duty to Tell Him Your HIV Status?

You have a legal right to the privacy of your health information. This includes your HIV status. So you usually get to decide who you tell about your HIV status. But the criminal law limits your legal right to privacy. Here is what the criminal law in Canada says:

Even if you use a condom for fucking, you might have a legal duty to tell him your HIV status before you fuck. The criminal law is not clear about this.

It is important to understand that it is a crime to expose someone to a significant risk of HIV infection. So you can be criminally charged and convicted even if your sex partner does not become infected with HIV. For more information about HIV disclosure, sex and the law, read HIV disclosure: a legal guide for gay men in Canada.


Handling "No" While Staying Positive and Proud

Your worth as a person didn't change when you got HIV.

Every guy has heard "no" when they ask another guy for sex, a date or a relationship. And each of us has probably said "no" to a guy. Sometimes guys say "no" to us when they find out we have HIV. That's far from certain, but it happens. So you may need to get some skills to handle the "no" while staying positive and proud. It may help you to think about these things:


Positives Attract ... Sex Between HIV Positive Guys

Some HIV positive guys decide to only have sex with other HIV positive guys. For a lot of us this is a way to prevent HIV transmission and to enjoy sex without condoms. Here are some things to think about before getting it on with the condom off.

How Do You Know His HIV Status?

How do you know each other's HIV status? Sometimes we assume or guess about a guy's HIV status. There could be serious consequences if we guess wrong. Unless you talk about it with him, you probably won't know for sure whether he is HIV positive.

Your Risk of HIV Re-Infection

Once you have been infected with HIV, you no longer risk becoming HIV positive. But you might be "re-infected" with HIV. Re-infection happens when a person gets infected with a different type (also known as a "strain") of HIV on top of the type the person already has. Re-infection is sometimes called super-infection.

Re-infection is hard to study. Nobody really knows how often re-infection happens. Only a few dozen cases in the entire world have been identified with total certainty. But re-infection may be more common than that. We just don't know.

What does re-infection mean for your health? We don't know for sure. We do know that there are different strains of HIV. Some strains of HIV are more powerful than others. We also know that HIV can become resistant to certain HIV medications. Suppose that a guy has a stronger strain of HIV. And his HIV is resistant to HIV medications that your HIV is not resistant to. You might get sicker faster if you are re-infected with his HIV.

Do You Have a Legal Duty to Disclose Your HIV Status to a Positive Guy?

Even if you know that the other guy is HIV positive, you might have a legal duty to tell him that you are HIV positive before having sex. Based on what we know about the criminal law, you might have a legal duty to tell him your HIV status if:

As far as we know, no one in Canada has been criminally charged for not disclosing his HIV status to another HIV positive person.

For more information about HIV disclosure, sex and the law, read HIV disclosure: a legal guide for gay men in Canada.


Sex, Drugs and Recreation

Your pharmacist should be able to answer questions about how your HIV medications react with other medications and party drugs.

Some guys use party drugs when they have sex -- or have sex when they are using party drugs. Other guys have strong negative views about party drugs and won't go anywhere near them. Party drugs are sometimes called "recreational" drugs.

Party drugs can affect your health, especially if you take party drugs often or take large doses of them. Party drugs can change the effect of HIV medications. And HIV medications can change the way your body reacts to party drugs. Here are some things to be aware of:

If you are not sure what HIV medications you are taking, check with your doctor or pharmacist. Your pharmacist should be able to answer questions about how your HIV medications react with other medications and party drugs.

You can get more information about HIV, HIV medications, party drugs and your health from CATIE (Canadian AIDS Treatment Information Exchange). Call 1-800-263-1638 [if you're in Canada] or visit www.catie.ca.


STI Information for HIV Positive Guys

Sexually transmitted infections (STIs) can affect your health. But there are things you can do to protect your health. Some people use the term "sexually transmitted disease" rather than "sexually transmitted infection" -- each term means the same thing.

The Bare Essentials About STIs

Be practical but not paranoid about STIs and your health. Speak with your doctor about making STI testing a regular part of your health care. Information on STIs is available from many sources -- some sources are listed at the end of this guide.

The most common STIs include:

Most STIs can be treated and cured with common antibiotic medications.

Genital herpes is different. Herpes sores and blisters can be treated with medication. But the viruses that cause herpes stay in your body. These viruses can cause flare-ups of herpes blisters and sores from time-to-time.

Hepatitis C and warts caused by HPV are also different.

Special Information for HIV Positive Guys

HIV positive guys don't get chlamydia or gonorrhea any easier than HIV negative guys. And the treatment for chlamydia and gonorrhea -- antibiotic pills -- is the same whether you have HIV or not. But HIV positive guys (compared to guys without HIV) may:

If you have an STI that has not been cured it is easier for you to pass HIV to your partner during unprotected sex. This is true even if all your symptoms are gone. Just because your symptoms are gone it doesn't mean the STI is cured.

HPV, Anal Warts and Anal Cancer

HPV means human papilloma virus. HPV is spread through skin-to-skin contact and can cause warts. These warts appear most often on the ass hole, inside the ass or on the cock. They usually look like tiny cauliflowers. These warts can be treated. But HPV can stay in your body. So even after the warts are treated they can re-appear in the same place, or appear in another place.

Certain types of HPV infections inside the ass can eventually lead to anal cancer. Compared to other people, HIV positive gay men have a higher risk of developing anal cancer. However, even if you have anal warts you will not necessarily get anal cancer.

Your doctor can give you an anal exam to check for abnormal lumps or bumps inside your ass (and check your prostate for cancer at the same time).

Hepatitis C

HCV means the hepatitis C virus. It is the virus that causes hepatitis C disease. HCV can be transmitted sexually. Guys with HIV are more likely than HIV negative guys to be infected with HCV.

You can't count on any symptoms to let you know you've got HCV. The only way to know for sure is to get a blood test. You should get tested for HCV regularly (probably at least once a year), especially if you are fucking without condoms, having rough sex, sharing sex toys or sharing needles if you inject drugs.


For More Information

For More Information About Gay Sex, Cruising, Dating and Relationships

For Information About HIV, STIs and the Law

For Information About HIV, Hepatitis C, Other STIs and Your Sexual Health

For Information About Safer Drug Use and HIV

*Available through the CATIE Ordering Centre, available online at www.catie.ca or by calling 1-800-263-1638 [if you're in Canada]


Notes

This guide, originally developed by Toronto People With AIDS Foundation through a partnership with Ontario's Gay Men's Sexual Health Alliance (GMSH), has been adapted and reprinted in partnership with CATIE (Canadian AIDS Treatment Information Exchange). Thanks to members of the Poz Prevention Working Group of the GMSH for their contribution. Thanks also to the medical / scientific reviewers.

Funding provided by the AIDS Bureau, Ontario Ministry of Health and Long-Term Care, Government of Ontario, and the Public Health Agency of Canada. The views expressed in this resource do not necessarily reflect the views of the Government of Ontario or the Public Health Agency of Canada.

A companion guide, HIV disclosure: a legal guide for gay men in Canada, is also available. Both guides are accompanied by a manual for service providers, Poz Prevention: knowledge and practice guidance for providing sexual health services to gay men living with HIV in Canada. Copies of these publications can be ordered through the CATIE Ordering Centre, available online at www.catie.ca or by calling 1-800-263-1638 [if you're in Canada].

Decisions about particular medical treatments should always be made in consultation with a qualified medical practitioner knowledgeable about HIV-related illness and the treatments in question.

Toronto People With AIDS Foundation and CATIE, in good faith, provide information resources to help people living with HIV/AIDS who wish to manage their own health care in partnership with their care providers. Information accessed through or published or provided by the Toronto People With AIDS Foundation or CATIE, however, is not to be considered medical advice. We do not guarantee the accuracy or completeness of any information published by the Toronto People With AIDS Foundation or CATIE. Users relying on this information do so entirely at their own risk.

Glenn Betteridge, Managing Editor
Derek Thaczuk, Writer
Top Drawer Creative, Design

© 2009 Toronto People With AIDS Foundation and Canadian AIDS Treatment Information Exchange




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