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Safer sex and prevention messages are often targeted solely to HIV-negative people. Yet, preventing HIV and other infections remains an important issue for people living with HIV as well. Whether your partner is HIV-positive, HIV-negative, female, male or transgendered, there are many reasons to be concerned about safer sex and prevention. This publication explores some of the most common sexual transmission concerns for people living with HIV.
What Are the Risks of Passing HIV to My HIV-Negative Partner?
A concern of many people living with HIV is passing HIV to their uninfected partner(s). While much evidence suggests that men transmit HIV more easily than women, women can still pass HIV to uninfected partners -- both male and female. 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 there's a low amount of HIV in your blood.
For women, HIV levels in vaginal fluids greatly increase when you have gynecological (GYN) conditions, like yeast infections or inflammation. Several studies in test tubes show that some sexually transmitted diseases (STDs), like chlamydia, increase HIV reproduction. Vaginal inflammation, a common symptom of these infections, causes tiny scrapes and cuts on the delicate skin of the vaginal area that can then harbor HIV. HIV levels can also temporarily increase after treating some of these conditions.
Likewise, men with active STDs, especially active herpes lesions, etc., are more likely to both acquire and transmit HIV. Less is known about whether HIV levels are actually higher in blood and semen during an active STD infection in men, but certainly any infection that causes a lesion, like herpes, provides a portal for HIV to pass through and makes transmission more likely. Studies do show that even when a man has undetectable levels of HIV in his blood, there are sometimes detectable HIV levels in semen and pre-cum fluid. HIV transmission from men with undetectable HIV levels in their blood has been documented several times.
In short, if you're not practicing safer sex, there's no way to know when you're more or less likely to pass HIV to your partner(s). Exposure to vaginal or anal secretions, semen or other blood with high levels of HIV increases your risk of transmission. The risk further increases when one's partner has an infection or inflammation. It's also possible to have active infections or GYN conditions without having symptoms or knowing it. (For more information, read the general guidelines on safer sex practices.)
Finally, a number of known cases have shown multi-drug resistant HIV being passed from people living with HIV to their partners. What this means is that the newly infected partners have a form of the virus difficult to treat with anti-HIV drugs, leaving them with limited options to treat their infections.
What Kinds of Infections Can I Protect Myself From Getting?
Prevention isn't just about protecting someone else from getting HIV; it's also about protecting yourself from other harmful infections. You can do something about many common and serious infections. The risks of unsafe sex are numerous because many STDs can cause serious harm in people living with HIV.
Cytomegalovirus (CMV) is such a condition. While most adults are infected with CMV, it doesn't cause disease in healthy, HIV-negative people. Therefore, most people carry the virus but don't have active CMV disease. However, once CMV becomes an active infection, it's the leading cause of blindness and among the major causes of death in people with AIDS. Ways to prevent CMV infection include practicing safer sex.
CMV prevention is probably much more relevant to women than to men, particularly adult gay men. The rate of CMV infection among women is generally lower (40% among women living with HIV) than what's seen among adult gay men (80-90% of whom are already infected with CMV, regardless of HIV status). The bottom line is that if you're not infected with CMV, safer sex remains a potent tool in helping to prevent CMV disease.
Like CMV, human papilloma virus (HPV) is another STD. HPV is the virus that causes genital warts in some people. These warts may or may not be visible by external examination, yet might be present in the anus or cervix. As one of the major causes of anal and cervical cancer, HPV is common and difficult to treat among people living with HIV. Some types of HPV are more likely to develop into cancer than other types.
Both men and women are at risk for anal cancer associated with HPV. Some studies suggest that a woman living with HIV is more at risk of developing anal cancer as opposed to cervical cancer associated with HPV infection. Unlike other conditions associated with HIV disease, the rate of anal and cervical cancer associated with HPV infection does not appear to be dramatically declining with increased use of anti-HIV therapy. Unfortunately, condom and other barrier protections may not protect you from HPV infection and transmission, but they might decrease the risk of transmission.
Hepatitis, cryptosporidiosis, parasites and other infections can also be passed during sexual activity. Every condition described above can be deadly in anyone living with HIV, especially with a weakened immune system. (For more information, read how to prevent these infections.)
It's important for people living with HIV to protect themselves from these unwanted and possibly dangerous infections. Lab tests can detect these infections, but your medical coverage may not pay for them. You can ask your doctor about possibly getting these tests. Then, use the results to build a prevention plan that helps protect you from getting new infections.
Transmission of Multi-Drug Resistant HIV
There is increasing concern over the transmission of drug-resistant virus and multi-drug resistant HIV. People infected with multi-drug resistant HIV are unlikely to optimally benefit from most, if not all, of the available anti-HIV therapies. While many known cases of AZT-resistant HIV transmission have occurred in the past, transmission of multi-drug resistant virus is being seen increasingly. These observations underscore the importance of including safer sex in your life, even when you and your partner(s) are both living with HIV.
We're Both Positive -- What Are Our Concerns?
For people whose partner(s) also live with HIV, prevention messages and reasons to practice safer sex sometimes become unclear. A common question is: "If I'm positive and my partner is positive, then why do we have to practice safer sex?" Simply put, safer sex remains important among positive partners. This is because in addition to preventing new infections as discussed above, other factors place positive sex partners at risk.
One of these factors is re-infection with HIV. While the issue of re-infection remains unclear, some new evidence shows that it can and does happen. If you're on therapy that HIV has become resistant to, it's possible for you to transmit the drug-resistant strain to your partner, possibly crippling the benefits of those therapies for your partner. On the other hand, if your partner is on anti-HIV therapy, you could become infected with his or her drug-resistant strain(s) and have decreased benefits from therapy. (For more information on drug-resistant virus, click here.)
Finally, it's important to remember that your partner's viral load (amount of HIV in blood) may not relate to the level of virus in semen or vaginal or anal fluids. Therefore, while HIV levels in blood may be undetectable by a lab test, they still may be present in high levels elsewhere. (Note: Standard viral load tests do not measure HIV in semen or vaginal or anal fluids. Also, in studies, even when viral load tests of semen came back undetectable, HIV-infected cells could still be found in the semen. These cells are believed important for passing HIV from person to person.)
When both partners live with HIV, consider these points when discussing safer sex:
- Infections like CMV, HPV, herpes, hepatitis (B and C) among others, remain major concerns. All these are potentially deadly infections in people living with HIV, but they can be prevented, to some degree, through practicing safer sex.
- Re-infection with drug-resistant or more aggressive strains of HIV remains a theoretical possibility. It must be considered when negotiating safer sex between positive partners.
HIV and STDs: Woman-to-Woman
Woman-to-woman sexual activity has generally been associated with a lower risk of passing HIV, although a number of cases have been reported. The risk of passing HIV and other STDs between women has not been thoroughly studied. But the few studies to date note that many women who have sex with women engage in a number of high-risk behaviors that may increase their risks of both getting and passing HIV and other STDs (including the types of HPV associated with cervical and anal cancer). So in the meantime, it's best to play safe and refrain from making easy assumptions about HIV and STD transmission during woman-to-woman sex.
The Reality of Safer Sex
You put yourself at risk for infections through unprotected sex with a partner -- activities that expose you to your partner's blood, blood products, urine, feces, semen or vaginal or anal fluids. In some cases these infections may never harm your partner, but they might be life-threatening to you should your immune system weaken as a result of HIV.
If your partner(s) is also living with HIV, neither of you is immune to new infections. Be aware of both the real and theoretical risks as you discuss and negotiate safer sex. Every sexual behavior or activity carries some level of infection risk. It's generally believed that some activities are less risky than others, but low risk obviously doesn't mean no risk.
Negotiating safer sex and using risk reduction to prevent passing or getting HIV or other infections is not easy. Safer sex requires the involvement of willing partners. This is especially difficult for women because safe and low-cost woman-initiated methods of HIV prevention do not currently exist. For people in situations where domestic violence occurs, this willing involvement can be almost impossible. In this case, seeking family violence prevention services is probably the safest and smartest plan of action.
Safer Sex Guidelines
In addition to protecting from HIV infection and transmission, practicing safer sex also reduces the risk of passing or contracting other diseases, like chlamydia, gonorrhea, herpes and hepatitis. These can be especially troublesome in people with weakened immune systems. A few tips on how to protect yourself and your partner during sex are found below.
One Word: Plastics!
Use latex condoms and plenty of water-based lubricant (K-Y Jelly, Astroglide, Probe) for vaginal and anal sex. If you're sensitive (allergic) to latex, try polyurethane condoms (Avanti). The female condom (Reality) is also made of polyurethane. However, polyurethane condoms may have higher breakage problem than latex.
Protect the Environment and Your Condoms!
Don't use oil-containing lubricants like Crisco, Vaseline, baby oil, lotion, or whipped cream as they can destroy latex. (Note: Oil-based lubes can be safely used with polyurethane condoms). Good water-based lubricants last longer and often feel better anyway.
Read the Label!
Many people avoid products with the spermicide, Nonoxynol-9. Some studies now show it can cause irritation that may promote STD infections, including HIV.
Wrap it to Go!
For oral sex with a man, it's safest to use a condom. For oral sex with a woman or oral-anal sex (rimming), it's safest to use a dental dam (latex square), plastic food wrap, or a condom or latex glove cut to make a flat sheet.
Try a Breath Mint Instead!
Avoid brushing or flossing your teeth up to two hours before or after oral sex to minimize small cuts. Be aware of bleeding gums, cuts or sores on or in the mouth.
Let Your Fingers Do the Walking!
Use latex gloves for hand jobs (sex with your hands) or fisting. Try powder-free latex or polyurethane gloves for folks who are sensitive to latex.
Good Clean Fun!
If you share sex toys (like dildos or vibrators), put on a fresh condom for each user and/or when going to or from the anus and vagina. Clean toys with bleach, alcohol or soap and water between uses.
On the Wild Side!
Avoid contact with blood, semen and vaginal and anal fluids. Sex toys like whips or knives can break the skin and should not be used on another person until they're disinfected with bleach or cleaning solution.
Preventing Your Risk of Infections
People living with HIV must consider taking precautions to avoid exposing themselves to common infections, which are possibly deadly in people with a weakened immune system. Although safer sex is usually thought of in regards to preventing HIV infection, exposure to many major infections and STDs can be reduced if safer sex is followed. Avoiding oral-anal contact can greatly reduce the risk of getting parasites that can cause diarrhea and other symptoms. (Examples of parasites include tape worms, scabies and more common among people with HIV are toxoplasma and cryptosporidium.)
Safer sex is not the only way to prevent exposure to infections, however. There are a number of things you can do to decrease your risk of potentially harmful infections.
In general, people with HIV should not eat raw or undercooked meats, poultry or seafood. Avoid unpasteurized dairy products, which may contain parasites, bacteria or viruses that in turn can cause severe illness. For example, eating raw shellfish can result in hepatitis A infection. Risks can be reduced further by following guidelines for "safer" food preparation. For more information, read Food Safety.
You Can Prevent Common Infections at Home!
Bartonella (Cat Scratch Fever)
A bacterial infection that can cause fevers, headaches and a marked reduction in red blood cells (anemia).
Put on the flea collar!
- Avoid adopting kittens or cats under one year old.
- Avoid cat scratches or allowing cats to lick open cuts or wounds.
- Promptly wash all cat scratches or wounds.
- Use flea control for cats.
A bacterial infection that can cause diarrhea, abdominal pain and vomiting.
When Fluffy has the runs, run!
- Avoid contact with animals that have diarrhea.
- In general, get someone else to handle potty duties for pets.
Coccidioidomycosis (Valley Fever)
A fungal infection that causes fevers, difficulty in breathing and night sweats.
On your next archeological dig, bring Endust!
- Although there are areas of the country such as the deserts of the Southwest where it may be impossible to avoid exposure to this pest, you can still reduce the risk of exposure by avoiding excavation sites and dust storms.
- For more information, read the publication, Valley Fever.
A fungal infection that primarily infects the brain resulting in headaches, fevers and altered mental behavior.
Don't feed the birds!
- Avoid areas that may be heavily contaminated with the pest that causes the infection (called cryptococcus), including areas with a lot of pigeon droppings. Avoid handling birds, even those kept as pets.
A parasite that can cause diarrhea.
Put down the baby, and move away from the goat!
- Wash hands after fecal contact (like after changing a baby's diaper) and after gardening or other contact with soil.
- Avoid contact with young farm animals or animals with diarrhea (including pet stores and animal shelters).
- Wash hands after handling pets and avoid contact with pet feces.
- Boil water for at least one minute. If possible, install a water filter system that can filter out cryptosporidium.
- Avoid swimming in water that may be contaminated by cryptosporidia. Some lakes, rivers, swimming pools and salt water beaches may be contaminated with human or animal waste that contains cryptosporidia.
- For more information on preventing infection with crypto, call Project Inform's Hotline.
- For more information, read the publication, Cryptosporidiosis.
A virus that infects the entire body. (Left untreated, CMV can cause diarrhea, blindness, inflammation of the brain, etc.)
Safer Sex is Hot Sex (and it's not just about HIV infection!)
- Wash hands after fecal contact.
- Follow safer sex practices.
- If blood transfusions are required, only CMV antibody negative or leukocyte-reduced blood products should be used.
- For more information, read Project Inform's publication, Cytomegalovirus.
Hepatitis A, B and C Virus (HAV, HBV and HCV)
Viral infections that can cause liver damage, failure and sometimes cancer.
- Talk to your doctor about the appropriateness of vaccination (for HAV and HBV).
- Follow safer sex practices.
- Learn about particular risks for HAV and traveling in areas where threat for exposure is great and vaccination prior to travel highly recommended.
- For more information, read Project Inform's publications, Hepatitis A, Hepatitis B and Hepatitis C.
A viral infection that can cause ulcer lesions around the mouth, genitals and rectum.
- Follow safer sex practices.
- For more information, read the publication, Oral and Genital Herpes.
A fungal infection that can cause fevers, reduction in red blood cells and difficulty in breathing.
Put down the mop and move away from the chicken coop!
- Although it may be impossible to avoid exposure to this organism in areas of the country like the Midwest river valleys, people can still reduce their risk by not cleaning chicken coops, disturbing soil under bird roosting sites or exploring caves.
- For more information, read the publication, Histoplasmosis.
A viral infection that can cause warts, which can become cancerous.
- Follow safer sex practices. Condoms cannot wholly prevent HPV transmission.
A bacterial infection that can cause meningitis, an inflammation in the brain.
- Avoid eating any non-pasteurized dairy products, such as soft cheeses like Brie and goat cheese.
- Heat ready-to-eat foods like hot dogs and ensure that they're steaming hot before eating them.
A parasite that can cause diarrhea.
- Wash hands frequently and follow other good personal hygiene measures.
A bacterial infection that can cause food poisoning and diarrhea.
- Avoid Caesar salads or anything that may contain raw eggs.
- Avoid eating under-cooked eggs and poultry.
- Avoid contact with animals that have diarrhea.
- Avoid contact with reptiles like snakes, lizards, iguanas and turtles.
A parasite that mostly infects the brain resulting in confusion and delusional behavior.
These recommendations only apply to people who are NOT antibody positive to toxoplasma.
- Avoid eating raw or under-cooked meats. (Cook to an internal temperature of 150°F or 65.5°C.)
- Wash hands after contact with raw meat and after gardening or other contact with soil.
- Wash fruits and vegetables in filtered water or in a 0.05% bleach solution before eating raw.
- Wash hands after changing a cat's litter box or preferably have an HIV-negative person change it.
- Cats should be kept indoors and be fed canned or dried commercial cat food and not raw or undercooked meats.
- For more information, read the publication, Toxoplasmosis.
Primarily infects the lungs and can cause cough, weight loss and fatigue.
- If possible, avoid working or volunteering in facilities considered high risk for tuberculosis, such as healthcare and correctional facilities and homeless shelters.
- For more information, read Project Inform's publication, Tuberculosis and HIV Disease.
A viral infection commonly known as chicken pox and shingles.
- People who have NOT had chicken pox or shingles should avoid direct contact with people with active chicken pox or shingles.