Living With HIV

The information on these pages is for HIV positive gay and bisexual men, and other men who have sex with men, and their partners.

It is about having HIV and sex. When you’re HIV positive, you may have many questions about sex. Some may be quite specific. Others may be more complex.

The sex you have, and who you have sex with, is your choice.
This information aims to provide you with clear and accurate information and advice about sex and sexual health, to enable you to make informed choices about your sexual life. The advice given will need to be considered according to your own personal health and sexual preferences. What may be beneficial and suitable for one person might not be as relevant to another.

For men who have tested negative for HIV or do not know their HIV status or the HIV status of their sexual partner, we hope this information gives you an insight into some of the issues that can arise for men living with HIV.

Sex - Will I, Won't I

All men, regardless of their HIV status, have the right to healthy and satisfying sex lives.

There is no single correct choice and the choices you make may change as you change.

Many find that having HIV has no impact on their sex lives while others find it difficult to form sexual relationships because of the prejudices or fear they feel or experience. Whatever the situation, it is important to become and remain informed about pleasure, desire, and safer sex. Being informed regarding the many aspects and complexities of HIV and sexuality makes it easier to negotiate the sex that you want, regardless of your HIV status.

It Takes Two

It’s not always easy to relax and just get into sex.

As a man living with HIV, it may often feel like you are held solely responsible for avoiding the further transmission of HIV.

When sex is not an individual act, everyone involved is individually and collectively responsible.
In order to become and remain comfortable with the choices that you make, it may be good to spend some time thinking through issues and talking to other HIV positive men, and other friends or partners. Speaking through some issues with a counsellor may also help.

For example, issues like responsibility for decisions around safer sex, talking about the sex that you want, enjoy, and are comfortable with, and disclosure.

Reading about all of the health issues associated with sex is not exactly sexy reading but this information can help you to make the right decisions for you.

Not all questions can be answered. You need to make decisions based on the information that you have, and you need to feel comfortable with your decision. That way you can feel most comfortable with your partner, and ultimately have better sex.

Relationships

Relationships and a good social support network, including peer support, are important components in maintaining self esteem and self confidence, particularly after an HIV positive diagnosis.

Relationships cover a range of issues like affection, intimacy, support, having someone to care about, and somebody who cares about you. Relationships can vary greatly. For some HIV positive men, this may mean a long-term intimate relationship with only one person. For others, this may mean a loving relationship with one partner but sexual activity with others. Others may have a series of casual sexual relationships with different people. Regardless of HIV status, relationships have their challenges, but can also be very rewarding. For some men the HIV status of their partner is unimportant; for others it can be a very important factor. For some couples it can feel as if there are three of you in the relationship – You, Him, and HIV.

If you are in a relationship when you receive an HIV positive diagnosis, don’t assume that your partner might also be HIV positive. The only way to know for sure is if your partner gets tested.

A relationship where one person is HIV positive and the other is HIV negative (sometimes referred to as a sero-discordant relationship) has its own set of challenges and anxieties. Initially, there may be the issue of disclosing. This may bring up a number of concerns for you both. The fear of transmitting HIV is a concern for some. You may need to renegotiate your relationship boundaries in relation to the types of sex you both want and enjoy. You should both be aware of post-exposure prophylaxis (PEP). PEP is a course of medication consisting of at least two anti-HIV drugs which is prescribed to someone who has been accidentally exposed to HIV. For more information on PEP, please see page PEP (Post Exposure Prophylaxis).

Some men living with HIV find that by having an HIV positive sexual partner they have a less anxious sex life. You may choose not to use condoms because you enjoy the intimacy of unprotected sex. This brings its own challenges, including possible health implications, which are outlined on the page Sex with other HIV Positive Men.

Anonymous or casual sex is a significant part of the lives of many men who have sex with men. If you enjoy casual sex with someone you don’t know it might be useful to discuss and agree on sexual boundaries before you engage in sexual activity.

Whatever relationship you desire, it is important that decisions made about future relationships are not based on HIV alone. How you feel, if it works for you, and if it’s what you want and enjoy, are all better reasons for making decisions.

Disclosure

Your HIV status is your personal information. The choice of disclosure is an individual one. Deciding who, how, why and when to tell someone you are HIV positive – whether it is a long-term partner or a casual partner – is a personal and often a difficult decision.

Disclosing to a sexual partner can be very different to disclosing to a friend or family member. A decision to disclose may depend on the kind of relationship you have or you want to have. It may also depend on the kind of sex you want to have. “Will I see this person just once?”; “Do I desire a longer term relationship?”; “Should I allow a person to get to know me and all my qualities before I disclose that I am HIV positive, particularly if we don’t have sex initially?”.

Many men living with HIV have faced rejection upon disclosing to potential short term sexual partners. Sometimes men say no when asked or approached for sex, a date, or a relationship. Other HIV positive men, however, particularly in longer term relationships, have received lots of support.

If you choose to disclose and he decides not to have sex with you, it’s worth remembering that his decision to say no may not always be about you personally. He may have little or no understanding of how HIV is or is not transmitted and he may simply be trying to lower his own risk of getting HIV. That is his choice to make.

Timing can be important also. It can be difficult to talk about HIV when you have only just met someone, but sometimes a casual relationship may develop into a more long-term loving relationship and this could cause problems if you have not disclosed.

Before making a decision about disclosure, many men feel that they want to get to know a person better, and develop a friendship and confidence in the person, where their privacy will be respected.

Some men find it useful to bring up casual conversations about HIV when they first meet someone.

There are no simple answers, as with many aspects of living with HIV. Talking to other HIV positive people, a peer support worker, or a counsellor about your concerns may be helpful.

Currently, in Ireland, there is no legal obligation to disclose one’s HIV status. However, there may be potential legal implications in the future with the non-disclosure of HIV status. For more information on HIV and Law, please see page The Law and HIV Transmission.

Law and HIV Transmission

Travel, mobility and migration are increasingly part of our lives. It’s important to be aware that in a number of countries, criminal law is being applied to people living with HIV who transmit or expose others to HIV infection. Different countries have different laws.

At the time of writing (December 2010), criminal prosecution for the sexual transmission of HIV remains untested in Irish law, both North and South.

The following is an example of how the law has been applied in England and Wales. This is not legal advice. It is an example to consider when making your choices about disclosure.

In England and Wales, people living with HIV may be prosecuted with ‘reckless HIV transmission’ under section 20 of the Offences Against the Person Act 1861. It's worth noting that this guidance applies to England and Wales only, although the Offences Against the Person Act still applies in Northern Ireland.

In the UK, based on the criminal prosecutions to date, a person may be prosecuted for reckless transmission of HIV if:

• the person knows he/she is HIV positive.
• the person understands the risk of HIV transmission.
• the person engages in risk taking sexual behaviour, and as a result the person infects his/her sexual partner.
• the person has not previously disclosed his/her HIV status to that sexual partner.

Although UK law does not precisely define ‘safer sex’, from the cases brought to court so far, it seems that a person will not be prosecuted if condoms are used for anal sex – as long as they have been used 100% of the time.

The UK law is not explicit in relation to a situation where a condom splits or slips off. The advice given in the UK is to disclose HIV status immediately and advise your sexual partner to get PEP.

There have been no prosecutions in the UK so far of HIV transmission through oral sex. The risk of infection from oral sex is much lower than anal sex, however HIV transmission is still possible and therefore a prosecution cannot be ruled out.

The UK law covers any serious infection that is passed on sexually, so a prosecution for the transmission of Hepatitis C is also possible.

Travel

Unfortunately some countries impose restrictions to those living with HIV and AIDS.

The restrictions vary from country to country.

Before making your travel arrangements, be sure to visit the Global Database on HIV-Specific Travel and Residence Restrictions website at http://www.hivtravel.org.

You will find specific details related to HIV and AIDS and immigration in most countries where related information is available.

Having a Fulfilling Sex Life

Having sex with someone can be an intense experience that takes a lot of emotional and physical energy.

The psychological and social effects of living with HIV can sometimes result in a loss of interest in sex. Some men may be unconcerned by this change. For others, expressing themselves sexually is a huge part of who they are.

Losing interest in sex and other sexual complications are common. For example, some men may have difficulty getting or keeping an erection. Often many sexual complications are exacerbated due to an HIV positive diagnosis.

Sometimes the cause can be physical such as tiredness or feeling ill, the use of recreational drugs or alcohol, or problems using condoms. It may even be that your testosterone levels have decreased.

Sometimes sexual difficulties may be caused by our own thoughts and feelings, such as anxiety about passing infections on, or feeling self-conscious about our body.

Anxieties and pressures of disclosure, stigma and discrimination, and sexual rejection are challenges. All these kind of issues can get in the way of the kind of sex you desire.

At different times we desire different things from sex and from our relationships. Sometimes sex is not always about the emotional connection. Sometimes it’s about more basic desires.

Losing your Bone

Erection difficulties affect many men, including men living with HIV.

Problems can include:

• Not getting hard at all
• Hard-on not lasting long
• Difficulty keeping a hard-on when using condoms

Hard-on problems can put people off from using condoms. Others end up taking the receptive (bottom) role to get round the problem.

If condoms interfere with your hard-on, it may help if you get the other person to put it on you, or to use a different size condom.

A cock ring can stop the blood leaving the penis once an erection happens, helping to keep you hard. Gripping the base of the penis can have the same effect.

Getting more exercise, following a low fat diet, and stopping smoking can all help improve hard-ons.

Using erection drugs such as Viagra™ is not safe for everyone but can often help. It increases the blood flow into the penis, helps you get an erection, and makes it harder and longer lasting.

It’s important to be aware that the underlying cause of hard-on problems may be affected by your mental and emotional health. Erection drugs will treat the symptom, but not the cause. If, for example you still get a hard-on in the morning, erection drugs are probably not the answer. You might consider finding a doctor, or another health professional or indeed a counsellor you feel comfortable talking to about your sex life.

Viagra™ should only be taken when prescribed by a doctor. For more information, please see page Drugs and Sex.

Your Sexual Health

Being honest with yourself about your sexual needs and planning ahead can be an important part of maintaining optimum sexual health.

Managing risk is also about managing your health. Be aware and keep informed of any health risks involved in having sex and how to minimise those risks while still getting pleasure from what you want to do.

Pleasurable safer sex starts with each partner taking mutual responsibility for protecting each other and himself. It can be further enhanced by understanding the risks involved in advance of having sex, then negotiating and consenting to the sex you both want.

Although condoms provide the best protection, it’s important to remember that what is regarded as safer sex for the prevention of HIV transmission may not protect against some other sexually transmitted infections (STIs) like Syphilis, or Hepatitis A.

Men living with HIV may wish to consider sexual activities that decrease the risk of contracting other STI’s, or avoiding the potential risk of re-infection with a different strain of HIV. For more information, please see page Sex with other HIV Positive Men.

Condoms are only one part of the equation. If you are sexually active, particularly with short term or casual partners, it is recommended that you get tested for STIs regularly.

Your Sexual Pleasure (s)

Sexual pleasure can be influenced by many factors and circumstances – the kind of sex you desire, where you are (home, online, sauna, club, pub, party), who you are with (whether having casual sex or a more intimate relationship), and whether you are drinking alcohol and/or using recreational drugs.

Whatever your sexual pleasure or desire, keep one basic principle in mind when you consider any sex act:

HIV-infected semen or blood has to enter the bloodstream of a person through an opening in the skin (or mucous membrane) for HIV to be transmitted.

Anal Sex without condoms remains the most common way HIV is passed on between two male partners, in particular if the HIV positive partner is on ‘top’ (inserting).

If the HIV positive partner is on the ‘bottom’ (receptive), a HIV negative partner is still at risk of HIV infection if blood is present which can enter the body through the eye of the penis, or through cuts and sores if another infection is present, for example genital warts or syphilis.

Using condoms for anal sex is the single best way to prevent HIV transmission and many other STIs.

Oral Sex presents an extremely low risk of transmitting HIV. However, if you are HIV positive and you are the ‘insertive’ partner, the risk is higher if you ejaculate into the mouth of an HIV negative partner especially if your partner has ulcers, bleeding gums and/or a sore throat.

Rough oral sex or deep-throating can cause small cuts in the lining of the throat increasing the risk. Brushing teeth can tear the flesh in the mouth causing gums to bleed also increasing the risk of infection.

Use a condom for oral sex to reduce the risk, and avoid brushing teeth before performing oral sex.

Rimming is only a risk for HIV transmission if blood is present. Rimming can be a high risk activity for transmitting Hepatitis A. Dental (glyde) dams, or a flavoured condom cut into a square, can be used to reduce the risk by placing it over the anus for rimming.

Sex toys only present a risk of transmitting HIV and other STIs if shared and not cleaned properly (with warm water and soap). Some people use condoms on their toys and change the condom between sharing. Others prefer not to share and use only their own toys.

Fisting presents little risk of HIV transmission. Using latex gloves and plenty of lube can reduce the risks. It is safer not to engage in fisting prior to penetrative sex as this can cause bleeding and therefore increase the risk of HIV transmission during anal sex, particularly if a condom is not used.

Kissing, sucking, wanking, nipple pulling, touching, rubbing, massaging, spanking, stroking, water sports are all safe. Using hands or fingers (not shared) to penetrate the anus are also safe providing there are no cuts, sores or scratches on the hands.

Sex with other HIV Positive Men

Some HIV positive men may prefer to only have sex with other men who are HIV positive. This is sometimes referred to as ‘serosorting’.

You may decide not to use condoms because you are both positive.

Some men may feel that unprotected sex with other positive men is a way to maximise pleasure and to reduce HIV-related stigma.

It’s important to consider that there are still health issues which you may want to think about:

• While the number of recorded cases are low, there have been cases where a person with HIV has been re-infected (sometimes referred to as super-infection) with another strain / sub-type of HIV. In some of the recorded cases, treatment options have been limited because the new strain / sub-type of HIV was already resistant to some or all of the anti-HIV drugs.
• Over the last few years it has become more evident that Hepatitis C, a serious liver infection, can be passed on during unprotected anal sex between men if blood is present. Co-infection with HIV can mean that liver disease develops more quickly and more severely.
• Other STIs can be transmitted during unprotected sex.
• Sometimes we assume or guess someone’s HIV status. Maybe you met on an internet site or at a certain venue where HIV status is assumed. Unless you talk about it, you probably won’t know for sure whether another person is HIV positive.

Drugs and Sex

Sometimes you might use recreational drugs when you have sex.

Alcohol and recreational drugs can help us to relax socially, make sexual encounters easier, and heighten pleasure or sexual intensity. However, they can also affect our choices and our judgement and perhaps make us more likely to take risks during sex.

Be aware of your limits and your right to say no to sex or to the sexual acts that you don’t feel comfortable with.

Stick to what is safe for you and your partner(s). Be prepared, plan in advance – carry condoms and lube.

Viagra™

Viagra™, like any drug, can cause side affects. Of particular concern to men with HIV are the possible drug interactions if the person with HIV is already on anti-HIV medication. If your doctor prescribes erection drugs for you, ask about potential interactions with any medications you may be on.

Be aware also of possible interactions if you plan to use recreational drugs.

Here are some examples of possible interactions, but these may differ from person to person, and will depend on the type of medication you are taking or drugs you may use.

Viagra™ + Protease Inhibitors (anti-HIV drugs)

Consult with your doctor. It’s safer to take a low dose of Viagra™, but safest not to mix erection drugs with protease inhibitors.

Viagra™ + Recreational Drugs (like ecstasy, speed, cocaine)

These all put a strain on the heart, which will be more dangerous if taken together.

Viagra™ + Poppers

Both dangerously lower blood pressure and should not be taken together.

Protease Inhibitors + Recreational Drugs

Recreational drugs can have a much stronger effect on you as protease inhibitors can increase the concentration of the drugs in your body.

Using Viagra™ (and other recreational drugs) can also result in longer durations of having penetrative sex which can increase the risk of condom failure. It’s advisable to always check condoms during sex and put on a fresh one if having sex for longer than 20 minutes. For more information on using condoms, please see page Condom Conundrums.

Poppers

Using poppers during unprotected anal sex can increase the risk of HIV transmission, in particular if you are the receptive (bottom) partner.

Poppers relaxes muscles in the body, including the sphincter muscles of the anus. This can cause the blood vessels in the anus to dilate thus making penetrative sex easier. This can also increase the risk of damage to the anus wall, potentially allowing semen to enter the bloodstream if bleeding occurs.

Mixing Drugs

If you are going to mix recreational drugs and HIV medication, avoid taking them at the same time.

If you are injecting or snorting drugs with friends or a partner, do not share drug using equipment.

Condomn Conundrums

Condoms, when used correctly, remain the single best way to prevent HIV transmission and many other STIs.

Condoms come in different sizes. The width measurement of the base of a condom is usually shown in millimetres on a box of condoms. Try different sizes to find the one that fits you best.

Condoms can be latex or non-latex (polyurethane). For those who may not be comfortable using latex condoms, it may be useful to try a non-latex condom. They can be sensitive and pleasure-enhancing, and are also ideal for those who are allergic or sensitive to latex.

You can reduce the risk of condoms splitting or slipping off by following these simple steps:

• The risk of condom failure increases after about 20 minutes of penetrative sex, so it’s advisable to check the condom during sex, and replace it with a new one if you are having sex for longer than 20 minutes.
• Never use saliva/spit as a lubricant; this increases the risk of a condom splitting because it dries quickly.
• When using lube, use only water-based or silicone-based lube and use plenty of it (such as ‘Wet Stuff’, ‘Pasante’, ‘Liquid Silk’, ‘TLC’, or ‘KY’).
• Put lube outside and all over the condom, and in and around the anus.
• Apply more lube during long periods of sex.
• Never put lube on the penis before putting the condom on. This can increase the risk of the condom slipping off.
• Never use two condoms together. This can cause friction between both condoms increasing the risk of them splitting or slipping off.

Remember that using condoms is as much about protecting you as it is about protecting your partner.

PEP (Post Exposure Prophylaxsis)

If your partner is exposed to HIV through unprotected sex or if a condom tears or slips off, there is a treatment option available that may prevent infection.

PEP involves taking a combination of at least two anti-HIV drugs for four weeks and aims to prevent HIV replicating itself in the body.

PEP must be taken within 72 hours (3 days) of exposure to HIV, but the earlier the treatment starts the better.

PEP is only available by prescription from some sexual health and STI clinics or Hospital Accident and Emergency Departments. Not everyone will be prescribed PEP. There are guidelines for prescribing and each person is assessed based on the information provided in relation to the potential risk of exposure to HIV.

If you and/or your partner find yourselves in such a situation, seek medical advice as soon as possible.

More information on PEP, and where to go for advice and assistance, is available in the GHN publication "PEP and You".

Viral Load

Viral load is the term used to describe the levels of HIV in the body at any one time. It is determined through a blood test. This is one of the key tests used to inform decisions about treatment.

The level of risk of HIV transmission during unsafe sex may be related to the levels of HIV present in the blood stream. Generally it is thought that the risk of transmission of HIV is lower if the viral load is lower, and that the risk is higher when the viral load is higher. HIV can still be transmitted through unprotected sex even if a person’s blood viral load is undetectable, as undetectable viral load does not mean zero viral load.

An undetectable or low viral load normally means that your immune system, together with your HIV treatments, are successfully controlling HIV in your body.

There are a number of reasons why viral load is not a good way to measure HIV transmission risks during sex:

• The viral load levels in semen and blood can be quite different. So if the blood’s viral load drops to undetectable levels, it can’t be certain that the viral load in the semen has dropped.
• Having another STI can increase the viral loading both in the blood and in semen.
• Viral load can vary quite quickly from day to day, in particular if a person is run down or is developing any type of infection. The latest viral load test result may be weeks or months old, so even if the viral load was low or undetectable when blood was taken, it doesn’t mean it is still at the same levels now.
• Viral load can rise if doses of HIV treatment are missed.

Sexually Transmitted Infections (STIs)

Having another infection can increase the risk of HIV transmission.

STIs, for example gonorrhoea or genital warts, can increase the viral load in an HIV positive man making it more likely for HIV to be passed on during unprotected sex.

If an HIV negative partner has another infection, this can increase the risk of HIV being passed on during unprotected sex. For example, STIs like genital warts, herpes and syphilis can cause sores, blisters or broken skin which can create openings where HIV can get in or get out.

Most STIs can be treated, but some can be more difficult to treat when you have HIV

Remember that some sexual practices which may be described as ‘safer’ in terms of HIV transmission, might still be risky for transmission of other STIs like syphilis or Hepatitis A.

Keep in mind that it is possible to have an STI and show no signs or symptoms.

If you are sexually active it is advisable to have a regular STI check-up every six months.

Vaccinations are available for Hepatitis A and Hepatitis B and are recommended for all men.

More information on STIs is available in the GHN publication 'Love Bugs'

Bottoms Up

Unprotected sexual activity remains a reality among some men who have sex with men.

• Condoms may not be available for one reason or another.
• Negotiating safer sex may be difficult.
• The situation may be influenced by alcohol and/or other recreational drugs.

Some HIV positive men may choose to reduce the risk of HIV transmission with an HIV negative partner by assuming the ‘bottoms up’ position during unprotected anal sex. This is sometimes referred to as ‘Strategic Positioning’.

While this may reduce the risk of transmission of HIV, it’s important to remember that HIV transmission can still occur when the HIV positive man is receptive (on the bottom). For example, a high viral load and/or the presence of another STI can increase the likelihood of HIV transmission.

This approach does not replace the use of condoms as an effective means of prevention. It still carries a risk of HIV transmission and transmission of other infections for both you and your sexual partner(s).

Support and Advice

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