HIV

Sex and Sexuality and HIV: Entire Lesson

When you are first diagnosed with HIV, you may not want to think about having sex. Some people may be afraid of infecting a partner and decide sex is too risky. These are common reactions, especially if you got HIV through sex. Chances are, however, that you will want to have sex again. The good news is that there is no reason why you can't. People living with HIV enjoy sex and fall in love, just like other people. And there are many ways to have satisfying and safe sexual relationships.

One of the most effective ways to prevent HIV from passing to an HIV-negative sex partner is to take your own HIV medications (antiretroviral therapy, or ART) every day — these not only protect your health but can prevent transmission of HIV.

If you are having a hard time dealing with negative feelings like anger or fear, you can get help. Talk to your VA health care provider about support groups or counseling. Sex is a difficult topic for many people living with HIV — you are not alone.

By reading this information, you are already taking a good first step toward a healthy sex life. Having good information will help you make good decisions.

Your provider or other members of your health care team may ask you about your sexual practices each time you go in for a checkup. It may feel embarrassing at first to be honest and open. But they are trying to help you stay healthy.

Your VA provider and staff will still give you care if you have had sex with someone of the same sex or someone other than your spouse. VA is not there to judge you. It's OK to tell your providers the truth. It will not affect your medical benefits. It will help your health care team take better care of you.

Make sure you set aside time to ask questions about safer sex, sexually transmitted diseases (STDs), or any other questions you might have. If you feel that you need help dealing with your feelings, ask about support groups or counseling.

Many people living with HIV ask their provider to talk with them and their partners about HIV and how it is transmitted. They can answer technical questions and address the specifics of your situation. If you live with someone, they may have questions about everyday contact as well as sexual contact.

This may be one of the hardest things you have to do. But you need to tell your sex partner(s) that you are living with HIV, whether you have a primary partner such as a spouse or girlfriend or boyfriend, have more than one partner, or are single or casually dating.

What follows are tips for talking to your main partner, other partners, and former partners.

Talking to your main partner

If you are in a relationship, one of the first things you will probably think about after learning that you have HIV is telling your partner or partners. For some couples, a positive HIV test may have been expected. For others, the news will be a surprise that can be difficult.

Your partner may not be prepared to offer you support during a time when you need it. Your partner may be worrying about their own HIV status. On the other hand, if you think you may have contracted HIV from your partner, you are probably dealing with your own feelings.

Unless your partner is known to have HIV infection, they should get an HIV test right away. Don't assume that the results will come back positive, even if you have been having unprotected sex or sharing needles. Your partner may assume the worst and may blame you for possibly spreading the disease. It is important that you discuss these feelings with each other in an open and honest way, perhaps with a licensed counselor.

Talking to new partners

Talking about HIV with someone you are dating casually or someone you met recently may be difficult. You might not know this person very well or know what kind of reaction to expect. When telling a casual partner or someone you are dating, each situation is different and you might use a different approach each time. Sometimes you may feel comfortable being direct and saying, "Before we have sex, I want you to know that I have HIV."

Other times, you may want to bring it up by saying something like, "Let's talk about safer sex." Whichever approach you choose, you should tell the person that you have HIV before you have sex the first time. Otherwise, there may be hurt feelings or mistrust later. Also be sure to take your HIV medications every day (this is very effective in protecting partners from infection) and practice safer sex (see the Protecting your partner section). Whatever way you decide to tell your partner, the tips at the bottom of this page may help.

Talking to former partners

With people you had sex with in the past or people you have shared needles with, it can be very difficult to explain that you have HIV. However, it is important that they know so that they can get tested.

If you need help telling people that you may have been exposed to HIV, most city or county health departments will tell them for you, without using your name. Ask your provider about this service.

Remember

Before telling your partner that you have HIV, take some time to think about how you want to bring it up.

• Decide when and where would be the best time and place to have a conversation. Choose a time when you expect that you will both be comfortable and as relaxed as possible.
• Think about how your partner may react to stressful situations. If there is a history of violence in your relationship, consider your safety first and make a plan with a social worker or counselor.
• Imagine several ways in which your partner might react to the news. Write down what they might say, and then think about what you might say in response.

We know a lot about how HIV is transmitted from person to person. Having safer sex means you take this into account and avoid risky practices.

There are two reasons to practice safer sex: to protect yourself and to protect others.

Protecting yourself

If you have HIV, you need to protect your health. When it comes to sex, this means practicing safer sex (like using condoms) to avoid sexually transmitted diseases like herpes and hepatitis. HIV makes it harder for your body to fight off diseases. What might be a small health problem for someone without HIV could be big health problem for you. Your VA provider can prescribe condoms for you if you need them.

Protecting your partner

Taking care of others means making sure that you do not pass HIV or any other sexually transmitted infections to them.

"Being safe" usually means protecting yourself and others by using condoms for the highest-risk sex activities, specifically for anal and vaginal sex. When done correctly, condom use is very effective at preventing HIV transmission. In recent years, "being safe" has come to include two other important strategies for reducing HIV infections:

1. HIV treatment (ART medications) for people with HIV and,
2. PrEP for HIV negative people (see below). Both are very effective at reducing the risk of HIV infection. One or more of them is likely to be appropriate for your situation — be sure to ask your health care provider for more information.

What about antiretroviral therapy (ART) for HIV prevention?

One of the most effective ways you can prevent HIV from passing to an HIV-negative sex partner is to take your ART (HIV medications) every day. If they are working well to suppress the HIV in your body they also will prevent transmission of HIV to others. Learn more about ART as a prevention strategy.

What about pre-exposure prophylaxis (PrEP)?

HIV-negative individuals may, under the supervision of their health care provider, take a pill every day to prevent HIV infection. We call this pre-exposure prophylaxis, or PrEP. Usually these are persons who are at relatively high risk of becoming infected with HIV (for example, because they have a partner with HIV, they have risky sexual exposures, or they share injection drug equipment). The medications used for PrEP are Truvada and Descovy. PrEP appears to be extremely effective if it is taken every day, and is not effective if it is taken irregularly. Your VA health care provider can tell you more about PrEP.

Risky sex is sex that may lead to infection of an HIV-negative individual. There are many ways to decrease the risk of HIV infection, like (for the partner living with HIV) taking HIV medications (ART) every day, or (for the HIV-negative partner) using PrEP, or (for partners of any HIV status) using condoms or other latex barriers during sex.

HIV is passed through body fluids such as semen, vaginal, or anal fluid, or blood. The less contact you have with these, the lower the risk. The most sensitive areas where these fluids are risky are in the vagina or anus and rectum (ass). The protective tissue there is thin, and is easily torn, which makes it easier for the virus to enter your body. Saliva (spit) and tears aren't as risky.

In general, vaginal or anal sex without a condom is the most risky.

Here is a list of sexual activities organized by level of risk to help you and your partner make decisions:

Get tips for using condoms and dental dams. You can find additional information on the Resources page at the end of this section.

You and your partners will have to decide what you are comfortable doing sexually.

Of course, only you and your partner can decide what level of risk you are willing to take.

The only forms of birth control that will protect against HIV are abstinence and using condoms while having sex. Other methods of birth control offer protection against unplanned pregnancy, but do not protect against HIV or other sexually transmitted diseases.

Considerations for women with HIV

If you are in a monogamous relationship and your partner also has HIV, you may decide to use a birth control method other than condoms. (These methods won't protect against other STDs or re-infection.)

If you need condoms, you can ask your VA provider for a prescription for condoms at your next visit. If you are not used to using condoms: practice, practice, practice.

Male condom dos and don'ts:

• For a visual guide to using male condoms, check out this CDC page
• Shop around: Use lubricated latex condoms. Always use latex, because lambskin condoms don't block HIV and STDs, and polyurethane condoms break more often than latex (if you are allergic to latex, polyurethane condoms are an option). There is a lot of variety--one will work for you!
• Keep it fresh: Store condoms loosely in a cool, dry place (not your wallet). Check the expiration date. Throw away condoms that have expired, were exposed to very hot temperatures, or were washed in the washer. If you think the condom might not be good, get a new one.
• Take it easy: Open the package carefully, so that you don't rip the condom and make sure that the condom package has not been punctured (there should be a pocket of air). Check the condom for damaged packaging and signs of aging such as brittleness, stickiness, and discoloration.
• Keep it hard: Put on the condom after the penis is erect and before it touches any part of a partner's body. If a penis is uncircumcised (uncut), the foreskin must be pulled back before putting on the condom.
• Heads up: Make sure the condom is right-side out. Before you put it on the penis, unroll the condom about half an inch to see which direction it is unrolling. Then put it on the head of the penis and hold the tip of the condom between your fingers as you roll it all the way down the shaft of the penis from head to base. This keeps out air bubbles that can cause the condom to break. It also leaves a space for semen to collect after ejaculation.
• Slippery when wet: If you use a lubricant (lube), it should be a water-soluble lubricant (for example, ID Glide, K-Y Jelly, Slippery Stuff, Foreplay, Wet, Astroglide) in order to prevent breakdown of the condom. Put lubricant on after you put on the condom, not before — it could slip off. Add more lube often. Dry condoms break more easily. Products such as petroleum jelly, massage oils, butter, Crisco, Vaseline, and hand creams are not considered water-soluble lubricants and should not be used.
• Come and go: Withdraw the penis immediately after ejaculation, while the penis is still erect; grasp the rim of the condom between your fingers and slowly withdraw the penis (with the condom still on) so that no semen is spilled.
• Clean up: Throw out the used condom right away. Tie it off to prevent spillage or wrap it in bathroom tissue and put it in the garbage. Condoms can clog toilets. Use a condom only once. Never use the same condom for vaginal and anal intercourse. Never use a condom that has been used by someone else.

Do you have to use a condom for oral sex?

It is possible for oral sex to transmit HIV, whether the infected partner is performing or receiving oral sex. But the risk is very low compared with unprotected vaginal or anal sex, however other sexually transmitted infections can be transmitted through oral sex.

If you choose to perform oral sex, you may:

• use a latex condom on the penis; or
• use a latex barrier (such as a natural rubber latex sheet, a dental dam, or a cut-open condom that makes a square) between your mouth and the vagina. A latex barrier such as a dental dam reduces the risk of blood or vaginal fluids entering your mouth. Plastic food wrap also can be used as a barrier. For a visual guide to using dental dams for oral sex, check out this CDC page.
• if either you or your partner are allergic to latex, plastic (polyurethane) condoms can be used.

If you perform oral sex and this sex includes oral contact with your partner's anus (anilingus or rimming),

• use a latex barrier (such as a natural rubber latex sheet, a dental dam, or a cut-open condom that makes a square) between your mouth and the anus. Plastic food wrap also can be used as a barrier.

If you share sex toys, such as dildos or vibrators, with your partner,

• each partner should use a new condom on the sex toy; and be sure to clean sex toys between each use.

Internal condom (also called female condom)

This type of condom was originally designed to be inserted into the vagina before sex. It also can be used in the anus, by either men or women, though its effectiveness in preventing HIV transmission via anal sex has not been studied.

The internal condom is a large condom fitted with larger and smaller flexible rings at each end. The rings help keep it inside the vagina during sex; for anal sex, the inner ring usually is removed before it is inserted. It is made of nitrile, so any lubricant can be used without damaging it. It may seem a little awkward at first, but can be a useful alternative to the traditional "male" condom. Female condoms generally cost more than male condoms. For a visual guide on using an internal condom, check out this CDC page. Remember to:

• Store the condom in a cool dry place, not in direct heat or sunlight.
• Throw away any condoms that have expired--the date is printed on the wrappers.
• Check the package for damage and check the condom for signs of aging such as brittleness, stickiness, and discoloration. The internal condom is lubricated, so it will be somewhat wet.
• Before inserting the condom, you can squeeze lubricant into the condom pouch and rub the sides together to spread it around.
• Put the condom in before sex play because pre-ejaculatory fluid, which comes from the penis, may contain HIV. The condom can be inserted up to 8 hours before sex.
• The internal condom has a firm but flexible ring at each end of it. To insert the condom in the vagina, squeeze the ring at the closed end between the fingers (like a diaphragm), and push it up into the back of the vagina. The open ring must stay outside the vagina at all times, and it will partly cover the lip area. For use in the anus, most people remove the internal ring before insertion.
• Do not use a male condom with the internal condom.
• Do not use an internal condom with a diaphragm.
• If the penis is inserted outside the condom pouch or if the outer ring (open ring) slips into the vagina, stop and take the condom out. Use a new condom before you start sex again.
• Don't tear the condom with fingernails or jewelry.
• Use a condom only once and properly dispose of it in the trash (not the toilet).

• Sexually Transmitted Infections (STIs) overview
• HIVE
  Website focused on advancing reproductive and sexual wellness for individuals, families, and communities affected by HIV.
• Relationships and Sex
  The Body's section on sex for people with HIV.
• Undetectable=Untransmittable (U=U): Frequently Asked Questions
  How taking HIV medicines to treat HIV can eliminate the risk of sexually transmitting the virus to an HIV-negative partner; NYC Department of Health

Information on Using Condoms

• Tips for Using Condoms
• CDC Fact Sheet on Condoms and STDs