Whenever you talk sex with other positive people there always seems to be an elephant in the room. And I’m not talking about jumbo appendages or huge sexual appetites, either. That elephant, of course, is unprotected sex.
It is not surprising that some people with HIV have started to weigh up the risks if they were to have unprotected sex. In 2011, the HPTN 052 trial conducted with serodiscordant couples showed a 96% reduction in transmission rates if the positive partner was on treatment and had an undetectable viral load.
It is also not surprising that many positive people are not willing to discuss the issue. We are understandably concerned about any risk of passing HIV onto our partners. We are wary of the possibility of criminal sanctions or public health management if we were to admit to having unsafe sex, particularly if disclosure hadn’t occurred. We are also acutely aware of the potential community backlash.
One woman I spoke to for this article told me that her positive female peers are talking about it amongst themselves and with their partners.
"We know there are still risks," she said. "We are only discussing it for people who have had an undetectable viral load for at least six months and are in regular monogamous relationships. "HPTN 052 made it clear that if you pick up an STI for instance, your viral load goes up. For quick meets online, I can’t imagine any positive woman not asking for condoms to be used."
Gay male serodiscordant couples are also talking, but can’t be certain about the relative risks as there are no comparable trial results. It will be some time before those that are underway will be reported, including an Australian one just started. 1
"There is no doubt that unprotected sex increases feelings of intimacy and adds to the spontaneity of sex," said an HIV-negative gay man who has been in a relationship with a positive guy for the past five years. "There is a lot of pressure maintaining condom use in a relationship for every sex act. Most of the time we are disciplined but sometimes it just happens," he said.
People would be well advised to take into account a recent study of HIV-positive gay men from Boston USA that showed that a quarter of the men with an undetectable viral load still had detectable virus in their semen. Although the seminal viral load was low, the researchers think it was still enough to be one of the explanations for ongoing transmissions in gay men, despite a high proportion being on antiretroviral therapy.2
The researchers noted that 24 of the 101 gay men in the study had undiagnosed urethral inflammation which is the likely cause of a higher seminal load in some of these men. While some of this urethral inflammation was due to the presence of an STI ,others weren’t, and the researchers postulate that some inflammation is due to them being the insertive partner during unprotected anal sex.
The report states that "this raises the possibility that seminal HIV in subjects engaging in UIAS (unprotected insertive anal sex) with HIV-infected (sic) partners may be attributable to urethral superinfection or contamination with HIV from rectal secretions of sex partners".
The report continues: "Reports of high numbers of HIV-target cells in the urethra and HIV-infected cells in urethral secretions from HIV-seropositive men with and without urethritis indicate that the urethra may be a primary HIV-infection site. Furthermore, higher concentrations of HIV RNA have been reported in rectal mucosa secretions than in blood and seminal plasma among MSM, and may be independent of ART."
Many positive people opt for relationships with other positive people to avoid the stresses of passing on the virus to a partner. But even then there is some dispute over whether poz-poz unprotected sex can cause re-infection or pass on resistant strains of the virus .Researchers are confident that re-infection with another strain (we largely have the subtype B of HIV in Australia) is unlikely if people have an undetectable viral load .
Treatment resistance can develop if people miss doses of their antiretrovirals or take short breaks from treatments. This treatment resistance can be passed on to a negative or positive partner and this could affect their responses to certain treatments down the track. Researchers are not clear how often it happens though. They think it is less likely if people maintain an undetectable viral load and more likely to occur in the first three years of being HIV-positive or if an STI like syphilis or herpes is present.3
Lost libido and sexual function
Another sexual dilemma that plagues many positive people is the loss of libido and sexual function. Some of this can be attributed to ageing but the high level suggests there may be a link with HIV and its treatments as well.
A Spanish review of research studies in this area, published in AIDS 2007 by Dr Jules Collazos, found the average prevalence of sexual dysfunction in HIV-positive people was 51%, which is substantially higher than the general population.4
Collazos examined the potential link with treatments and these problems and found some researchers suggested there may be an association with protease inhibitors, particularly ritonavir and indinavir. However, other researchers could see no association and cautioned against people trying to change their regimens as they may be essential to maintaining general health. There also seemed to be some evidence that people have improved sexual function when taking NNRTIs, including nevirapine.
Richardson and colleagues from St Mary’s Hospital in London found that sexual dysfunction was often related to anxiety and depression, which are both substantially higher in HIV-positive people. They also attributed it to the use of antidepressants and recreational drugs, in particular methamphetamine.5
Undoubtedly changes in body shape for those who have experienced lipodystrophy from antiretrovirals used in previous years have affected people’s sexual confidence.
What to do about it?
A GP I spoke to about this issue said that about 30% of sexual problems probably had a physical cause. Erectile difficulties may be caused by circulation problems. Getting risk factors for cardiovascular disease under control can help these people, with the greatest benefit from regular exercise and giving up smoking.
A drop in testosterone levels can be caused by adrenal problems related to HIV as well as ageing. Testosterone replacement certainly works for some men although the GP warns that there are lots of people with high testosterone levels who still have no libido and vice versa. Limited studies on the role of testosterone replacement in women suggest it may also help their sexual function.6
Women with HIV who experience early menopause can be given hormone replacement but need to be monitored closely for signs of masculinisation. Early menopause is not necessarily associated with a loss of libido however, and women will often continue to have an interest in sex while experiencing it.
For men with erectile difficulties, there are the options of Viagra, Levitra and Cialis. These are all metabolised by the cytochrome p450 enzyme system and interact with many antiretroviral agents including protease inhibitors. They are often prescribed at lower doses by doctors to avoid potential interactions. These drugs should not be used with amyl nitrate due to the possibility of a drop in blood pressure. Other options include the use of penile injections like Caverject. (See James’ story)
The GP also stressed the importance of PLHIV raising any sexual concerns with their doctor; although he admitted that some doctors handle the sensitivities involved better than others.
"I would also say that people need to change the way they think about sex as they get older. It may not be as vigorous or lead to the greatest climaxes ever, but if there is openness and emotional attachment with a partner this can lead to continued enjoyable sexual relationships."
Deanna, 40s, partnered heterosexual woman
Deanna has had HIV for 16 years. In that time, she has experienced several AIDS-defining illnesses but is now in robust health, regularly participating in endurance sports and long bicycle trips.
"I’m a great believer in fitness and eating highly nutritious foods to help not only with management of your HIV but also to increase your interest in a healthy sex life. There is no doubt it helps with body image, energy and self-esteem, particularly for those of us who have had to cope with lipodystrophy in the past," she says.
Deanna has experienced early menopause with the onset of heavier periods, night sweats and hot flushes occurring in her mid-30s. This, she says, is not uncommon amongst her positive-women peers, particularly those who have lived with HIV for a long time. She is not prepared to take hormone replacement for it and relies on her fitness and lifestyle to get her through.
Deanna says that most of the positive women she mixes with have partners, most of whom are HIV-negative.
"The male partners seem to cope quite well with it and look to the person, not the virus ,as the relationship gets stronger."
Ben, 35, single gay man
"When I found out I was positive several years ago, I wasn’t sure how to treat my sex life. Should I look for another HIV-positive partner? I was too scared to reveal my status to HIV-negative people online and before long, a positive friend got me onto a bareback site.
"He told me it was the best place to meet other poz guys and they were there in abundance! But it started a difficult period in my life. I got invited to sex parties and consumed heaps of recreational drugs and had a lot of sex. This led to me getting several STIs and an awful attack of shigella which really knocked me about.
"Apart from the problem with STIs, I go through a lot of guilt if I’ve had unprotected sex in those venues without disclosing. It’s so hard to do and you kind of think that the other person is giving you permission to go ahead. I am undetectable and I know there is this talk about that making you un-infectious but the risks make the sex unenjoyable for me. I usually use condoms. What I need is a positive partner so I don’t have to deal with all these issues."
James, 58, single gay man
James has lived with HIV for more than 25 years and has had multiple illnesses along the way with the most recent being a diagnosis of diabetes .
"I know that having HIV for such a long time, and now diabetes ,is taking a toll on my body and inevitably it’s going to affect my sex life. I can’t deny I’m getting older either and other negative friends my age have erectile problems just like me.
"For whatever reason (I blame HIV but probably unfairly), I have not found a partner to settle down with. That means I look for sexual partners online or at sex-on-premises venues. There’s no use beating around the bush around this – gay guys at those places are only interested in someone who can get an erection on demand!
"I’ve tried Cialis when my doctor suggested it was the safest of those drugs to take with ritonavir, although I only take half a normal dose. After a while it stopped working and I was thinking I would have to adjust to the idea of being impotent and celibate.
"A friend referred me to a men’s health clinic where the doctor recommended I try penile injections. The thought worried me at first. But after I saw the small needle and the instant reaction when the nurse tried it on me, I was hooked! It has its problems, including difficulties ejaculating and the erection doesn’t go down after orgasm. But it shows me that people shouldn’t necessarily give up if they still have an interest in sex but things aren’t working down there."
Thanks to Jennifer Stewart from the HIV Hepatitis and STI Education and Resource Centre, Alfred Hospital for help with this article.
- ‘Opposites Attract’ is a trial being run in several Australian cities with gay serodiscordant couples. The Kirby Institute in NSW is examining whether transmissions occur between partners over a two year period if the positive partner has an undetectable viral load . For more details go to www.oppositesattract.net.au
- Poltich JA et al. Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active men who have sex with men AIDS 26 doi:10.1097/QAD.0b013e328353b11b.2012
- HIV positive Gay Sex, AFAO NAPWHA publication, pages 27-28
- Collazos J. Sexual dysfunction in the highly active antiretroviral era AIDS Rev 2007:9:237-245
- Richardson D et al. Factors associated with sexual dysfunction in men with HIV
- Davison SL and David SR Androgenic hormones and aging – the link with female sexual function. Horm Behav 2011.doi:10.1016/j.yhbeh.2010.12.013