Sex

All too often, relationships between people of different HIV status are thought of only in terms of sex and the risk of HIV transmission.

Yes, sex is important to many intimate relationships – but few successful relationships are purely based upon sex, and the sexual side of relationships usually changes significantly over time.

But one way or another, HIV will affect the way you and your partner feel about sex, and have implications for the type of sex you have. The presence of any illness in a relationship can affect sex. This is especially the case with HIV because it can be transmitted through sexual contact.

It therefore makes very good sense for you and your partner to talk about this. You may wish to discuss how you feel about having sex together when there’s a risk of HIV being passed on, and how this will affect your intimacy.

It also makes good sense to talk about ways of preventing HIV transmission in the relationship.

Many people find it difficult to talk about sex, even with the person who is closest to them. If this is the case, you might want to discuss your concerns with someone at your HIV clinic. This may help you clarify your thoughts and what you’d like to say. Sometimes, couple’s counselling can provide a safe space to work through difficult issues with your partner. Your clinic or a local HIV organisation may be able to arrange this. If you’re not sure where to start, you could contact the Terrence Higgins Trust helpline, THT Direct, on 0845 12 21 200 for information on local services and organisations.

Properly used condoms are a good way of preventing the transmission of HIV, other sexually transmitted infections, and can also prevent unplanned pregnancies.

This is a solution for some couples, but others find it difficult to use condoms all the time or at all.

If you are having problems using condoms, then it’s a good idea to talk to your partner about it. You might also find it helpful to talk to someone at your clinic, such as a health adviser. There may be practical problems with using condoms that are easy to resolve. For example, some people find that standard condoms break because they are too small, or slip off because they are too big, and trying different sizes of condoms might solve these problems. For some couples, using female condoms or different types of lubricants can vary the experience of using condoms.

However, difficulties with using condoms are sometimes more connected to feelings about HIV and intimacy, and talking through your feelings with your partner, or a professional such as a health adviser or counsellor might help in these situations.

If you are not using condoms, it’s important that you both understand and accept the possible risks and have considered the impact on both of you if your partner were to contract HIV. There’s a lot of debate at the moment about how infectious people with HIV are if they are taking HIV treatment and have an undetectable viral load. The section on infectiousness looks at this question in detail.

Should you or your partner be concerned about the possibility of HIV transmission after having unprotected sex, then it’s good to know that a course of HIV medication may be able to prevent your partner from contracting the virus.

This is called post-exposure prophylaxis, or PEP for short. It needs to be started as soon as possible after a person has been exposed to HIV, and certainly within 72 hours, and needs to be taken for four weeks. It can be highly effective if started soon enough, but it’s not 100% effective and can cause side-effects.

In the UK PEP can be obtained from HIV and sexual health or GUM (genitourinary medicine) clinics, or accident and emergency when these are closed.

Should you be considering PEP for your partner, it’s a good idea to contact your HIV clinic for advice. If the clinic is closed, most will have a doctor on call who specialises in HIV and who can be contacted through the hospital switchboard. But remember PEP should be started as soon as possible after a possible exposure, so if you cannot contact someone at your HIV clinic, it’s a good idea to go to your nearest accident and emergency without delay.

If you are taking HIV treatment, it may be tempting to use your own drugs as PEP for your partner. It’s important to remember that not all anti-HIV drugs are thought suitable for use as PEP, and some drugs – for example abacavir (Ziagen, also in the combination pills Kivexa and Trizivir), nevirapine (Viramune) and etravirine (Intelence) can cause potentially dangerous allergic reactions.

Also remember that giving your anti-HIV drugs to someone else could mean that you run out of supplies for your own treatment.

Research is currently underway to see if an HIV-negative person is protected from infection with HIV if they take anti-HIV drugs before having risky sex. If you are tempted to do this, you should remember that the safety and effectiveness of this approach has not yet been proven. The same cautions regarding the use of your anti-HIV drugs as PEP also apply.

If you are having unprotected sex with your partner, it’s important that you discuss the possible risks of infection. Many people are infected with HIV within relationships.

The risk of HIV transmission from unprotected sex is partly related to viral load. The higher your viral load, the greater the risk of HIV transmission to your partner.

There’s a lot of debate at the moment about the infectiousness of a person taking HIV treatment who has an undetectable viral load. Doctors and researchers have different views about this issue, but there seems to be a consensus that HIV treatment that lowers viral load to undetectable levels does substantially reduce the risk of HIV transmission.

Studies conducted in monogamous heterosexual couples, have shown no HIV infections in couples where one partner was HIV-positive and the other HIV-negative when the HIV-positive person was taking HIV treatment and had an undetectable or very low viral load.

There’s been less research into the impact of treatment on infectiousness in gay men, but what little has been done does suggest that transmissions from people taking HIV treatment with an undetectable viral load are very rare.

There have, however, been a few case reports of HIV transmissions in couples where the HIV-positive partner was taking HIV treatment and had an undetectable viral load.

It’s important to note that sexually transmitted infections can increase viral load. To have the best chance of getting your viral load undetectable and keeping it undetectable, you need to take your HIV treatment properly.

This is a very fast-moving area of HIV medicine and new research is being published on this topic all the time. This research is reported on NAM’s other website, aidsmap.com.

If you have any questions about infectiousness, then you may want to discuss them with your doctor or another member of your healthcare team. Because this is such a new and controversial area, many doctors and nurses have differing opinions on the impact of treatment on infectiousness, so it could be the case that what you are told differs between individuals.

If you and your partner want to have children, then you may want to discuss the methods of conception available to you. There are a range of options, including a number of procedures involving ‘assisted conception’. Some of these mean that any child born as a result will not be the biological offspring of both parents.   

Your healthcare team will be able to help you think through the issues relating to the different methods, including the risk of HIV transmission and how you feel about the options available.

If you are an HIV-positive woman, then one option is self-insemination. This means using a syringe to insert your partner’s semen.

If you are an HIV-positive man, then you could consider having a procedure called sperm washing, which removes HIV from sperm. The ‘washed’ sperm is then used to inseminate the female partner.

Neither of these methods involve a risk of HIV transmission. But they have their disadvantages – they don’t always work and sperm washing is not always available from the NHS.

Therefore couples sometimes choose to have unprotected sex to conceive. It’s important that you and your partner discuss this beforehand, and have considered the risk of HIV transmission. If you have unprotected sex and are worried that you’ve exposed your partner to HIV, then a course of PEP (discussed above) may be appropriate.

It’s also good to know that it’s possible to prevent mother-to-child transmission of HIV in most cases.