Unprotected sex

Unprotected sex is the term used to describe anal or vaginal sex if a condom is not used.

HIV and sexually transmitted diseases infections (STIs) can be passed on via by unprotected sex. Unprotected penetrative (the insertion of the penis into the body of another person) anal and vaginal sex carries the greatest risk of STIs, however, infections can also be transmitted through oral sex (mouth to genitals), and oral-anal sex (mouth to anus), also called 'rimming.'

Unprotected sex with HIV-negative and untested people

If you are HIV-positive, using condoms during sex with people who know that they are HIV-negative or are unsure of their HIV status will protect them against HIV and protect both of you from STIs.

There's a lot of debate about how infectious people with HIV are if they are taking HIV treatment and have an undetectable viral load. Most experts seem to agree HIV treatment means that the risk of HIV transmission is reduced, but that some risk still exists.

The law is also an important consideration. In the UK a number of people have been recently been sent to prison after infecting their sexual partners with HIV after failing to tell them they had HIV. You should also be aware that in some countries including you are legally required to disclose your HIV status to sexual partners.

Sex with other HIV-positive people

Many people with HIV have unprotected sex with their HIV-positive partners. Positi ve reasons for this include intimacy and pleasure

However, If you are HIV-positive and having sex with another person who is also HIV-positive, there are some important considerations that many HIV doctors and HIV prevention workers believe you should be aware of so you can make an informed decision about sex. These issues include:

• There is a risk of pregnancy as a consequence of unprotected vaginal sex between men and women. There is a risk of transmission to the baby, when an HIV positive man has unprotected sex with an HIV negative woman who is pregnant or breast-feeding. However, with the right treatment and care, it's possible for an HIV-positive woman to have an HIV-negative baby.

• There have been a small number of cases of so-called 'superinfection' with a new strain or strains of HIV, which may either be more aggressive than or resistant to anti-HIV drugs. This could lead to the failure of treatments that might otherwise have been effective. This applies to both men and women. But the number of recorded cases of superinfection is small. The cases have almost all involved people who were infected with HIV for less than four years and either were not on HIV treatment, or were taking a treatment break.

• Unprotected sex puts you at risk of other sexually transmitted infections. This applies to both men and women.

Bacterial STIs, such as gonorrhoea, and chlamydia can be treated just as easily and successfully in most people with HIV as in people who are HIV-negative, provided that they are diagnosed and treated. Failure to get prompt treatment can lead to infertility and in some cases damage to the internal organs. Syphilis, particularly in people with a low CD4 cell count can be harder to diagnose and cure and can be more aggressive when the immune system is damaged.

There are also viral STIs. Genital herpes and genital warts are not curable, even in people who are HIV-negative. Although both these infections will respond to treatment, they can reoccur and can be harder to control if you have a very weak immune system. Genital herpes is linked to an increased risk of HIV transmission, especially when ulcers are present. Some strains of the virus which cause genital warts have been linked with the development of genital cervical and anal cancers.

The liver viruses hepatitis A and  hepatitis B and (less easily) hepatitis C, can also be passed on sexually and can be more complicated in people with HIV. Hepatitis can cause liver damage which can limit HIV treatment options and make you very unwell in its own right.

There are vaccines for hepatitis A and B (but not C), which should be available at your HIV treatment centre. Gay men in particular are advised to be vaccinated against hepatitis A and B. After you have been vaccinated it is important to have your immunity to hepatitis A and B checked regularly, as the vaccines do not offer permanent protection. There's now good evidence that hepatitis C can be passed on sexually. Some HIV-positive gay men have been infected with hepatitis C after having unprotected sex, and 'rougher' sex such as fisting.

Some of the opportunistic infections which affect people with HIV can be passed on through sex.   Kaposi's sarcoma is thought to be passed on sexually through a form of herpes virus. Both HIV-positive and negative people can be affected by gut infections such as Giardia, amoebas (small parasites which live in the gut and cause diarrhoea), cryptosporidium and microsporidium which can be passed on through oral-anal contact or any sexual activity which leads to contaminated faeces getting into the mouth. These infections can cause very severe diarrhoea which is particularly in people with very low CD4 cell counts.

Having an untreated STI increases the amount of HIV in the genital fluids, making HIV easier to pass on if you have unprotected sex.

It is recommended that all sexually active people have regular sexual health check-ups. Many HIV treatment centres have sexual health clinics attached, which in the UK offer free and confidential testing and treatment.