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Part 1: HIV, sex and me
Although it’s not certain to happen, you may find that your feelings about sex change after you find out you have HIV. It could be that your interest in sex dips or goes away altogether for some or all of the time, or the opposite might happen. This could be due to natural fluctuations in your desire for sex and is something that you are prepared to put up with but. Alternatively, it could cause you problems, particularly if it makes you unhappy or interferes with other aspects of your life.
Finding out you have HIV can make you feel differently about yourself. It may well be a shock and may result in you going off sex, at least temporarily. Some people say that having HIV makes them feel less physically and sexually desirable and they lose confidence dating or with their sexual partners.
Having HIV can make you to look at yourself and sex very negatively. It could make you feel bad about the kind of sex you had or are having, make you worry about the risk of infecting somebody else with a potentially fatal illness, or make you angry with the person or people who could have infected you.
An HIV diagnosis might also feed wider negative feelings you have about who you are. HIV has been used as a moral and political tool to criticise and stigmatise the groups most affected in this country – gay men, Africans and drug users.
It is important to remember that HIV is an infection - it is not a moral judgment or a punishment.
Anxiety about infecting sexual partners with HIV is also common and this can mean that your desire to have sex or your sexual performance dips.
An additional source of anxiety may be telling your past, present or potential sexual partners that you have HIV. This can be daunting and you need to decide yourself whether you tell none, some or all of your sexual partners.
Think about how and when you are going to tell people that you have HIV, and how you would react if somebody rejected you. Although many HIV-positive people have HIV-negative long-term partners or casual partners, people are rejected because they have HIV. It can hurt (or even in some circumstances put your personal safety at risk) and it is important that you develop strategies to cope if this happens to you.
Many HIV-positive people have partners who are HIV-negative. Many couples are able to have protected sex all the time, but others find this difficult or impossible and are willing to accept the risk of the uninfected partner contracting HIV. In some circumstances power imbalances in a relationship can mean that even though one partner wants to have safer sex, the other partner insists that condoms are not used.
HIV can also lead to a loss of sexual intimacy in relationships. Enjoying and valuing intimacy in ways other than sex might be valuable if this occurs.
Some HIV-positive people choose only to have sex with people who also have HIV. This can be motivated by a wish not to risk infecting a partner with HIV. Another reason might be a wish to have unprotected sex with other HIV-positive people. This can be pleasurable and intimate, but there can be health risks including sexually transmitted infections, infection with hepatitis C and possible reinfection with another strain of HIV. These issues are discussed in greater detail in the following pages.
Dealing with sexual problems
Whilst sexual problems - often called sexual dysfunction - can be a problem for anyone, people living with HIV may be particularly affected. Loss of sexual drive or desire (libido) can have a significant impact on quality of life and feelings of self-worth, and may contribute to emotional problems such as anxiety and depression.
Sexual problems are common during times of stress, such as when one receives an HIV-positive diagnosis. This can be a time of shock, worry, and disbelief and sexual desire and performance can suffer as a result. Concerns about possibly infecting your sexual partners can also affect sex and intimacy. Negative associations between HIV – a potentially life-threatening infection – and sex could also cause sexual problems.
Other everyday issues can also affect sexual desire and performance, for example work or relationship difficulties. If they do not go away, ask for help.
Excessive intake of alcohol or recreational drugs can also diminish both the desire and ability to have sex.
Many of the drugs commonly used to treat depression, e.g. fluoxetine (Prozac) or paroxetine (Seroxat) can also affect sexual function. Additionally, megestrol acetate (Megace), an appetite stimulant, has been shown to cause loss of libido.
Sexual dysfunction among men can often be a result of decreased testosterone levels (hypogonadism), which can also lead to fatigue. Lower than normal testosterone levels have been found in people with advanced HIV infection, and can be caused both by the direct effects of HIV or chronic ill health itself. Many men receive testosterone treatment to alleviate these problems. Men who use testosterone replacement therapy usually gain muscle mass, experience an emotional 'lift', and an increase in their libido.
Impotence, or the inability to get or maintain an erection, can be caused by HIV damaging the nerves in the penis that control an erection (this is called autonomic neuropathy). Similarly, anti-HIV drugs that cause neuropathy such as ddC (zalcitabine, Hivid, production of which will cease in 2006), ddI (didanosine, Videx/Videx EC) and d4T (stavudine, Zerit) may cause numbness in the genital area, which can make it difficult to sustain an erection. Protease inhibitors have also been reported to cause impotence, with some evidence suggesting that those containing ritonavir are particularly likely to cause sexual dysfunction.
Don’t be ashamed if you’re not happy with the way you feel about sex or about your sexual performance. Try talking to your partner or a close and trusted friend about what you are feeling or experiencing. Your HIV doctor will help or refer you to a specialist, nurse, health advisor or counsellor who can. If it is a medicine which is causing your sexual problems it might be possible to change it to one that does not have these side-effects. It is also possible that your doctor might be able to refer you to a specialist HIV counsellor where you will have an opportunity to talk through your concerns and problems. In other cases a referral to specialist HIV mental health services might be appropriate. Here you may be offered a course of cognitive behavioural therapy (CBT) to help you recognise and over-come your sexual problems.
Medicines may also be able to help. The drugs sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) are tablets used to treat impotence which works by increasing blood flow to the penis, making it more sensitive to touch. However, these drugs should be taken with care by people using protease inhibitors, non-nucleoside analogues (NNRTIs), the anti-fungal drug ketoconazole (Nizoral), itraconazole (Sporanox) or the antibiotic erythromycin. For people taking full-dose ritonavir (Norvir), it is recommended that Viagra should not be used at all given the potential health risks. Similarly, the recreational drug poppers must not be used with Viagra, Cialis, or Levitra under any circumstances as this can result in a dangerous drop in blood pressure.
HIV, sex and the law
Recently several people in the UK have been sent to prison after being convicted of grievous bodily harm because they infected their sexual partners with HIV through unprotected sex without first informing them that they had HIV. Other cases involving all the communities most affected by HIV are being investigated by the police and it is thought that there could be many more prosecutions.
It is also important to know that condoms, when used properly provide excellent protection against HIV and most other sexually transmitted infections. Many lawyers think that even if HIV transmission does occur with a partner who you did not tell that you had HIV, the use of a condom for the entire duration of sex every time you had sex together would provide a defence. However, this argument has yet to be tested in court.
Ultimately, it is your decision whether or not you tell your sexual partners that you have HIV. You may want to consider if the kind of sex you are having involves a substantial risk of HIV transmission – unprotected anal and vaginal sex have the highest risk, but there is good evidence that there is a smaller risk from oral sex. Other issues you will need to consider are how and when to tell your partners. Think about how you will react if you are rejected, or if you are verbally or physically threatened or attacked.
A lot of sex happens in the heat of the moment. There might not be the opportunity to mention that you have HIV, or your partner might not want to discuss it. You may also find that your partner actually initiates unprotected sex. Think about how you might respond to these situations. Don’t assume that just because your partner doesn’t want to talk about HIV or is willing or even eager to have unprotected sex that they are HIV-positive.
Ideally, HIV-positive people have a responsibility not to pass on HIV, just as HIV-negative people have a responsibility to look after their own health. The law as it now stands means that the balance of responsibility has shifted to people with HIV.
Your doctor and other members of the medical profession have a duty to think about your best interests. The criminalisation of HIV transmission is an evolving and controversial area of the law, which has had consequences for the doctor - patient relationship. The recent convictions mean that some healthcare professionals now believe that they have a responsibility to tell their patients that as HIV is an incurable infection that can be transmitted during sex, that they must inform all their sexual partners that they are infected with HIV before they have sex. Some fear that if they fail to do so they will have been negligent and could be prosecuted themselves.
There are regular news updates on the criminalisation of HIV transmission on NAM’s website, www.aidsmap.com. If you want to speak to somebody in confidence, or are being investigated by the police for the transmission of HIV contact THT Direct on 0845 12 21 200. THT also have an information leaflet on criminalisation that can be read on their website www.tht.org.uk.