HTU asked some readers what they thought
of the guidelines.
Paul Clift, HIV patient representative at King’s College Hospital
in south London
and a member of the BHIVA Guidelines Subcommittee, says:
really is important that the guidelines emphasise the positive effect of
programmes to improve condom use. The effect of this work is often understated.
The hard financial cost of one HIV infection, including all expenses incurred, is
at least half a million pounds, but because this money is not seen ‘up front’,
it becomes easy for a cost-cutting government or commissioning consortium
simply not to spend on necessary prevention.
Clutterbuck’s comment that “professionals advising people with HIV or at risk
will require increased knowledge and risk literacy, as will their clients.” is very
important. I hear a lot of confusion about the effect of condoms and of viral
suppression in the patients I represent, and I’m concerned that those who are
educationally or intellectually capable, and who are Western-orientated in
their cultural references, will be able to make this work for them, while those
who cannot will be left behind and possibly placed in greater danger of
inadvertent onward transmission of HIV and possible criminal charges.
patients in writing guidelines would help “turn science into patient-friendly
advice for individuals”, as BHIVA has done before. A patient representative
should be included in necessary further work on translating advice intended for
healthcare workers into advice comprehensible to patients.
Silvia Petretti, patient representative on the BHIVA Executive, says:
have definitely positive feelings about a greater recognition of the role of
treatment in reducing risk and the freedom given to serodifferent couples to
negotiate levels of risk they feel comfortable with. I do fear though, that as
messages around safer sex become more complex, people may feel confused - but
over-simplification is patronising. People need appropriate support and
counselling to make informed choices, especially as there is a lot of complex
information to process and to apply on sexual choices. How this support will be
available with the current cuts in the NHS taking place is a cause of anxiety.
hope the oral sex section will distinguish clearly between vaginal and penile
oral sex (cunnilingus and fellatio) because it does often get very confusing.
Ben Cromarty, of North Yorkshire
AIDS Action, says:
the article says that safer-sex advice works, and goes on to quantify this, I
am not so sure that this has been the case over the past decade. The number of
HIV and most STI infections acquired in the UK, in both MSM and heterosexuals,
has risen steadily, year on year. This suggests that there has been little
change in behaviour.
use is a real issue. For some people, the lack of spontaneity is enough to
discourage condom use…comments like “it destroys the moment” are commonplace.
For these people – and there are many – even repeated messages about condom use
are unlikely to change behaviour. Other risk-avoiding strategies may be used by
people with HIV - “I don’t come inside him” or “I am now always passive, never
active” – in an attempt to minimise risk. Perhaps the most effective message
might be (for someone who is HIV-positive) to go onto treatment and maintain an
undetectable viral load.
other folks, though, condom use is no big deal – however, these may by
definition be the folks who don’t catch STIs and don’t go to GUM clinics. When
they do turn up, advice given to first-timers at a GUM clinic may need to be
much more detailed than that given to someone coming for a routine sexual
Robert James, patient representative
at the Lawson Unit clinic in Brighton, says:
document is a very impressive one, evaluating the merits of a much wider range
of different safer-sex methods than I expected.
‘safe’ option for these guidelines would be to stick to saying 100% condom use
and ignore the problems of achieving this. This is particularly so because the
Crown Prosecution Service (CPS) has defined reckless sexual behaviour as
ignoring “safeguards [that] satisfy medical experts as reasonable”. This means, if this is what clinicians advise
their patients on safer sex, doing something different could be seen as a sign
of reckless sexual behaviour in the eyes of the CPS and make a person liable to
things do read strangely: partner reduction is recommended for oral sex but not
anal or vaginal. Partly this is because of evidence for one and lack of it for
another but it does look odd though and implies it is OK to shag lots of people
as long as nobody sucks anyone off!
for HIV is acknowledged to have an impact, even if nothing like as much as
condom use, but increases other STI infections.
issue of HIV treatment and condoms is probably the only place it feels a little
cautious. Treatment alone comes with a
caution that it is not always effective, but condom use does not, and the
‘Swiss Statement’ is posed as a problem, not a solution. I think they bottled
out of exploring whether treatment is as good as condoms, rather than whether
treatment means people are uninfectious. I do think, though, that in
circumstances where using condoms is impossible (e.g. in a violent relationship
with someone who refuses) they could have recommended HIV treatment as the best
safer-sex method. Such specifics might help some very vulnerable people who
could end up in court.