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.

One way or another, HIV may affect the way you and your partner feel about sex, and have implications for the type of sex you have. The presence of any long-term health condition in a relationship can sometimes affect sex. The fact that HIV can be transmitted through sex may also colour your feelings about sex and intimacy, if only for a short while. It makes very good sense for you and your partner to talk about any of these things if they are the case for you.

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 start with an initial discussion about the possible risks to both of you and what each of you feels comfortable with. You can find out more about the level of risk different sexual activities pose in NAM’s resource HIV transmission and testing.

You can discuss your concerns with someone at your HIV clinic – perhaps your doctor, nurse, health adviser or patient representative. 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 0808 802 1221 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, or if either of you were to get another sexually transmitted infection, or if the female partner became pregnant.

Infectiousness

If you are having unprotected sex with your partner, it’s important that you discuss the possible risks of HIV 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 is now significant evidence that HIV treatment can be an effective method of preventing HIV transmission. This is the case when:

  • the partner who is HIV positive is on combination HIV treatment and is taking their treatment as prescribed, and
  • they have had an undetectable viral load for more than six months, and
  • neither of you has any sexually transmitted infections (STIs).

When taken properly, HIV treatment can lower viral load in genital fluids. This can greatly reduce the risk of HIV transmission during sex, but continued condom use will further reduce the risk, as well as protecting you and your partner from other sexually transmitted infections and prevent unwanted pregnancy. A consequence of not taking your HIV treatment properly can be that the amount of virus in your genital fluids increases, therefore increasing the risk of passing on HIV to your sexual partner(s).

You can find out more about these topics in our factsheets HIV treatment and sexual transmission and Options for conception, or find out more detail about the research in this area in our resource Preventing HIV.

The largest study to date showed that the risk of transmission was reduced by 96%. It involved monogamous heterosexual couples. 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. In early 2013, the British HIV Association issued a statement saying that the expectation was that if a person with HIV was taking treatment and had an undetectable viral load then there would be a very low risk of transmission from anal sex.

If you have any questions about infectiousness, then you may want to discuss them with your doctor or another member of your healthcare team. UK treatment guidelines say that your doctor should discuss treatment and infectiousness with you. If you decide you would like to start HIV treatment to reduce the risk of transmission to partners, talk to your doctor about this. You can start treatment at any CD4 cell count for the purposes of prevention of HIV transmission to sexual partners.

PEP and PrEP

Should you or your partner be concerned about the possibility of HIV transmission after having unprotected sex, 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 no later than 72 hours – and preferably as soon as possible – after possible exposure to HIV has taken place, 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 the accident and emergency department of a hospital when these are closed. You can look for services that provide PEP on NAM’s e-atlas.

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 potential exposure, so if you cannot contact someone at your HIV clinic, it’s a good idea to go to your nearest A&E department 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 sex that may pose a risk for transmission. This is called pre-exposure prophylaxis, or PrEP. Studies looking at the effectiveness of PrEP have had mixed results, but Truvada  has been licensed in the US for use as PrEP. If you are tempted to offer your partner your drugs as PrEP, you should remember that research into the safety and effectiveness of PrEP is still ongoing. The same cautions regarding the use of your anti-HIV drugs as PEP also apply.

Conception

Having HIV does not prevent you from starting a family, or having more children. Many women and men with HIV have done so and are raising happy, healthy children. For many people, although not for everyone, the desire to have a baby is strong and starting a family now or in the future is very important. Having HIV does not have to change that.

If you and your partner want to have children, then you will need to discuss the methods of conception available to you.  

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.

You can find more information on options available in the section on Having a baby.

Contact NAM to find out more about the scientific research and information used to produce this section.

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.