Your Sexual Health: A guide for people living with HIV

Today, people living with HIV have more opportunities to live happy and successful lives. This is due to improvements in care and treatment. These changes have greatly affected the way we talk about sex and sexual health.

We now know that medications that treat HIV also prevent its transmission. This means that if you take medication that suppresses your HIV to undetectable levels, you can’t pass the virus to your sexual partners. This is sometimes called treatment as prevention (“TasP”) or “undetectable = untransmittable” (“U=U”). Along with the use of post-exposure prophylaxis (“PEP”) and pre-exposure prophylaxis (“PrEP”) in HIV-negative people, this development gives HIV-positive people and their partners even more options when it comes to sex.

Who is this information for?

This information is for people living with HIV. The goal is to describe the impact of the U=U campaign and to explain what it means for the sexual health of people living with HIV. This guide also outlines the pleasures and the pitfalls of the new approaches to sex in the context of HIV. It gives accurate, non-judgmental information to help you to maintain lifelong sexual health in plain, understandable language. For example: there are now lots of ways to have sex without worrying about HIV transmission, but sexually transmitted infections (STIs) are more easily spread when condoms are not used.

Most of the information here will apply if you are a sexually active person, regardless of your gender or sexual orientation. However, this resource does acknowledge that gay, bisexual and other men who have sex with men make up more than half the people living with HIV in Canada. For that reason, we’ve included information specific to the needs of this group. This includes information about party n’ play.

Sexual health

For people living with HIV, sex has traditionally mixed pleasure with risk in a bit of a balancing act. But U=U has changed things. When talking about sexual health in this resource, we are looking at ways that you can get what you want from sex while reducing the possible risks or harms to your physical and mental/emotional health.

Now, more than ever, it’s up to you to think carefully about your sexual health. You get to decide, in consultation with your partner(s), what you are comfortable with. You are free to change your ideas as your circumstances change. We’ll give you information to help you stay healthy and happy with the decisions you make for yourself throughout your life.

What role does HIV treatment play in my sexual health?

HIV treatment plays an important role in your sexual health, especially when it comes to your viral load. Viral load refers to the amount of HIV in the blood of a person living with the virus. Successful treatment can reduce the amount of HIV in the blood to a level too low to be measured by a viral load test. When this occurs, a person’s viral load is said to be undetectable. For most people, this occurs after they’ve taken HIV treatment for three to six months.

Having an undetectable viral load doesn’t mean that you are cured of HIV. You need to keep taking your medications to stay healthy and keep your viral load undetectable. What it does mean is that there is not enough HIV in your bodily fluids (blood, semen, pre-cum, vaginal fluid and rectal fluid) to pass on the virus during sex. If you take your HIV medications and achieve and maintain an undetectable viral load, you are not infectious to your sexual partner(s). For those who don’t have an undetectable viral load, PrEP is an option for their HIV-negative partners. You no longer need a condom to prevent passing on HIV if you have an undetectable viral load and/or your partner is on PrEP. However, condoms are still a highly effective way to prevent many STIs.

For many people with HIV, this information provides huge relief from fear and anxiety. It helps to improve sexual self-esteem and can make talking about HIV with others easier by reducing stigma. As a result, people with HIV may find themselves having more sex, different sex and better sex.

See CATIE’s “The Power of Undetectable” for what you need to know about HIV treatment and prevention.

What are the basics of sexual health?

HIV drugs, and their use in both the treatment and prevention of HIV, have changed the way we think about the virus. These days, sexual health needs to be considered in a comprehensive way that includes both HIV and STIs.

HIV treatment

If you have HIV but are not on treatment, talk to your doctor about starting treatment. HIV drugs protect your health and prevent HIV transmission. When you are on HIV treatment and your viral load is fully suppressed or undetectable, you cannot pass HIV to your sexual partners.

PrEP

If you do not have an undetectable viral load, PrEP is an option for your HIV-negative partners. PrEP involves an HIV-negative person taking certain HIV drugs to reduce the risk of getting HIV. A doctor can provide further information about PrEP.

PEP

If an HIV-negative person is exposed to HIV, they can take HIV drugs for 28 days to reduce the risk of transmission. However, they must start taking these drugs as soon as possible, and definitely within 72 hours of their HIV exposure.

Condoms and lube

Use a new condom every time you have sex. If you are having group sex, use a new condom with each partner. This will protect against HIV as well as other STIs, like gonorrhea and syphilis. Use only water-based or silicone-based lubricants. Oil-based lubricants can make a condom break.

Sex Toys

Avoid sharing sex toys if possible. If you choose to share a toy, cover the toy with a condom before each use. Clean your toys between vaginal and anal use.

Other forms of sexual stimulation

Choose oral sex, masturbation and forms of sexual stimulation that pose little or no risk of HIV. However, STIs can be passed through some of these types of sex.

Get tested regularly

Get tested regularly for other STIs if you are sexually active.

Looking after your sexual health is important when you have HIV. Having this virus can make STIs and other sexual health problems more complicated to diagnose and treat. U=U means that you have more flexibility about when to use condoms, but you will need to think about your STI risk and other related conditions. If you are living with HIV and are sexually active, it is important to do what you can do to maintain your sexual health. This means having regular sexual health checkups with a knowledgeable doctor or service provider who knows your HIV status and your sexual history.

How do I make an appointment for a sexual health checkup?

Your family doctor or your HIV doctor can provide you with a sexual health checkup. In larger cities, sexual health clinics can be an excellent resource for sexual healthcare. The tests involved are often free of charge. Some clinics have walk-in hours. Otherwise, it may take a few days to get an appointment. If you have symptoms, let your care provider (or the office receptionist) know and they may be able to see you more quickly, on an emergency basis.

What will I be tested for at a sexual health checkup?

Unless you are in a monogamous relationship with one partner, you should be tested regularly for STIs. This is even more important if you are not using condoms. At a routine sexual health appointment, you will be tested for a range of infections.

Chlamydia

• This often has no symptoms. If you do have symptoms, they can include pain when peeing or discharge from the penis, vagina or anus. Chlamydia can also infect the throat, causing it to be sore.
• Tests will include a urine sample and swabs of the rectum, vagina and throat, depending on the kinds of sex you are having. A swab of the penis may be taken if you have discharge.
• If you have chlamydia, it can be cured with a short course of antibiotics.

Syphilis

• Syphilis involves several stages but often has no symptoms. If you do have symptoms, these can include a painless red sore, rash or fever.
• Your blood will be taken to test for infection, and if you have a rash or sore this will be swabbed.
• If you have syphilis, it can be cured with antibiotics. However, if it is left untreated for a long time, it can cause serious complications.

Gonorrhea

• This often has no symptoms. If you do have symptoms, they can include pain when peeing or discharge from the penis, vagina or anus. Gonorrhea can also infect the throat, causing it to be sore.
• Tests will include a urine sample and swabs of the rectum, vagina and throat, depending on the kinds of sex you are having. A swab of the penis may be taken if you have discharge.
• If you have gonorrhea, it can be cured with antibiotics. Some strains of gonorrhea have become resistant to some antibiotics, which can sometimes make treatment a little more complicated.

Hepatitis C

• If you are a gay or bisexual man or a trans woman who has condomless sex, you may be tested for hepatitis C. This often has no symptoms.
• Your blood will be taken to test for infection.
• If you have hepatitis C, it can be treated with direct-acting antivirals (DAAs). These are highly effective and cure over 95% of people with hepatitis C.

Some STIs, like genital herpes and genital warts, are not tested for unless you have symptoms such as sores, blisters or warts on your genitals or anus. These cannot be cured, but symptoms can be managed with treatment. You may also be offered vaccinations. These vary depending on who you are and the kind of sex you have:

• If you are a gay or bisexual man or a trans woman, you may be offered vaccinations against hepatitis A and B if you haven’t already been vaccinated.
• Anyone, regardless of gender, may be offered vaccination against human papillomavirus (HPV).

A sexual health checkup can also identify other rare but potentially serious infections such as the following:

Lymphogranuloma venereum (LGV)

• This is caused by a more invasive type of chlamydia.
• Symptoms may include rectal or anal pain with bloody discharge, fever, swollen lymph nodes (“glands”) in the groin, and pain or discharge from the vagina or penis.
• Testing will usually include a swab from the affected area.
• If you have LGV, it can be cured with a course of antibiotics.

Shigella

• Symptoms may include diarrhea, abdominal pain and stomach cramps.
• Antibiotics can cure Shigella, but they may not always be necessary.

Trichomoniasis

• Screening is usually not recommended if you have a penis, as the infection is often transient and symptomless in these cases.
• If you have symptoms, these can include discharge from the vagina or penis, itching, and pain when peeing.
• Tests can include a physical exam and urine sample or swabs from the affected area. Trichomoniasis may also be diagnosed during a Pap test.
• If you have trichomoniasis, it can be cured with antibiotics.

STIs can cause illness, even if you don’t have any symptoms. Left without treatment, they can cause long-term health issues. Also, you can be re-infected after having been treated successfully. Regular sexual health checkups will help you to keep on top of the situation.

What should I expect at a sexual health checkup?

There is a long history of homophobia and transphobia, racism and HIV stigma in healthcare, which shapes how people with HIV access services like sexual health checkups. Many people with HIV are reluctant to get the sexual healthcare that they need for fear of judgment or discrimination. But don’t let this put you off! Your local HIV service organization can help you find safe, respectful sexual health services in your area.

Throughout a sexual health checkup, you should be treated in a welcoming and non-judgmental way by the office staff and healthcare providers. During the checkup, the healthcare provider may ask you some questions about the kind of sex you have. Try to answer these as fully and honestly as possible, so you can receive the right tests. When you are able to talk openly about your sexual history, your care provider is able to make the best recommendations for you. If you feel comfortable, a sexual health checkup is also a good time to talk to your healthcare provider about related issues such as drug and alcohol use, mental health, sexual dysfunction, pain during sex and domestic/sexual violence.

The speed with which you are diagnosed and receive treatment depends on where you receive care and what tools they have on site. Certain test results may be available immediately if you have symptoms, and if treatment is needed you can receive it at the same appointment.

Other test results may take longer; in these cases, your healthcare provider will tell you how you’ll receive your results and treatment. If you are diagnosed with chlamydia, gonorrhea or syphilis, your healthcare provider can also help you to notify any recent sexual partners so they can be tested and treated if necessary.

The rates of HPV-associated anal cancers among HIV positive gay men are much higher than among gay men who do not have HIV. Some doctors recommend that men living with HIV get screened for anal pre-cancers that could lead to cancer, with follow-up if abnormalities are found. HIV-positive women have a higher risk of getting HPV, cervical cancer and other HPV-related precancerous lesions than women who do not have HIV. HIV-positive women should receive a cervical Pap test at their first sexual health checkup, again at six months and then yearly for those with normal results. If you are living with HIV, ask your doctor about getting screened for anal cancer.

How often should I have a sexual health checkup?

While no official Canadian guidelines currently exist to guide sexually active people with HIV about how often they should have checkups, here are some tips:

• If you have no regular partner and are having casual sex, go for a sexual health checkup every three months.
• At the start of each new relationship, get checked!
• If you have symptoms of an STI, see a doctor right away and don’t have condomless sex until you have been treated and the infection has cleared up.

Why are regular sexual health checkups important?

STIs are major concerns for the health of many people living with HIV. If you are sexually active, and particularly if you are not using condoms regularly, you can easily get STIs and give them to other people. It’s important for you to go for sexual health checkups for your own health, for the health of your partner(s) and for the health of your community.

What can I do for my sexual health?

Try to keep your viral load undetectable and have it tested regularly, every three to six months. An undetectable viral load lets you decide when you use condoms and when you don’t.

Be honest about the sex that you are having. Does it make you feel good about yourself? Does it look and feel like the sex you want to be having? How can you pay attention to your sexual health while having great sex? Think through some strategies before you hook up. Review them afterwards. How did it go? What worked? What didn’t? Adjust. Give yourself some love for trying to have your own back!

Try to communicate honestly with all your partners about HIV and STIs. Let them know a bit about you, what you are comfortable with (or not) and your boundaries. Don’t be afraid to say “slow down” or “stop” if things are not going as you expected.

Make sure you are vaccinated for HPV and hepatitis A and B, as appropriate.

Think about your use of drugs and alcohol with sex. Drugs and alcohol can lower your inhibitions and lead to risky behaviours, like having sex without a condom in a situation where you don’t know a lot about the health of your partner(s).

Consider using condoms.

Think about the kind of sex you’re having. If you want to, you can choose lower risk activities like mutual masturbation or reduce your number of partners.

PnP or Chemsex

Party n’ play (PnP) or chemsex is a part of gay sexual culture. It involves the use of drugs like crystal meth and GHB/GBL – and sometimes cocaine and ketamine – to prolong and enhance sexual pleasure. Parties (or “chillouts”) often involve multiple participants, are arranged through apps and usually take place outside traditional venues like clubs and bathhouses. Though not all gay men engage in PnP, some do. And while some can manage their drug use, others may experience problems with it.

For many gay men, it can be difficult to feel good about the sex they have, or want to be having.  Some reasons for this are widespread homophobia, higher rates of anxiety and depression among gay men, HIV-related stigma and the trauma of the AIDS crisis. The drugs used in PnP can compensate for these feelings by reducing people’s sexual inhibitions and making them feel more impulsive and confident. They are often used with erectile dysfunction drugs (like Viagra, Cialis and Levitra) to prolong arousal for long periods of time. It’s important to note that using these drugs with poppers (amyl nitrate) can cause a potentially lethal drop in blood pressure, and they should never be combined.

PnP drugs and the environments they are used in create a loss of inhibition that can lead to sex that feels mind-blowing at the time but can negatively affect your health. This could leave you with feelings of shame and concerns about risk after the high has worn off, and there could be more long-term effects on your quality of life and mental health. While some guys can balance their engagement in PnP with other aspects of their life, some cannot. If a person does not have harm reduction supplies and safer sex information – or is dealing with other underlying issues like loneliness, boredom or low self-esteem – they might find themselves coming to depend on the scene and the drugs used in it. The addictive nature of drugs like crystal meth and the come-downs they produce can make these problems worse.

PnP is related to the sexual health of people with HIV because of the STI transmission risks that exist in this environment. If you have a detectable viral load and are not using condoms, then transmission of HIV to others is also a risk. Extended periods of drug use can also mean you miss doses of medication or doctor appointments, which can lead to treatment complications. HIV health providers are becoming more aware of PnP and have started to offer tailored support and programming. This aims to help guys reduce or stop their problematic drug use and learn ways to reduce harms like STIs and overdose.

Consent

Consent is for everyone. It means feeling safe and comfortable with what is going on. Consent is not a one-time thing – it is an ongoing process. It also means you have the right to change your mind or stop any activity that does not feel safe at any point. Consent is an important and necessary part of sex, regardless of viral status. In environments like PnP, drugs or alcohol can affect people’s ability to consent: make sure to regularly check in with your partners to make sure that they are fully consenting to what you are doing together, and talk about what feels safe for you and them. If in doubt, ask! Don’t be worried about killing the mood.

Sexual Dysfunction

Sexual dysfunction is a broad term that covers things like loss of sexual desire (libido), pain during sex and problems with erection or orgasm. Some of the things that can contribute to this are:

• Stress
• Heaving smoking, drinking or recreation drug use
• Other health conditions and the drugs prescribes to treat them. For example, some antidepressants have sexual side effects.

Your regular sexual health checkup provides a good opportunity for you to talk to your doctor about sexual dysfunction if you are experiencing it.

Communication and Disclosure

In Canada people living with HIV can face criminal charges for not telling their sexual partner(s) about their status before having sex. This is usually called the “criminalization of HIV nondisclosure.” The good news is that you don’t have to disclose before vaginal or anal sex if you use a condom and you have a “low” viral load (under 1500 copies per ml). Whether someone can be prosecuted for not disclosing their status in other situations is still evolving, although it is becoming more established that being on treatment and having a suppressed viral load could protect you against this.

In December 2018, the Attorney General of Canada told federal lawyers to stop prosecuting people who have maintained a suppressed viral load (under 200 copies per ml). She also told them to “generally” not prosecute people who used a condom, took treatment as prescribed or had only oral sex. Unfortunately, this only applies in the three territories (Nunavut, Northwest Territories and Yukon). However, some provinces have adopted their own guidelines for prosecutors.

 

New information about PrEP, PEP and U=U gives us new choices about how we have sex. Now more than ever, open, honest, non-stigmatizing communication about our sexual health, desires and preferences as well as our boundaries and limits will keep the sex we have respectful, consensual and healthy.