Safe Sex and HIV
A Clinical Perspective
Ruth Hennessy
Psychology Unit Manager/
Clinical Psychologist
The Albion Street Centre,
Sydney NSW
Outline
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Activity
PLWHA and transmission
Impacts on disclosure and safe sex
Professional considerations
Treatment
Case
Sit down if you have ever…
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• Bungee jumped
Got a speeding ticket
Run a red light
Used recreational drugs/ drunk too much
alcohol
Gone abseiling
Spent money you didn’t really have
Sit down if you have ever…
• Encouraged a friend to drink more
alcohol/ try drugs
• Woken up next to someone and had no
idea who they are!
• Talked on the phone during an
electrical storm
• Had sex without protection having
assumed a sexual partner is STI free &
HIV negative
Hhmm…
• What do you think the level of risk
was?
• How did others rate the level of risk?
• Did the potential positive
consequences outweigh the negative
ones?
• What would be motivations & barriers
to change?
PLWHA and transmission
Majority of PLWHA are adamant that they
would never want to infect anyone else
(regardless of the law)
and
knowing their HIV status has been overall
beneficial
Intentional Transmission
• Very rare
• Likely to have sociopathic, borderline
and/or narcissistic personality traits
Motivations for change:
• Egocentric- for own benefit
• To avoid negative consequences:
– loss/rejection
– STIs
– public outing/humiliation,
incarceration
Intentional HIV Acquisition
• Very rarely identified
• Personality traits
• Beliefs re increasing intimacy or
keeping a relationship or belonging to a
community
• Impact of coercion, bullying from
peers/partner
Sero-Discordant Relationships
• Unprotected sex = a relationship
Sero-disco and unprotected sex:
• Strategic positioning
• UI viewed as sign of commitment/love
• HIV:
– status differences viewed as barrier to
intimacy
– not viewed as a negative consequence
– resolves ongoing fears of transmission
– mutual support
HIV transmission and sexual
behaviour
• Strategic positioning (top/bottom)
• Withdrawal method
• Undetectable viral load
• Sero sorting
“I only go to poz parties or venues”
Beliefs attached to behaviour
No/Low risk perception
What impacts on PLWHA
around disclosure/safe sex
Stigma
• Shame and discrimination
• Criminalisation of HIV – ‘demonising’ of
PLWHA
• Fear of recrimination/litigation
• Privacy issues around disclosure
Responsibility Beliefs
• It takes two to tango…
“I have been responsible in knowing my
status – now I carry this burden with
me…I am not taking on anyone else’s
too…”
• Law says otherwise
Skill deficits
• Sexual negotiation
• Communication
“If he doesn’t talk about the issue or
doesn’t bring it up, I don’t”
“I don’t like to mention it in case he
might reject me”
Mood State
“I didn’t want to think about it”
“I didn’t care”
“I just wanted to escape from everything”
Trust
“He would have told me/used a condom
if there was a problem…”
Condom Difficulties
Dislike of condoms; concern about diminished
pleasure
“It’s like having a shower in your raincoat”
Erectile loss
“If I use a condom I will lose my erection”
Unavailability/Inconvenience of condoms
“The condom broke and we only had one”
Lack of Control
Passion, excitement, impulsivity,
substance use
“It was a passionate moment”
“I was off my head”
“I didn't know he had taken it off”
Impact of Mental Health
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Mood Disorders (depression)
Anxiety Disorders (social anxiety)
Sexual Disorders (erectile dysfunction)
Substance Disorders (drug use)
Personality Disorders (poor empathy,
self concept or communication skills,
impulsive behaviours, substance use)
Other Issues
• Own view & experience of HIV
• Own view & experience of sex
“I deserve to have sex as I like”
“I am a sex pig”
• Sexuality issues
• Multiple sex partners
• Anonymity of sex
• Use of sexual stimulants (eg. Viagra)
Who do we see?
Who identifies the behaviour as a problem?
Referral from:
• self
• other health services eg. GP, treating doctors
• partners
• Health Department/Advisory Board
Aim to highlight benefits of change to self
Engaging people in discussions
around HIV and risk
Normalise the process: part of standard
assessment , similar to Domestic
Violence, Child Protection
“The following questions cover areas
that we always ask about as they are
pertinent to your health and HIV”
HIV/STI disclosure
• Highlight your and their obligations
(incl. Public Health)
• Limits to confidentiality
Risk of harm to self
Risk of harm to others
HIV/STI disclosure
“The law requires people to disclose
their STI/HIV status/practise protected
sex. Sometimes people have trouble
disclosing their HIV status and/ or
practising safe sex. This is something I
have experience in and would like to
work on if this is an issue for you. How
do you approach disclosure and
protected sex?”
Professional Obligations
• Duty of care
• Minister of Health can breach
confidentiality
• Board or senior advisory committee
• Supervisor and Managers
• Case notes and documentation
General Treatment
Strategies
Treatment
• Rapport building
• Importance of engagement
• Acknowledge and validate client’s
willingness to raise/address issue
• Assessment of motivations
Strategies
• Help identify personal obstacles to
disclosure/condom use
• Ask if there are any possible benefits to
disclosure/condom use
• Acknowledge and validate strong
feelings
Correct Knowledge Gaps
Discuss the limitations of statistics
“What is your understanding of HIV
transmission and viral load? …”
Cognitive Strategies
Teach to challenge obstacles to
disclosure/condom use and generate
more helpful and realistic beliefs
eg. Rejection fears
“Have you ever known anyone to accept
a positive sexual partner?”
Skills Training
• Assertiveness and social skills training
(role plays, modelling)
• Planning and problem solving
• Peer support
Erection difficulties
eg. patient practises masturbation without and
with condoms,
partner stimulates without and with condom
Encouraging Empathy
Discuss:
• Partners’ motivations for placing
themselves at risk
• Conflict between unsafe sex and
concern for partners’ health
• Non risk intimate practices eg. mutual
masturbation, kissing
Specific Treatments
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Brief Interventions
Motivational Interviewing
CBT
Dialectic Behavioural Therapy
Motivational Interviewing
• Identify the motivators (and barriers) to
assist in resolving ambivalence
(making change)
• Monitor the degree of readiness to
change to avoid resistance
• Affirm self-direction
Case & Panel
Randy
Randy is a 38 year old gay man. He has been
HIV positive for the last 15 years.
His GP referred him because he recently said
he was contemplating stopping his HIV
medications.
He also says he has been having a lot of
unprotected sex with different partners in a
sex club. This sex has mostly been
associated with crystal meth use. Randy has
used recreational drugs on and off for many
years.
Randy
Randy used to work part-time for a friend but
they had a falling out and he now has no
friends, no job and little money.
About his sexual behaviour he says
‘I don’t have to worry about HIV so why should
I care about not using a condom?’.
About his drug use he says
‘It’s the only time I feel good’
About stopping his medications he says
‘I am over them’.
He complains of everyone ‘attacking’ him.
GROUP ACTIVITY
1. What might this person be FEELING?
2. What might be key MENTAL HEALTH
CONCERNS?
3. What REFERRAL OPTIONS and
STRATEGIES can you suggest?
4. How does your ORGANISATION /
PROJECT ROLE assist people like
Randy?