Ceri Evans
Senior Sexual Health Adviser
West London Centre for Sexual
Health
Chelsea and Westminster
Hospital Foundation Trust
use condoms
use condoms
use condoms
Listening to what people say is
the first way forward
Condoms….
create a barrier
prevent intimacy
caused erectile dysfunction
loss of desire
A reminder that HIV is part of a
relationship and can’t be ignored.
Often unprotected sex is a sign of intimacy and
trust in a relationship where both people are
negative – using condoms because one person
is positive may psychologically suggest that the
relationship is not to be trusted
How much risk is each partner willing to take?
This will vary with each couple and needs to be
addressed if one of the partners is not to feel
that they are under pressure
What type of safer practices will be used (if
any)? – in MSM will the positive partner always
be receptive? If unprotected receptive Vaginal
Intercourse/Anal Intercourse, will the positive
partner not ejaculate?
Problems may occur in the relationship if both
partners are not fully informed/educated or
agreeable to a risk.
What if one partner wants unprotected sex more
than the other? How divisive will this be? Who
will be there to support both parties?
The key to all of this is being informed,
being educated, being supported and
being able to make a choice – whether
that is to use condoms – or not
Case Studies
MSM couple 1 positive 1 negative been
having unprotected anal sex (active and
receptive) for many years based on
undetectable load and high CD4 count.
They had worked this out for themselves
before the Swiss Statement. Very happy
with the arrangement
Positive man very anxious around
unprotected sex as he feels that if his
negative partner became positive he
would never forgive himself – feels could
not cope with the knowledge he had
infected someone he loved even though
the negative partner was fully aware of
risks and willing to take them.
Case Studies
Heterosexual couple man positive, wife negative. Both
partners fully aware and informed of transmission issues
However, female negative partner not keen on having
unprotected SI with her husband despite the fact he had
undetectable VL and CD4 of 745. She is highly anxious
about becoming infected despite her husbands
keenness to have unprotected sex and assurances of
neglible rate of transmission. She started avoiding sex
as she felt she was being emotionally pressured (“if you
loved me you would”) and felt a total lack of desire.
Husband described himself as feeling neglected,
unloved and unclean
We must also be aware that there are
relationships which are not equal, where
emotional and psychological coercion happens.
We know that there are relationships where
people are not totally honest with each other. We
must be sure that we offer dedicated support to
people making these vital decisions – the Swiss
statement is very clear that there needs to be
stringent individual and couple counselling for
those who are going to stop using condoms
For those not in stable, equal
relationships, it is possible that there is
very little alternative to advising condom
use as prevention. Treatment as
prevention will only have an effect, if, as
has been suggested in some papers,
everyone who tests positive starts on
treatment immediately, regardless of their
CD4 count.
Even then, this depends on the treatment
being effective, people taking their
treatment without fail, people not being
resistant to treatment, people keeping
appointments for regular VLCD4 counts.
Even so there will be a significant minority
who will not keep to this who will ensure
that it is still not safe to have unprotected
sex with anyone you meet
MSM has current BF of 6 months who is
HIV +. Having unprotected AAI. Uses
reasoning that not only has BF got high
CD4/low VL, but client is the active partner
in sex and is also circumcised. All well and
good – an informed decision made by the
both of them on facts and figures. He
believes that he is unlikely to become HIV
+ from this situation.
However, client also goes onto describe that he
has also had 30 casual male sexual partners in
the past 3/12, mostly unprotected active anal
sex. He only uses condoms if the sexual contact
insists on it, which he says is rare. He tested HIV
negative, although was still well within the
window period. The client still believes that he is
unlikely to get HIV from this situation as he
thinks that the people who insist on condom use
are the people who have HIV, therefore the
people who have unprotected SI are all
negative.
The key to all of this is being informed,
being educated, being supported and
being able to make a choice – whether
that is to use condoms – or not