First, congratulations on joining the rEVOLUTION! Your decision to get tested for HIV and to know your status has empowered you to craft the most effective prevention program for you. The rEVOLUTION is about choices.
While HIV is disproportionately impacting transgender women, gay, bisexual and other men who have sex with men; that doesn’t mean you have to resign yourself to eventually getting the virus. We’ve come a long ways since the 1980s in our understanding of the virus, how it’s transmitted and how we can prevent its transmission.
When HIV first started killing our community, we responded with the most successful public health behavioral change movement in history. A community that had never used condoms before, had, by 1988, developed a 50 percent adoption rate of condoms for sex. That is a stunning accomplishment in just eight short years, five really if you start counting from the 1983 How to Have Sex in an Epidemic booklet. But condom use has not increased much since, despite over two decades of public health messaging telling us to use a condom each and every time we have sex. Studies have consistently placed condom use at about 50 percent for men who have sex with men in the U.S.
Yet here we are, over thirty years into the epidemic and our knowledge has expanded by light years from those early, terrifying days. Medical and scientific advances have changed the course of the epidemic. We now have a better grasp and understanding of HIV transmission and progression; and as a result we have a better understanding of how to prevent new infections and how to stop those with the virus from passing it on to others. Your choices are the rEVOLUTION that can lead to the end of HIV.
So what are the choices?
Prevention Options Regardless of HIV Status
Condoms are, without a doubt, one of the mainstays for HIV prevention. And they are not just about preventing HIV, they also help stop other sexually transmitted infections like gonorrhea and syphilis which can increase your chance of getting infected with HIV. There are two types of condoms: The external condom and the internal condom.
The external condom is what we know as the condom. It is made of latex or another synthetic material (don’t ever use lambskin condoms, they won’t stop HIV or other infections) and is rolled on the erect penis before penetration. Unless you are using a polyurethane condom, don’t use lubricants that aren’t water based. The oil based lubricants destroy the condom and it falls apart; defeating the protective purposes of wearing a condom in the first place. To learn more about using the male condom, check out this video.
The internal condom is a pouch which is inserted in either the vagina or the anus — so it is not quite aptly named. This pouch condom puts control in the hands of the receptive partner since they don’t have to rely on their partner to roll one on. It is also made of polyurethane, which means you can use a much broader selection of lubricants — oil and water based. To learn more about using the female condom for anal sex, check out this video.
Sex is not necessarily about anal penetration. You can explore each other’s bodies without ever penetrating or being penetrated. Kissing, hugging, frottage (rubbing on each other), and mutual masturbation are just some ideas that can provide you both the intimacy of sexual contact and reduce your risk of being infected with any sexually transmitted infection.
Some people disagree about this, but the science is pretty convincing, oral sex without a condom can be a risk reduction technique. HIV is a very difficult virus to transmit — as these transmission probabilities from the CDC show — and oral sex is so unlikely to transmit the virus, the risk can’t be defined within the probabilities from the CDC. Even performing oral sex, with ejaculation, on a guy with HIV is very low risk activity. A word of caution however, make sure you don’t brush your teeth for several hours before oral sex, and that you absolutely don’t have any oral ulcers. Both of those can increase your chance of being infected. It is also important to remember that oral sex without a condom does not prevent transmission of gonorrhea, syphilis or any other sexually transmitted infections — so make sure you check your partner for signs and symptoms of those infections. For more on STIs, check out the Mayo Clinic’s website here.
Prevention Options for Those Who are HIV-Negative
Everyone has seen the HIV-negative you be too comments on social network and dating sites for gay, bisexual and other men who have sex with men as well as transgender women. That actually has a label in prevention — it’s called sero-sorting. While sero-sorting might seem like a perfectly logical way to prevent HIV — that is HIV-negative folks having sex only with HIV-negative folks and HIV-positive folks only having sex with HIV-positive folks — it doesn’t quite work like that. Sero-sorting is only effective at stopping about 50 percent of transmissions.
Why does something that seems, on a logical level, would work, fail? Because sadly, gay, bisexual and other men who have sex with men and transgender women simply are not getting tested enough. The CDC recommends that sexually active men who have sex with men get tested every three months, but most men are getting tested only on a yearly basis — if that. In 2010, a CDC study found that 1 in 5 gay and bisexual men were infected with HIV. Of those who were infected, 44 percent were unaware of their status. A person who is infected, but unaware is 3.5 times more likely to transmit their virus.
So, if you want to use sero-sorting as your prevention option make sure you and your partner get tested together and share your results. But at the end of the day, sero-sorting is not a very effective option. Remember, too, that a person who knows they are infected with HIV, on medicine and has attained an undetectable viral load is extremely unlikely to transmit the virus. In fact, it might be less risky for a person who is HIV-negative to have sex with a person with HIV and an undetectable viral load than it is to have sex with a person who says they are HIV-negative but doesn’t actually know their status because they haven’t been tested in a year.
Of course, as noted above, you could use condoms, regardless of your sexual partner’s HIV status. If they are used every time, correctly and consistently, they prevent 74 percent of transmissions. A word of caution, however. Studies show that if you don’t use condoms every time, then you have the same chances of being infected as you would if you never used condoms.
The next most effective option is sero-positioning. That means you choose whether to be the bottom or the top depending on your partner’s HIV status. It’s also called strategic positioning. Strategic positioning can reduce your risk by as much as 75 percent.
If you have sex without a condom and are exposed to HIV — or think you were exposed — you can also access post-exposure prophylaxis (PEP). This is the use of anti-HIV medications to prevent the virus from taking hold. People taking PEP are prescribed a month long regimen of the drugs that must be taken daily. The drugs have to be started within 72 hours, or they won’t work. The sooner you start PEP after an exposure the more effective it can be. Studies place its effectiveness at 81 percent.
Topping only is even more effective. That means you are always the inserting partner or the top. That’s 85 percent effective in reducing your risk.
Monogamy is 91.5 percent effective in reducing your risk. But, it should be noted, that both partners need to be tested regularly for HIV. A recent study from the CDC found that 68 percent of new infections among men who have sex with men occurred within their primary sexual partnership.
The newest tool in the prevention arsenal in Pre-Exposure Prophylaxis, or PrEP. This is the use of the anti-HIV drug Truvada taken daily by an HIV-negative person. If taken daily, the drug is 99 percent effective at preventing HIV transmission. The drug was approved for this use in 2012, and in 2013 the CDC issued detailed clinical guidance for physicians to prescribe PrEP to all people at risk for HIV. The Stigma Project has done a fantastic job of creating an online tool to help you evaluate whether PrEP may be the right choice for you. Those on PrEP are counseled to use condoms as well as the drug, but this is more about preventing other sexual transmitted infections than preventing HIV. As already noted, being infected with another STI increases your risk of being infected with HIV, even when on PrEP. Click here for more about PrEP.
All the prevention options above are about choices. You can mix and match them to meet your needs. Maybe you choose condoms and the top-only strategy. Maybe you want to be monogamous, a top and use PrEP. The choices are yours, and they are based on your knowledge of your HIV status.
That’s a rEVOLUTION.
Prevention Options for Those who are HIV-Positive
Of course,many of the above options exist for people living with HIV, too. But perhaps the greatest rEVOLUTION for people living with the virus is Treatment as Prevention (TasP). Studies have shown that a person living with HIV who is on treatment with a combination of anti-HIV drugs and has an undetectable viral load reduces the risk of transmitting the virus as much as 96 percent. In fact, scientists have never documented a single case of HIV transmission from a person with a suppressed viral load to an HIV-negative person. That’s not to say it can’t happen, rather, it says it is exceedingly unlikely it would, or could, happen.
And being on treatment has significant benefits for the person with HIV. Studies now show that those on successful treatment will live a normal life span. Other studies show that starting medications for HIV infection as early as possible after infection can also help control and slow the progression of the infection even further, benefiting the health of the person living with HIV.