Who do you love? Sex and relationships

Material for the following sections were influenced by some ideas from Positively Living, the Seattle King County Department of Public Health HIV manual. The last two sections, Safer Sex Guidelines and How to Use a Condom, are reprinted with permission.

"  I'm not afraid of love, but it's hard to find true love. I'm kinda scared of opening my heart, cuz there's so much disappointment out there...I'm looking for someone who I really can trust...and who can trust me.

-Dikeeta

"

Is there more to life than sex and love? Of course there is. Most of what we see and experience on TV, in movies, and on the radio can sometimes convince us otherwise. Society today is bent on the idea that there is one person out there whose mere presence will make everything better. If we base our ideas about relationships on this belief, we will dive in with our eyes closed, expecting and assuming that just being with this lover, girlfriend, or boyfriend will solve all of our problems; that it will clear up our skin, give us a renewed fashion sense, and teach us how to balance a check book.

Relationships can be exciting, and it can be comforting to believe in happy, healthy ones. But the fact is, most people will go through several unhealthy, or at the least, unbalanced relationships, before they know what they want and need from a partner. As great as another person makes you feel, he or she should not come first. When you are making decisions about your health and well-being, your well-being should come first.

You could say that there are as many kinds of relationships as there are different kinds of people. And figuring out what kind is right for you may take a lot of searching and patience, and a strong sense of yourself. As you may have gathered from other chapters, this means that you should know how to take care of yourself and to make choices based on keeping yourself the most healthy. When deep emotion or sexual desire comes into the picture, however, this may be very difficult to do.

Depending on the number and the kinds of romantic relationships you have had, you may or may not have a lot of experience talking to a boyfriend or girlfriend. Either way, now is a time to look closer at how you do that. It is also possible that you may not be looking for the same thing as the person or people you are dating. You may just want to have fun, while the other person may want a serious commitment, or vice-versa.

In any case, remember you are young, and as your mother used to say, you have plenty of time to find Mr. or Ms. Right, even if right now you don't feel that way.

Sex

If you know that sex may have led to your contracting HIV there may be a time after you test positive when it will be hard to see yourself having sex ever again! A lot of young people remember feeling this way at first. It's completely understandable. Whether or not you were aware that you were putting yourself at risk when you did, you may feel guilty about it. Once you have accepted this, however, you can decide to move in a new direction. It is not too late to start making responsible choices about sex.

You may have feelings of shame and/or regret associated with sex. Then again, you may react or rebel from these feelings by wanting to have sex more often. Whatever your feelings may be, try to accept them as normal feelings. Acknowledging and accepting these feelings can be the first steps to getting over them. And that' s important if you want to develop a healthy attitude towards sex.

"  I keep saying that to myself. 'I am not toxic.' I am a vital human being! 'I am more than a virus!' 'I am not toxic.' My semen may contain the virus, but my cock isn't poison. I am not toxic.

-Vittorio

"

It is not uncommon for people to feel that they may be carrying a toxin or poison in their body once they have tested positive for HIV. While this is a perfectly normal way to feel right now, it can be a very harmful perception for you to hold onto for very long. You are worth no less than you were before you had HIV in your bloodstream. It is important to be conscious of the fact that you could pass it on to another person if you are not careful. But your body is still vital and alive, and the potential for life, growth, change, fulfillment, and happiness (sexual and otherwise) has not gone away.

(See the How am I Supposed to Feel Chapter? for more about disclosure.)

Disclosing Your Status to Your Sexual Partner

In San Francisco, at this point, no one can force you to tell new sex partner(s) about your HIV status. There is a lot of controversy around this issue right now, however, and, depending on where you live, it may be illegal not to tell your partner(s) that you are HIV-positive. In general, talking about it and being up front as soon as it feels comfortable is a very good idea. You may not be used to talking about very much with your sex partners. You may have never had a long-term partner or you may have practiced anonymous or public sex in the past. Again there are no rules here, but it is important that you pay close attention to your health and safety (see STDs and reinfection later in this chapter), as well as the safety of your partner. There is a lot of controversy around disclosure. While you may feel obligated to disclose your status, your partners also have to take responsibility for themselves. It is more respectful for you both to be as open and non-judgmental as possible, because you will both have to live with the consequences of your actions now, regardless of whether or not you form a close relationship.

When you're dating, or looking for a partner, it is OK to take your time to disclose. But don't wait until after you have been intimate. Starting from an honest place about every aspect of your self (even if you don't see HIV as central to your identity) is a good way to increase the possibilities of a healthy, trusting relationship.

"  If the person [I'm dating] is negative, I go through head trips, cuz I don't want to infect them. So I'll sabotage it. [The sex] is not relaxing at all. It's tense, even if you use protection, it's still not 100%, you know, so it's still scary.

I don't want HIV to be the reason either, I don't want to go with them just because they are positive. I [feel like I] have to tell people I've had pneumocystis, [a kind of pneumonia.] If they come in contact with my bodily fluids, they could be at risk of re-infection.

I'm kind of used to it, but then I'm kind of not. I don't like it when people leave me because of what I have. It discourages me. I wind up [sleeping with] people who I don't even like. And it is usually because they know about my HIV status and they're O.K. with it. And we take precautions and all that. I don't usually feel happy with the people I'm with, but I don't want them to leave me.

-Marie
"

Talking About It

Before you knew you were positive, you and your partner may have thought that safer sex talk was unnecessary. Now it is more important than ever to think about what you consider safe, safer and unsafe. Thinking ahead, before you encounter a sexual situation, helps prevent the worry or remorse that could follow sexual activity you don't really consider safe. Many people avoid conversations about safer sex because they are afraid that their boyfriend or girlfriend will leave them. Even worse, sometimes they fear a violent reaction. These are both situations in which you may want to talk with a friend, a counselor or a support group in order to think things through and prepare yourself.

When you feel ready to talk to your partner(s) about sex, choose a time and place like a coffee shop or park, that is separate and far away from where or when you have sex with your partner. Take the time to be honest and think about what you need. Talking about sex can make it better, even though the idea may make you feel uncomfortable or insecure. Like a lot of other things, this will get easier the more you do it. Focus on how to be safe with your partner but also on how to make that safety fun! If both partners only do those things they are open to and comfortable with, you will both feel more relaxed and free to let go of your inhibitions. This does not mean doing the same old thing over and over again, but can include experimentation that you have openly talked about earlier. Remember: surprising a partner with something you haven't talked about can be risky. Similarly, saying no in the heat of passion can be very difficult for you.

There may be a time, after your partner(s) finds out that you are positive, when other, intimate types of closeness, like hugging, kissing, and touching, will need to replace the more physical acts. You both may need time to adjust to this change, and these are good ways to remain close in the interim.

"  Does anyone honestly believe wearing a condom feels better than not wearing one? We should not be forced to eroticize something we would never wear if we didn't have to. How often do we make exciting the use of seatbelts or bike helmets? We wear them because, if we don't, we could become injured, period.

-Alex

"

If you have not had the opportunity to explore your sexual self with a trusting partner who knows you well, now may be the time to think about what you are and are not comfortable with, particularly when you think about safer sex. (Try making a few lists for yourself. One that starts What I like, one that starts What I hate and one that starts What I might try.)

You may think you have heard everything about safer sex, and maybe you have. Regardless of how much you know, now is the time to put it into action and to develop a plan that works for you. Once you've found out what you like, be consistent. Safer sex is important, whether you are with someone for the first time or the hundredth time.

What do you want from sex?

Fun?
Emotional connection or support?
Closeness?
Physical expression?
Relaxation?
Escape? Stability? Safety? Money?
Acceptance from your peers?

Reinfection and STDs

Recently, there has been a lot of discussion around Barebacking or raw sex. The discussions have been very controversial for a number of reasons involving the safety of both partners. Again, in this guide, we are not looking to tell you what to do. But we do want you to be informed.

Whether or not someone can be reinfected by having sex with another HIV positive person (and whether or not this reinfection means anything in terms of causing the disease to progress faster) has been debated for many years. At this point, there are still no definite answers. Some experts believe that the risk is a very real one, while others believe it to be minimal. We do know that other STDs pose a very clear risk to your health, for reasons we will explain soon.

We do know that it is possible for an HIV-positive person to be infected with different strains of HIV through unprotected sex or needle sharing. It is difficult to know for sure what such reinfection would mean, since scientists cannot ethically reinfect people experimentally to see what would happen. It is possible that unprotected sex could expose you to a more virulent (nastier) strain or version of the HIV virus, or a strain that is resistant to some of the antiviral medications available, so that you would be unable to benefit from certain treatments. It is also possible that exposure to other strains of the virus could cause your HIV disease to progress, or get worse, faster. As you may see, these are all very serious risks!

In addition to the possibility that you could be reinfected, unprotected sex with anybody can put you in danger of getting certain STDs or sexually transmitted diseases (also called STIs, or sexually transmitted infections). There is evidence that STDs may accelerate disease progression as well as make it easier for you to pass HIV on to your sex partners. Here is a description of some of the more common, dangerous STDs.


Herpes

Herpes is a virus that causes blisters around the mouth, penis, vagina, or anus. They can be controlled with the drugs acyclovir and famciclovir, but there is no cure for herpes, meaning, they keep coming back. If you are HIV positive, blisters may flare up more often. For people whose immune systems are weakened, herpes blisters can be especially severe.

Remember: herpes can be passed from one person to another during unprotected sex, regardless of whether there are herpes blisters visible!


Hepatitis

Hepatitis is a condition that keeps your liver from working properly. (See What's in a Liver, in the When You're Kickin It chapter.) It can make you sick or can possibly be deadly. There are several viruses which can cause hepatitis the three most important to know are hepatitis A, B an C.

Hepatitis A causes an intense short illness which can often be worse for people living with HIV. It is extremely contagious and you can get it by coming into contact with traces of infected feces (shit) such as on the hands of one who has not washed well enough after using the bathroom. This can also happen during sex when a penis, fingers, or toys are in someone's butt, because small amounts of feces may then find their way back into either partner's mouth. To avoid getting Hepatitis A, you can have protected sex, avoid rimming (or putting your mouth on your partner's butt hole), and wash up thoroughly after sex. There is also a vaccine for hep A, which can help protect you from getting infected. Ask your doctor about this vaccine.

Hepatitis B is more dangerous because it is a chronic (long-term) infection that can eventually lead to liver cancer and death. It can also complicate HIV disease by making it difficult to take HIV medicines that are processed in the liver. Hep B is transmitted in much the same way as HIV-through infected blood and body fluids. Having safe sex can help you avoid contracting Hep B; so can a vaccine that is available through your doctor.

Hepatitis C is most commonly passed through needle sharing, but can also be passed through sex, (but we don't how often this happens.) Like Hep B, it can cause chronic illness which can lead to liver cancer or death. There is no vaccine for Hep C, but having safer sex and avoiding sharing needles will keep you from becoming infected.


HPV

HPV stands for Human Papilloma Virus. It is the virus that causes warts, including anal and genital warts. HPV can cause changes in body tissue which may lead to cancers of the cervix, penis or anus. People with HIV are at much higher risk of such cancers due to HPV. Avoiding HPV can be tricky because it is easily passed through skin to skin contact with the vagina, penis, butt, hand or fingers. Using a latex glove as well as a condom will help prevent you from getting HPV.


Gonorrhea and Chlamydia

Gonorrhea and chlamydia are sexually transmitted diseases which can infect the urethra, cervix, anus, or throat. Both infections can cause a number of different symptoms, including local discomfort, pain, or discharge; or sometimes no symptoms at all. The symptoms may vary between men and women, and both infections have the potential to cause severe complications. It is important to keep in mind that with HIV, any additional infection has the potential to increase viral replication. Luckily, there are antibiotic treatments for both gonorrhea and chlamydia. It is important to talk to your doctor if you have symptoms or think you have been exposed. Safer sex is the key to prevention of both infections.


Syphilis

Syphilis is caused by a microorganism called a spirochete. It can be transmitted by unprotected oral, anal, and vaginal sex. The early symptoms are usually a lesion at the site of infection which lasts for several weeks, followed by rashes and a number of other complications. Symptoms may then disappear for years, only to recur as a very serious syndrome which affects the nervous system and other organs. Syphilis can be successfully treated with penicillin, but it must be detected first. Your doctor can test your blood to see if you have syphilis. It can be prevented by having safer sex.

You may have noticed that the bottom line with all of these STDs seems to be:
  1. they can be a lot worse if you have HIV,
  2. you can prevent them by having safer sex.

Which STDs can be cured? Which can't?

STDs all differ from each other because STDs have different causes: bacteria, viruses and parasites.

Bacterial infections are caused by bacteria and can be treated and cured with antibiotics. Some examples of bacterial STDs are: chlamydia, gonorrhea, syphilis, chancroid and pelvic inflammatory disease (PID).

Viral STDs are caused by viruses. Viral STDs can be treated, but not cured. Medication is available for the symptoms of the infection to keep it under control. Some examples of viral STDs are: Herpes (also called HSV, Herpes Simplex Virus), genital warts (also called Human Papilloma Virus), Hepatitis (A, B and C) and HIV (Human Immunodeficiency Virus).

Parasitic infections are caused by tiny organisms called parasites. These can be treated with creams and lotions. Some examples of parasitic infections are: scabies, trichomonas vaginalis (trich), and pubic lice (crabs).


Safer Sex

What is the safe-safer-safest sex? The following list shows the relative riskiness of specific sexual activities. Ultimately, as with all things we do, we must make our own decisions about what is acceptable risk like deciding whether to wear a seatbelt. But as you have read about STDs and reinfection, we hope you see that is a lot easier to take precautions to prevent these issues than it is to try to deal with them after it is too late. Except with solo masturbation, the risks we take with sex require the participation of other people, so it is important that both partners be aware of what exactly is involved.

Safer Sex Guidelines

The following is the most up-to-date information to help you in lowering the risk to you and your partner(s).


High Risk
  • Unprotected Receptive anal or vaginal sex (having a penis inside your butt or vagina without the protection of a rubber). This is very risky EVEN IF HE DOESN'T EJACULATE (come).
  • Unprotected Insertive anal or vaginal sex WITHOUT a condom (having your penis inside someone's butt or vagina without the protection of a rubber). This is because body fluids from your partner's butt or vagina can enter the penis through the urethra (pee hole) or small cuts on your penis.

(It is important to note that one is more at risk of being infected or reinfected with HIV if they are on the receptive side of either anal or vaginal sex)


Medium Risk
  • Receptive anal or vaginal sex WITH a condom (having a man's penis in a condom inside your butt or vagina). This is because condoms are not 100% guaranteed although when condoms fail it is usually from incorrect use (see How to Use a Latex Condom).
  • Oral sex on a man WITHOUT a condom (giving a blow job). This is risky even if the man does not ejaculate (cum) because virus can be present in the clear fluid called pre-cum.
  • Oral sex on a woman NOT USING a latex barrier (going down on a woman without a dental dam or plastic wrap to protect against exposure to vaginal fluids or menstrual blood).
  • Sharing uncovered sex toys (dildos, anal beads or plugs). Again, this is because infected body fluids remaining on the toys could be exchanged. IMPORTANT: use condoms with sex toys whenever possible.
  • Fisting (inserting a hand into the butt or vagina) greatly increases the risk of HIV transmission when combined with any of the above activities.

Low Risk
  • Insertive anal or vaginal sex with a condom (inserting your penis WITH a condom into your partner's butt or vagina). Some small risk is possible when a condom is not used correctly or if it breaks.
  • Rimming (contact between mouth and rectum) WITHOUT a latex or plastic barrier is low-risk for transmission of HIV, but is a likely way to get giardia or hepatitis A; be kind to your immune system and avoid exposure to these organisms.
  • Receiving oral sex WITHOUT a condom (having someone give you a blow job). The risk here is because your partner may have blood or sores in his or her mouth, and fluids can get into your urethra (pee hole). Saliva or spit is not a risk for HIV, although there is some risk for other STD's.
  • Finger/hand stimulation of your partner's penis or vagina is very low risk, but can transmit the virus if body fluids contact cuts or rashes on your skin.
  • Oral sex on a man WITHOUT a condom, but NOT taking the head of the penis into the mouth. Give attention to all other parts of the penis, including the testicles (balls).
  • Giving or receiving oral sex (blow job/cunnilingus) WITH a condom/dental dam.
  • Deep kissing (French kissing or tongue kissing).
  • Sharing sex toys that have been cleaned, disinfected or covered with a new condom between your use and your partner's use.

No Risk
  • Hugging, massage, clothed body rubbing.
  • Self-masturbation, fantasizing, dry kissing, phone sex, cyber sex, unshared sex toys.

How to Use a Condom
  1. Use latex or polyurethane condoms. Natural skin/lambskin condoms are much more likely to contain small holes, allowing transmission of HIV.
  2. Use plenty of water-based lubricant to reduce the friction that can cause breakage. (but not before you put the condom on). If your penis is too slippery, it may slip off. Do not use oil-based lubricants with latex condoms. Massage oils, butter, Crisco, Vaseline, and hand creams all contain oils that cause latex to break down. Water-based lubricants include K-Y Jelly, Slippery Stuff, Foreplay, Wet, Astroglide, and most contraceptive gels.
  3. Choose a condom that fits. Condoms come in many sizes, colors, styles, shapes, and flavors. Have a lot of different condoms on hand to suit your mood and your partner. Practice putting condoms on your own penis, your partner's penis, or a sex toy sometime when you are not in the heat of passion. Condoms should be stored loosely in a cool, dry place (not your wallet); check for expiration dates.
  4. Make sure that the condom package has not been punctured (there should be a pocket of air). Open the package carefully to avoid tearing the condom.
  5. Put the condom on after the penis is erect but before it enters the butt or the vagina. Pinch the tip as you unroll the condom for two reasons: (1) it leaves some room for discharged semen (cum), and (2) to prevent air bubbles from being trapped inside the condom; pressure could build up and the condom may pop. Unroll the condom all the way down to the base of the penis. The current recommendation for uncircumcised men is to pull back the foreskin before rolling on the condom.
  6. After intercourse, withdraw the penis while it is still erect, and hold the base of the condom to prevent it slipping off.
  7. Use a condom only once. Tie it off to prevent spillage or wrap it in bathroom tissue and put it in the garbage. Condoms can clog toilets.

Dental Dams

Dental Dams are small squares of latex that were made originally for use in dental procedures. They are now used as a common barrier during oral sex on women, to keep in vaginal fluids or menstrual blood that could transmit HIV or other STDS. They can also be used on someone's butt.

Plastic wrap is also very useful when going down on a woman because you can see through it and you can cut a piece large enough to cover the entire labia, clitoris, and vagina. You can also use a dab of lube on her side, to add sensitivity. Remember, always use a different dental dam or piece of plastic wrap each time, and be careful not to wipe germs from the anus to the vagina.


The Female Condom

The Reality female condom is a large condom made of polyurethane fitted with larger and smaller rings at each end that help to keep it inside the vagina. It may seem a little awkward at first, but can be a viable alternative to the male condom. It is made of polyurethane so any lubricant can be used without damaging the condom. The Reality condom has been approved by the Food & Drug Administration (FDA) for use in preventing transmission of HIV and STDs in vaginal intercourse.

Remember: You are responsible for your own health and well-being. Having unsafe sex can be as dangerous for you as it is for your partner.

Some users have reported success and satisfaction with the Reality condom for anal intercourse, despite some initial awkwardness and minor discomfort (the condom contains small plastic rings to help hold the shape). FDA has NOT approved the Reality condom as a means of preventing transmission of HIV and STDs through anal intercourse at this point.


Polyurethane Condoms

New polyurethane condoms for men are also now available. The only brand currently available is called Avanti, and they are more expensive than latex condoms. If you or your partner is allergic to latex, polyurethane condoms may be a solution. (Note: The polyurethane condom has not yet been approved by the FDA for preventing the transmission of HIV.)

Some Questions You May Have
  1. What should I know about birth control? (More discussion about pregnancy in the What's Next? chapter)

    As you may know, latex condoms are the only form of birth control which is also effective in reducing transmission of HIV and STDs such as gonorrhea, chlamydia, and syphilis. Some HIV-positive women use an additional birth control method to increase their pregnancy protection. The diaphragm and tubal ligation (getting your tubes tied) are both safe forms of birth control for HIV-positive women. Another option that does not stop the transmission of HIV or STDs is a vasectomy for a man.

    There are three hormonal birth control methods: birth control pills, Depo-Provera, and Norplant. These methods are often safe for HIV positive women, but they may interact with other medications you are taking. If you are interested in one of these methods, discuss it with your health care provider.

    The intra-uterine device (IUD) is NOT recommended for women with HIV because the presence of this foreign object in your body may cause irritation and infection, something you want to avoid.

  2. Is it OK for someone to give me a blow job if they stop before I come?

    This is a tough question to answer. HIV is found in ejaculate (cum) and pre-cum. For men who do have pre-cum, the amount of virus found in it can be different from person to person. The risk is low but can increase if there are cuts or sores in your partner's mouth. Condoms are the best prevention.

  3. Should I only have sex with other HIV positive people?

    This is a choice for some people with HIV; they see it as a way of reducing both the chance of being rejected for having HIV and the chance of infecting someone else. They may also feel that they simply have more in common with other HIV-positive people. Only you can decide if this approach is a good one for you.

  4. If I tell someone I have HIV and they still want to have unsafe sex, what should I do?

    This is a question that you definitely want to think about in advance, to avoid being caught off guard. Your partner may seem to be making an informed decision, but it may be one made in the heat of passion. One thing to consider is how you would feel if he or she became infected.

  5. I worry about kissing my children and other family members; is it OK?

    Don't worry about showing affection for your children, aunts, uncles, friends anyone. Holding, touching, or kissing others is safe because no body fluids are exposed or transferred. Deep kissing with sexual partners is very low risk, and dry kissing, as you would do with family and friends, is a no-risk thing.

  6. If I am jerking off with someone and I get cum on their skin, can they get HIV from me?

    Intact skin (healthy skin without rashes, chapping, or cuts) is a good and strong barrier to disease. Body fluids should be kept away from injured skin, rashes, and sores, because breaks in the skin make it possible for disease to get into the bloodstream. HIV can get through mucous membranes (inside of nose, eyes, mouth, vagina, and anus and urethra ) so don't get blood, semen or vaginal fluids near these areas either.

"  I'd like to believe that safe sex is as simple as all of our posters and ad campaigns would have us believe. Not that I'm knocking them but in my most recent relationship it seemed a little more complex than one liners about gloving before loving.' In the midst of all the boiling emotions and tumultuous passion, discussions about protection seemed not to take precedence.

I understand that there is still a need to protect myself and my partner, even if we are both positive. Reinfection and viral mutations are just as real as initial exposure and seroconversion. But the feeling of being constantly on alert, of never being able let my guard down and not think about HIV, was overwhelming. Comparatively, the fears that come with being with someone who is also positive are much less intense than with a partner who is negative.

-Brett

"

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