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Sex and Sexuality for People with HIV

for Veterans and the Public

Sex and Sexuality and HIV: Entire Lesson

Overview

If you just tested positive for HIV, you may not want to think about having sex. Some people who get HIV feel guilty or embarrassed. These are common reactions, especially if you got HIV through sex. Chances are, however, that you will want to have sex again. The good news is that there is no reason why you can't. People with HIV enjoy sex and fall in love, just like other people.

You can have a good sex life, even if you have HIV.

If you are having a hard time dealing with negative feelings like anger or fear, you can get help. Talk to your doctor about support groups or counseling. Sex is a very tough topic for many people with HIV--you are not alone.

By reading this information, you are already taking a good first step toward a healthy sex life. Having good information will help you make good decisions.

Talking to your doctor

Your doctor or other members of your health care team may ask you about your sexual practices each time you go in for a checkup. It may feel embarrassing at first to be honest and open with your doctor. But he or she is trying to help you stay healthy.

Your VA doctor and staff will still give you care if you have had sex with someone of the same sex or someone other than your spouse. The VA is not there to judge you. It's OK to tell your doctor the truth. It will not affect your medical benefits. It will help your health care team take better care of you.

Make sure you set aside time to ask your doctor questions about safer sex, sexually transmitted diseases (STDs), re-infection, or any other questions you might have. If you feel that you need help dealing with your feelings, ask about support groups or counseling.

Many people with HIV ask their doctor or nurse to talk with them and their partners about HIV and how it is transmitted. They can answer technical questions and address the specifics of your situation. If you live with someone, he or she may have questions about everyday contact as well as sexual contact.

Telling your sexual partners

This may be one of the hardest things you have to do. But you need to tell your sexual partner that you are HIV positive, whether you have a primary partner such as a spouse or girlfriend or boyfriend, have more than one partner, or are single or casually dating.

What follows are tips for talking to your main partner, other partners, and former partners.

Talking to your main partner

If you are in a relationship, one of the first things you will probably think about after learning that you have HIV is telling your partner or partners. For some couples, a positive HIV test may have been expected. For others, the news will be a surprise that can bring up difficult issues.

Your partner may not be prepared to offer you support during a time when you need it. Your partner may be worrying about his or her own HIV status. On the other hand, if you think you may have contracted HIV from your partner, you are probably dealing with your own feelings.

If your partner is not already HIV positive, he or she should get an HIV test right away. Don't assume that the results will come back positive, even if you have been having unsafe sex or sharing needles. Until he or she has been tested, your partner may assume the worst and may blame you for possibly spreading the disease. It is important that you discuss these feelings with each other in an open and honest way, perhaps with a licensed counselor.

Talking to new partners

Talking with someone you are dating casually or someone you met recently about HIV may be difficult. You might not know this person very well or know what kind of reaction to expect. When telling a casual partner or someone you are dating, each situation is different and you might use a different approach each time. Sometimes you may feel comfortable being direct and saying, "Before we have sex, I want you to know that I have HIV."

Another time, you may want to bring it up by saying something like, "Let's talk about safer sex." Whichever approach you choose, you probably want to tell the person that you have HIV before you have sex the first time. Otherwise, there may be hurt feelings or mistrust later. Also be sure to practice safer sex. Whatever way you decide to tell, these tips might help:

Talking to former partners

With people you have had sex with in the past or people you have shared needles with, it can be very difficult to explain that you have HIV. However, it is important that they know so that they can decide whether to get tested.

If you need help telling people that you may have been exposed to HIV, most city or county health departments will tell them for you, without using your name. Ask your doctor about this service.

Remember

Before telling your partner that you have HIV, take some time alone to think about how you want to bring it up.

  • Decide when and where would be the best time and place to have a conversation. Choose a time when you expect that you will both be comfortable, rested, and as relaxed as possible.
  • Think about how your partner may react to stressful situations. If there is a history of violence in your relationship, consider your safety first and plan the situation with a case manager or counselor.
  • Imagine several ways in which your partner might react to the news that you are HIV positive. Write down what she or he might say, and then think about what you might say in response.

What is 'safer sex'?

We know a lot about how HIV is transmitted from person to person. Having safer sex means you take this into account and avoid risky practices.

There are two reasons to practice safer sex: to protect yourself and to protect others.

Protecting yourself

If you have HIV, you need to protect your health. When it comes to sex, this means practicing safer sex to avoid sexually transmitted diseases like herpes, hepatitis, and even HIV. HIV makes it harder for your body to fight off diseases. What might be a small health problem for someone without HIV could be big health problem for you.

Practicing safer sex can protect you from getting re-infected or "super-infected" with a different strain of HIV. Some strains are resistant to certain drugs, so getting a new strain of HIV could make the disease harder to treat. Experts believe that re-infection is possible although not very likely, but researchers are continuing to study the issue.

Protecting your partner

Taking care of others means making sure that you do not pass along HIV to them. If your sex partners already have HIV, you should still avoid infecting them with a different strain of HIV or with another sexually transmitted disease you may be carrying.

Most people would agree that you owe it to your sexual partners to tell them that you have HIV. This is being honest with them. Even though it can be very hard to do, in the long run you will probably feel much better about yourself.

Some people with HIV have found that people who love them think that unsafe sex is a sign of greater love or trust. If someone offers to have unsafe sex with you, it is still up to you to protect them by being safe.

To protect yourself and others, the rules are pretty simple, but you might need to make some changes. Because anal and vaginal sex have the highest risk of transmitting HIV, it is important that you use a condom every time you have anal or vaginal sex.

What is risky sex?

HIV is passed through body fluids such as semen, vaginal fluid, or blood. The less contact you have with these, the lower the risk. The most sensitive areas where these fluids are risky are in the vagina or anus (ass). The skin there is thin, and is easily torn, which makes it easier for the virus to enter your body.

In general, vaginal or anal sex without a condom is the most risky. Kissing, touching, hugging, and mutual masturbation are very low risk. Saliva (spit) and tears aren't risky.

Here is a list of sexual activities organized by level of risk to help you and your partner make decisions:

High risk

  • Anal sex without a condom (penis in the anus)
  • Vaginal sex without a condom (penis in the vagina)

Low risk

  • Sex with a condom when you use it right
  • Oral sex, but don't swallow semen (cum)
  • Deep kissing (French kissing or tongue kissing)
  • Sharing sex toys that have been cleaned or covered with a new condom between uses

No risk

  • Hugging, massage
  • Masturbation
  • Fantasizing
  • Dry kissing
  • Phone sex
  • Cyber sex
  • Sex toys you don't share

You can find details on protective barriers like condoms on the Resources page at the end of this section.

Talking about safer sex

You and your partners will have to decide what you are comfortable doing sexually. If you aren't used to talking openly about sex, this could be hard to get used to.

Here are some tips:

  • Find a time and place outside the bedroom to talk.
  • Decide what are your boundaries, concerns and desires before you start to talk.
  • Make sure you clearly state what you want. Use only "I" statements, for example: "I want to use a condom when we have sex."
  • Make sure you don't do, or agree to do, anything that you're not 100% comfortable with.
  • Listen to what your partner is saying. Acknowledge your partner's feelings and opinions. You will need to come up with solutions that work for both of you.
  • Be positive. Use reasons for safer sex that are about you, not your partner.

Of course, only you and your partner can decide what level of risk you are willing to take.

Birth control and HIV

The only forms of birth control that will protect against HIV are abstinence, or using condoms while having sex. Other methods of birth control offer protection against unplanned pregnancy, but do not protect against HIV or other sexually transmitted diseases.

Birth control options that DO protect against HIV:

  • abstinence (not having sex)
  • male condom
  • female condom

Birth control options that DO NOT protect against HIV:

  • oral contraceptive ("the pill")
  • Depo-Provera (shot)
  • emergency contraception ("morning-after pill")
  • Norplant
  • IUD (intrauterine device)
  • diaphragm, cap, and shield
  • vasectomy (getting your tubes tied if you are a man)
  • tubal ligation (getting your tubes tied if you are a woman)
  • withdrawal

Considerations for HIV-positive women

If you are in a monogamous relationship and your partner also is HIV positive, you may decide to use a birth control method other than condoms. (These methods won't protect against other STDs or re-infection.)

Safe methods of birth control for HIV-positive women with an HIV-positive partner include:

  • using a diaphragm
  • tubal ligation (getting your tubes tied)

Use only after checking with your provider (these may interact with your anti-HIV medications):

  • birth control pills
  • Depo-Provera
  • Norplant

Not recommended (may cause irritation and infection, something you want to avoid):

  • IUD (intrauterine device)

Tips for using condoms and dental dams

Some people think that using a condom makes sex less fun. Other people have become creative and find condoms sexy. Not having to worry about infecting someone will definitely make sex much more enjoyable!

If you are not used to using condoms: practice, practice, practice.

Condom dos and don'ts:

  • Shop around: Use lubricated latex condoms. Always use latex, because lambskin condoms don't block HIV and STDs, and polyurethane condoms break more often than latex. Shop around and find your favorite brand. Try different sizes and shapes (yes, they come in different sizes and shapes!). There are a lot of choices--one will work for you.
  • Keep it fresh: Store condoms loosely in a cool, dry place (not your wallet). Make sure your condoms are fresh--check the expiration date. Throw away condoms that have expired, been very hot, or been washed in the washer. If you think the condom might not be good, get a new one. You and your partner are worth it.
  • Take it easy: Open the package carefully, so that you don't rip the condom. Be careful if you use your teeth. Make sure that the condom package has not been punctured (there should be a pocket of air). Check the condom for damaged packaging and signs of aging such as brittleness, stickiness, and discoloration.
  • Keep it hard: Put on the condom after the penis is erect and before it touches any part of a partner's body. If a penis is uncircumcised (uncut), the foreskin must be pulled back before putting on the condom.
  • Heads up! Make sure the condom is right-side out. It's like a sock--there's a right side and a wrong side. Before you put it on the penis, unroll the condom about half an inch to see which direction it is unrolling. Then put it on the head of the penis and hold the tip of the condom between your fingers as you roll it all the way down the shaft of the penis from head to base. This keeps out air bubbles that can cause the condom to break. It also leaves a space for semen to collect after ejaculation.
  • Slippery when wet: If you use a lubricant (lube), it should be a water-soluble lubricant (for example, ID Glide, K-Y Jelly, Slippery Stuff, Foreplay, Wet, Astroglide) in order to prevent breakdown of the condom. Products such as petroleum jelly, massage oils, butter, Crisco, Vaseline, and hand creams are not considered water-soluble lubricants and should not be used.
  • Slippery when wet--part 2: Put lubricant on after you put on the condom, not before--it could slip off. Add more lube often. Dry condoms break more easily.
  • Come and go...: Withdraw the penis immediately after ejaculation, while the penis is still erect; grasp the rim of the condom between your fingers and slowly withdraw the penis (with the condom still on) so that no semen is spilled.
  • Clean up: Throw out the used condom right away. Tie it off to prevent spillage or wrap it in bathroom tissue and put it in the garbage. Condoms can clog toilets. Use a condom only once. Never use the same condom for vaginal and anal intercourse. Never use a condom that has been used by someone else.

Do you have to use a condom for oral sex?

It is possible for oral sex to transmit HIV, whether the infected partner is performing or receiving oral sex. But the risk is low compared with unprotected vaginal or anal sex.

If you choose to perform oral sex, and your partner is male,

  • use a latex condom on the penis; or
  • if you or your partner is allergic to latex, plastic (polyurethane) condoms can be used.

If you choose to have oral sex, and your partner is female,

  • use a latex barrier (such as a natural rubber latex sheet, a dental dam, or a cut-open condom that makes a square) between your mouth and the vagina. A latex barrier such as a dental dam reduces the risk of blood or vaginal fluids entering your mouth. Plastic food wrap also can be used as a barrier.

If you choose to perform oral sex with either a male or female partner and this sex includes oral contact with your partner's anus (anilingus or rimming),

  • use a latex barrier (such as a natural rubber latex sheet, a dental dam, or a cut-open condom that makes a square) between your mouth and the anus. Plastic food wrap also can be used as a barrier. This barrier is to prevent getting another sexually transmitted disease or parasites, not HIV.

If you choose to share sex toys, such as dildos or vibrators, with your partner,

  • each partner should use a new condom on the sex toy; and be sure to clean sex toys between each use.

Female condom

Most people have never heard of these, but they may be helpful for you. The female condom is a large condom made of polyurethane fitted with larger and smaller rings at each end that help keep it inside the vagina. They may seem a little awkward at first, but can be an alternative to the male condom. They are made of polyurethane, so any lubricant can be used without damaging them. Female condoms generally cost more than male condoms, and if you aren't used to them, you'll definitely need to practice.

  • Store the condom in a cool dry place, not in direct heat or sunlight.
  • Throw away any condoms that have expired--the date is printed on individual condom wrappers.
  • Check the package for damage and check the condom for signs of aging such as brittleness, stickiness, and discoloration. The female condom is lubricated, so it will be somewhat wet.
  • Before inserting the condom, you can squeeze lubricant into the condom pouch and rub the sides together to spread it around.
  • Put the condom in before sex play because pre-ejacliatory fluid, which comes from the penis, may contain HIV. The condom can be inserted up to 8 hours before sex.
  • The female condom has a firm ring at each end of it. To insert the condom, squeeze the ring at the closed end between the fingers (like a diaphragm), and push it up into the back of the vagina. The open ring must stay outside the vagina at all times, and it will partly cover the lip area.
  • Do not use a male condom with the female condom.
  • Do not use a female condom with a diaphragm.
  • If the penis is inserted outside the condom pouch or if the outer ring (open ring) slips into the vagina, stop and take the condom out. Use a new condom before you start sex again.
  • Don't tear the condom with fingernails or jewelry.
  • Use a female condom only once and properly dispose of it in the trash (not the toilet).

Dental dams and plastic wrap

Even though oral sex is a low-risk sexual practice, you may want to use protection when performing oral sex on someone who has HIV.

Dental dams are small squares of latex that were made originally for use in dental procedures. They are now commonly used as barriers when performing oral sex on women, to keep in vaginal fluids or menstrual blood that could transmit HIV or other STDs.

Some people use plastic wrap instead of a dental dam. It's thinner.

Here are some things to remember:

  • Before using a dental dam, first check it visually for any holes.
  • If the dental dam has cornstarch on it, rinse that off with water (starch in the vagina can lead to an infection).
  • Cover the woman's genital area with the dental dam.
  • For oral-anal sex, cover the opening of the anus with a new dental dam.
  • A new dental dam should be used for each act of oral sex; it should never be reused.

Resources

  • CDC Fact Sheet on Oral Sex and HIV RiskLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    This fact sheet highlights the current public health knowledge concerning oral sex and HIV risk.
  • Evading the VirusLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    Fertility, technology, and HIV. Radio programs on parenthood and HIV, from American Radio Works, Minnesota Public Radio.
  • Forum on Mixed-Status CouplesLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    The Body's online forum, hosted by clinical psychologist Dr. Robert Remien.
  • Nursing Your RelationshipLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    Tips for when a partner is seriously ill, from the Partners Task Force for Gay & Lesbian Couples.
  • San Francisco Sex Information LineLink will take you outside the VA website. VA is not responsible for the content of the linked site.
    (SFSI) 1-415-989-7374. A free information and referral switchboard providing anonymous, accurate, non-judgmental information about all aspects of sex, including safer sex. Hours are: Monday-Thursday 3-9pm PT; Friday 3-6pm PT; Saturday 2-5pm PT.

Information on Using Condoms