| Think Prevention|
Health care providers can play an important role in HIV prevention1. Many people consider their doctor the person they most trust to give advice about the issues around health and sexuality. Some health care providers find that the most useful approach to talking about safer sex with their patients is to include it in a broader discussion about all aspects of healthier living. Just as a physician may discuss with his or her patient the importance of exercise or seat belts, or the health benefits of quitting smoking, he or she may discuss ways the patient can reduce the risk for HIV infection. Communicate About Sexuality
In our culture, sexuality is rarely talked about in honest, open terms. Given this, few people have experience asking and responding to questions about sex. One way to overcome this barrier is to assess and then speak about sexuality in terms that are familiar and comfortable for the patient. These terms may vary based on the age, race, gender, sexual orientation, and other identities of the patient. If you develop a communication style that works for you both, it will enable you to ask the questions and get the answers you need to provide your patients with appropriate education, support, and referral. Workshops and trainings on this issue are offered at conferences and other locations throughout the country. Build Trust
People at risk for HIV are diverse; many have a wide range of sexual experiences. Some may have experienced prejudice or discrimination because of their sexuality. In order to be an effective HIV educator for your patients, it is important to earn their trust. One way to do this is to have brochures, posters, pamphlets and other information in your office that are welcoming to people of all sexual orientations. This serves as positive reinforcement for patients that they will be respected for who they are. Another means of building trust is to not make any assumptions about the type or amount of sex a person is having. Just because a person is married, for example, does not mean that he or she is monogamous or heterosexual. Effective trust-building results in a patient feeling comfortable talking about his or her risks around HIV regardless of sexual orientation or past sexual experience. Communicate The Risks
Patients may have questions about the risk of being infected with HIV as a result of engaging in particular sexual activities. For example, a patient might ask, "How risky is oral sex?" Questions like this provide a good opportunity to engage patients in a discussion about what risks they are taking and how to reduce their overall risk for HIV. One way of responding to the oral sex question above is to ask the patient: "Riskier than what?" Answering this question helps the patient probe deeper into how they understand the risk of oral sex in the context of their own lives. Oral sex is safer than unprotected vaginal or anal sex. Recognize the Links
When counseling patients about safer sex, it is important to help patients make connections between their sexual risk-taking and other issues in their lives. Substance use, for example, can put a person at higher risk for HIV. A client concerned about his or her unsafe sex while under the influence of alcohol or other drugs, would need counseling about substance use as well as about safer sex. Other issues, including domestic violence, sex for drugs or money, and sexual assault are opportunities for counseling, support, and referral. The Biology of Safer Sex
HIV is present in semen and cervicovaginal secretions, both as cell-free and cell-associated virus. Genital tract secretions may contain millions of particles of HIV, especially in individuals who are acutely infected, who have advanced disease, and who are not receiving antiretroviral therapy. HIV inhabits white blood cells, particularly CD4 lymphocytes, and monocyte-macrophages. In some individuals who are asymptomatic, there may be more than a million of these white blood cells in genital secretions. Other sexually transmitted diseases, including gonorrhea, chlamydia, trichomonas, and herpes may increase the number of genital tract white cells and may make HIV infected people more infectious to their partners. Thus, people with HIV infection may range in their level of infectiousness to potential partners. The Impact of Antiretroviral Therapy
Antiretroviral therapy usually decreases the amount of HIV in the genital tract as well as the blood. There are individuals, however, who have been shown to have undetectable levels of virus in the blood, and yet have virus found in the genital tract. Therefore, individuals cannot assume that because the virus is suppressed in the blood due to therapy, they are not potentially infectious to their partners. There are individuals who have received antiretrioviral therapy and have transmitted multi-drug resistant HIV to their partners. Thus, although people taking combination antiretroviral therapy may be less likely to be infectious, they need to be counseled that for any given sex act, they are potentially infectious, and thus should practice safer sex. Susceptibility May Vary
Just as the level of infectiousness of HIV may vary, the level of susceptibility to HIV may vary between different groups of people, and the same person has different levels at separate times. Sexually transmitted diseases in HIV uninfected people may enhance susceptibility, either by causing ulcerations in which the mucous membranes are exposed (e. g. herpes), or the enhanced inflammation of infections like gonorrhea or chlamydia, may result in more target cells for HIV to infect. In addition, genital infections result in the production of cytokines, which increase the ability of HIV to multiply at the site of sexual contact. Some individuals may be genetically more resistant to HIV because they lack or have decreased amounts of some of the receptors to which HIV binds in order to enter cells.
Other factors that may influence the efficiency of HIV transmission include the absence of circumcision and cervical ectopy. Both the human foreskin and the endocervix contain cells that have increased number of receptors to bind HIV. Hormonal contraception may also increase HIV susceptibility. Sexual practices that increase trauma and or inflammation in the genital tract, like certain douching products, may also increase risk for HIV transmission. Sexual Practice and Risk
Not all sexual practices are equally likely to result in HIV transmission. The most efficient ways are through the rectal mucous membranes, or the cervical vaginal mucosa. These tissues seem to have more receptors to bind HIV, and in the case of the rectal mucous membranes, the tissue is more easily traumatized, leading to more easy access for HIV transmission. Because cervicovaginal secretions contain less HIV on the average than semen, and because the amount of exposed tissue of the male urethra is limited for HIV binding, it is more efficient for men to transmit HIV to women through heterosexual contact than vice-versa. Likewise, it is harder for an insertive partner to acquire HIV through anal intercourse than a receptive partner.
As mentioned above, there are many factors that may influence the amount of virus in genital tract secretions and the susceptibility of individuals at risk for HIV to acquire HIV. Therefore, it is impossible to give precise numbers for the individual risks of each sexual act between an infected person and an uninfected person. It is clear from many epidemiological and biological studies, that most HIV transmission between men who have sex with men occurs via unprotected anal intercourse, either to the insertive or receptive partner; and for heterosexuals, most of the contact is through unprotected penile-vaginal intercourse. Well-documented cases of HIV transmission through oral exposure to semen or cervicovaginal secretions have been documented so that fellatio and cunnilingus cannot be considered to be safe practices. However, the relative inefficiency of HIV transmission in the upper digestive system suggests that the likelihood of HIV transmission by the oral route is several logs less likely than penile-vaginal or penile-anal intercourse. For these higher risk practices, the per contact risk of HIV acquisition, ranges from less than 1/1000 to more than 1/10. There is wide biological variability for each behavior, in terms of the amount of risk for each act.
Other sexual practices are substantially less likely to transmit HIV. For example, although HIV has been shown to be present in minute quantities in preejaculate, there are documented reports that suggest exposure to preejaculate has resulted in transmission. Other body fluids such as saliva have been shown to contain substances that inhibit HIV transmission, so in the absence of visible blood, there has been no incidence of HIV transmission by kissing. HIV can be transmitted via blood contact, and thus shared sharp objects, piercing, shared sex toys, etc. have the potential to transmit HIV. Intimate skin contact, mutual masturbation, and other practices, which do not result in genital secretions coming directly into contact with mucus membranes or abraded skin have not been documented to transmit HIV (i. e. the intact skin is a good barrier to HIV transmission). Other practices may not transmit HIV, but may result in other health problems. For example, although anal-oral contact without blood present has not been shown to result in HIV transmission, it can result in the transmission of enteric parasites, and serious bacterial infections, like salmonella. Practices involving other bodily fluids may transmit STDs as well, and need to be evaluated on a case-by-case basis.
Reproduced with permission. Written by Marshall Miller, Kenneth Mayer, MD, and Harvey J. Makadon, MD. Published by The Fenway Institute / Fenway Community Health, 7 Haviland Street, Boston, MA 02115. Copyright 1999. This brochure was made possible through a grant from the Kaiser Family Foundation, Putting HIV Prevention Into Clinical Practice, Harvey J. Makadon, MD, Principal Investigator.