Preventing HIV infection
© The Terrence Higgins Trust 1997
This booklet is for people who want to understand how they can protect themselves or others from HIV, the virus that can lead to AIDS. It describes how HIV can be passed from one person to another, and how this can be prevented. (material reproduced with kind permission from the The Terrence Higgins Trust - visit their informative website for further information)
If you would like to talk to someone about HIV and AIDS, please telephone the Terrence Higgins Helpline:
0171-242 1010 12 noon - 10 pm, every day of the year. revised Jan 1998 © The Terrence Higgins Trust
What are HIV and AIDS?
HIV stands for Human Immunodeficiency Virus. This virus attacks the human immune system, the body's defence against disease.
A person with HIV may feel completely well and have no symptoms. However over a long period of time the virus may damage the immune system. As a result the body may not be able to fight off certain rare illnesses and cancers. When this happens the person is said to have AIDS.
AIDS stands for Acquired Immune Deficiency Syndrome. The 'syndrome' is a collection of rare illnesses which people with HIV can get if their immune system is weakened by the virus.
How is HIV passed on?
HIV is not a very infectious virus. It cannot pass through unbroken skin, or through the air like cold germs. It cannot be passed on through ordinary social contact. People with HIV and AIDS live and work with uninfected people without putting them at any risk.
There are three main ways in which HIV can pass from someone who has HIV to an uninfected person:
It is very uncommon for HIV to be passed on in any other way. However a small number of people have been infected from giving oral sex to a man with HIV (sucking his penis), and there have been a few cases of health care workers (doctors, nurses etc) being infected through accidents with needles while caring for patients with HIV.
In the past, people who were given blood transfusions, blood factor treatments (for haemophilia) or organ transplants sometimes became infected because the donor had HIV. All blood and organ donations in the UK are now screened to prevent this happening, though it is still a risk in some parts of the world.
HOW INFECTION HAPPENS
HIV can only be passed from a person with HIV to another person in the following body fluids:
Infection can only happen if HIV - in one of the body fluids listed above - gets into someone else's bloodstream. This can only happen in certain ways:
For men this means through the rectum or the urethra (the tube in the penis). HIV may also pass through the glans (the head of the penis)
For women, this means through the vagina, the cervix (the entrance to the womb), the urethra term(the urethra is in front of the vagina) and the rectum
The saliva, sweat and urine of someone who has HIV do not contain enough virus to infect another person.
OTHER ROUTES OF TRANSMISSION
There are no recorded cases of people becoming infected with HIV by the following activities, but other more infectious viruses carried in the blood, such as hepatitis, certainly could be passed in these ways:
IS IT A RISK?
Remember that for someone to be infected with HIV, three things must all be present. They can be summed up as source, quantity and route:
If you are worried that you could have been at risk or you are not sure whether a particular activity is risky, you could talk it through with someone on a Helpline. There are phone numbers at the end of this booklet.
Who has HIV?
WHO HAS BEEN MOST AFFECTED BY HIV?
Although anyone may become infected with HIV, some UK communities have been affected more than others:
People who have unsafe sex within these groups are at increased risk of meeting a partner who has HIV.
In addition, numbers of people (almost all men or boys) with haemophilia were infected with HIV through blood products used in haemophilia therapy. Sexual partners of some of the men infected in this way were also infected. Haemophilia treatments used in the UK are now safe from HIV.
Levels of HIV infection remain highest within these population groups. At the moment it is very uncommon in the UK amongst people who have had no sexual contact with them. However, HIV and safer sex is an issue for everyone, and increasingly so:
DO I HAVE HIV?
Many people feel they have some idea of whether they have HIV or not. Perhaps you suspect that you could have, based on things you have done in the past. You can never really be sure unless you have an HIV test, and deciding to have a test can be difficult - there is a big difference between thinking you may have a serious medical condition and finding out that you definitely have. Some people choose to delay having an HIV test until the time feels right. Others decide that there are advantages to knowing, such as access to anti-HIV treatments, which make it worthwhile.
If you are thinking about having an HIV test, see the Terrence Higgins Trust's booklet Testing Issues for more information to help you decide.
It can sometimes be tempting to make guesses about sexual partners too: "this person could never have HIV" or "I know this person so well now, I just know they have not got HIV." But there is no easy way to tell if someone has HIV or not, and they may not know themselves. Many people with HIV are healthy and well after several years of living with the virus, so you cannot tell from how someone looks, or how well you know them, whether or not they have HIV.
IF YOU HAVE HIV
Whether you think you have HIV, or know that you do, safer sex and safer drug use will not only prevent you infecting other people. They will also help you stay healthy:
For more information about sex and living with HIV, see the Terrence Higgins Trust's leaflet Sex Positive (for gay men) or Living with HIV & AIDS (available from NAM Publications, 0171-627 3200).
PREVENTING INFECTION The rest of this booklet gives detailed information about the ways in which you can avoid getting HIV from other people or giving it to them. These are:
There is also more information on how HIV transmission is prevented in medical settings.
HIV and sex
If someone has HIV, it can be passed to another person through anal or vaginal sex. This can happen whether the person with HIV is doing the penetrating or being penetrated.
If either you or your partner has HIV (or could have HIV), the only way to protect each other when having sex is to have safer sex.
Safer sex principally means using condoms or Femidoms (the female condom) and lubricant if you have penetrative sex, or having sex where the penis does not penetrate the vagina or anus.
It is "safer" not safe sex, because there will always be a tiny risk (for example, condoms can break), but the risk can be made so small that it does not interfere with enjoyment of sex.
As well as preventing HIV transmission, safer sex protects against most other sexually transmitted infections (STDs). Some STDs can do serious long-term damage if they are not treated promptly.
Safer sex will also prevent pregnancy.
This section gives a general overview of safer sex. Other Terrence Higgins Trust publications provide information about safer sex for particular groups of people:
Safer sex for gay men
HIV and AIDS - information for women
Reducing the risks (for drug users)
HIV and AIDS - information for lesbians
SEXUAL INTERCOURSE WITH A CONDOM OR FEMIDOM
Condoms and Femidoms (the female condom) can make penetrative sexual intercourse - anal or vaginal - very much safer. Condoms and Femidoms will also protect from most other sexually transmitted infections.
The male condom
Condoms with the British Kitemark or the new European CEN mark are recommended for use in vaginal sexual intercourse. No condoms have been scientifically tested for anal sex, but extra strong condoms such as Durex Ultra Strong and Mates Super Strong are widely used.
Standard and extra strong condoms are available free from family planning clinics, genitourinary medicine clinics (known as GUM clinics or STD clinics) and some GPs. Extra strong condoms are sometimes available free from gay venues. Not all chemists stock extra strong condoms.
Most condoms are already lubricated, but extra lubricant should always be used for anal sex to help prevent damage to the rectum or the condom. Vaginal sex is safer and more pleasurable with extra lubricant, particularly when the vagina is dry. Put the lubricant on the condom when it is on the penis, or on the anus or the entrance to the vagina before penetration. To increase the penis's sensitivity, some people also like to put a dab of lubricant inside the tip of the condom before it is put on - don't use a lot, or the condom could come off. Water-based lubricants, such as KY jelly or Boots own brand, are safe to use with latex condoms (all recommended male condoms are made of latex). Oil-based lubricants, such as Vaseline or massage oils, will damage latex and make the condom unsafe.
Nonoxynol-9 is a chemical used on some ready-lubricated condoms and in spermicidal creams. As well as killing sperm it provides some protection against HIV and other STDs. But some men and women are allergic to it - it can cause abrasions (roughness) and this increases vulnerability to HIV. If you experience discomfort with a product containing nonoxynol-9, stop using it. Lubricants such as KY and Boots own have no spermicidal properties and will not cause irritation.
The female condom
Femidoms (female condoms) also carry the Kitemark. Like Kitemarked male condoms, they protect against HIV, other sexually transmitted diseases and pregnancy.They can be used with most lubricants because they are made of plastic, not latex. They sit inside the vagina instead of fitting onto the penis. If you are using lubricant with a Femidom, put it inside the Femidom or on the penis.
Although designed for use in the vagina, a Femidom can also be inserted into the anus for anal sex. It can be worn by a man as a baggy condom for vaginal or anal sex. Some people remove the Femidom's inner ring before using it for anal sex or as a baggy condom. If it is used for anal sex, lubricant should be put on the inside and outside of the Femidom. Femidoms have not been scientifically tested for use as a baggy male condom or for anal sex.
Condoms are sometimes criticised as being unreliable, based on their failure rate as a contraceptive. In fact, condom failure is usually due to incorrect use or not enough lubricant. It is important to follow the instructions carefully. Neither male nor female condoms should ever be reused.
It is very rare for HIV to be passed to someone giving oral sex to a man with HIV. Not one single case is known of a person being infected by giving oral sex to a woman with HIV.
Sucking the penis of a man with HIV
As far as we know, this is the only kind of oral sex in which HIV can be passed on, but the risk is still very small. Though there is enough virus in semen to infect another person, it is difficult for the virus to survive in the mouth, and it is difficult for the virus to get from the mouth into the bloodstream. Gay men - who have been the most affected by HIV in the UK - continue using oral sex as a successful form of safer sex.
There are about a dozen cases of HIV world-wide where infection is believed to have taken place by this route. If you are the person doing the sucking, and your partner has, or could have, HIV:
If you are the man whose penis is being sucked, you can make it safer for your partner by withdrawing before coming. Some people choose to be even safer by using condoms. Watch out for lipstick or lip salve as these are oil based and will damage condoms.
Other kinds of oral sex
Licking the labia or clitoris of a woman who has HIV is even less risky than oral sex with a man who has HIV. This is because there is less virus in vaginal fluid at the entrance to the vagina than in semen. If menstrual fluid (blood) is also present there will be more virus, but it is still very unlikely to get through the mouth lining of the person doing the licking. There are no confirmed reports of infection occurring by this route.
When the person who is doing the sucking or licking has HIV, there is no risk to the partner who is having his penis sucked or her labia licked, because there is not enough HIV in saliva to infect another person.
OTHER SEXUAL ACTIVITIES
(rimming, licking a man or woman's anus). HIV is not transmitted in this way, though this is a route for transmission of other infections. If you have HIV it can be dangerous to lick your partner's anus as you could get an infection that could lead to serious illness. A dental dam (oral shield) or a piece of non-microwaveable clingfilm placed over the anus will prevent infections being passed during rimming.
Sharing sex toys
If a sex toy such as a vibrator or dildo is used to penetrate both partners, the virus could be passed on. A dildo should be washed between users, or a fresh condom put on it.
Cuts and injuries.
If sex results in cuts or broken skin, it is good basic hygiene to cover the wound with a waterproof plaster.
Other sexual activities like deep kissing, body rubbing, fingering and mutual masturbation will not transmit the virus.
SAFER SEX AND COMMUNICATION
Communication is important in all sex, but it is especially important if you want to have safer sex.
Try to be clear with your partner from the start that you want to have safer sex. This may mean that you need to talk about safer sex before you're in a situation together where sex could happen.
Don't risk being unprepared - the right moment for sex could arrive when neither of you has condoms with you. Don't rely on your partner to provide the condoms and lubricant. Remember also that you don't have to have intercourse to have good sex: you can explore ways of having fun together without intercourse.
Talking about sex sometimes feels awkward or embarrassing. It may seem easier to just let things take their course. But delaying the discussion until you are both sexually aroused could mean the discussion doesn't happen. Perhaps your partner was hoping you would raise the subject first.
Although talking about sex can be difficult, it can also be fun - some people find that discussing sex can be a great way of turning each other on.
GETTING USED TO CONDOMS
Some people have said that stopping to put on a condom kills spontaneity and deadens sensation. It would be foolish to suggest that intercourse with a condom is exactly the same as intercourse without. But many people have made condoms an integral part of a satisfying sex life.
Getting out the condoms before any sexual activity has taken place can raise the sexual temperature: a hint of what is to follow. Rolling a condom down your partner's penis (or your partner rolling one down yours - whatever applies) can be a sexy experience for both of you.
If you are in a relationship (or starting one), the prospect of always having safer sex may be daunting. Some people choose not to use condoms in this situation. However, this is only a reliable way of avoiding HIV infection if you know that neither of you has HIV, and you are confident that neither of you will have unsafe sex with anyone else.
Having an HIV test is the only way of being sure that this strategy will work. For more information, see the Terrence Higgins Trust's booklet Testing Issues
Safer Drug Use
Sharing any drug injecting equipment (works) can easily lead to HIV and other diseases carried in the blood (such as hepatitis B and C) being passed on. Works are not just the needle and syringe but include spoons, mixing dishes, filters, water and citric acid.
If you inject drugs, use a new needle and syringe each time and don't share any injecting equipment. New equipment can be bought from some chemists, or is available free from needle exchanges, most drug agencies and some chemists. Look out for this sign:
It is best to go to a needle exchange and get a new set of works. But if sharing is impossible to avoid, works can be cleaned between users as a last resort. Cleaning works will kill HIV, but not hepatitis C. Hep C is more common among drug users than HIV and can have serious long-term effects.
This is what you should do to clean works:
draw fresh cold water through the needle into the syringe and flush x 3
The bleach should stay in the syringe for 30 seconds. Remember not to flush out into the clean water.
Do not use hot water: it will make the blood congeal so traces may be left behind. Boiling works may not remove all the blood for the same reason, and anyway disposable works usually buckle if boiled.
The Terrence Higgins Trust leaflet Reducing the Risks gives more information about keeping as healthy as you can if you are a drug user.
If you are concerned about your own or a friend or partner's drug use, you could contact the Terrence Higgins Trust for support and information about further help available.
HIV and health care
HIV AND DONATED BLOOD AND ORGANS
Before it was known that AIDS is caused by a virus carried in the blood, a number of people became infected through transfusions of blood donated by people with HIV.
The UK blood supply is now one of the safest in the world. All donations are tested for HIV antibodies (the test which shows whether HIV is present). People from population groups which have been severely affected by HIV are asked not to give blood, because there is a gap (the window period) between infection and an accurate test result. A newly infected person could unwittingly donate during this time. Blood used for blood transfusions must be used whole and untreated, and it must be used quite quickly, so these measures ensure the supply remains as safe as possible.
You cannot get HIV from donating blood.
In some countries of the world, infection through blood transfusion is still a significant risk, due to lack of resources to ensure the safety of the blood supply. Travellers can telephone MASTA at the London School of Hygiene and Tropical Medicine (0891-224100) or the Foreign and Commonwealth Office Consular Department's Travel Office (0171-270 3000) for up-to-date information and advice.
People with haemophilia are treated with blood products derived from donated blood. Before the link between HIV and AIDS was understood, many people with haemophilia became infected because they were given blood products derived from infected blood. Blood products for use in haemophilia treatment can be heated, and this kills HIV. Treatment with blood products is now safe from HIV in the UK.
All organ donors are now tested for HIV.
HIV AND HEALTH CARE WORKERS
Health care workers are sometimes said to be at particular risk of getting HIV, either from sprays or spillage of infected blood, or injuries from needles. In fact, the standard infection control measures ("universal precautions") designed to protect against hepatitis B in health care settings will also protect against HIV transmission. Hepatitis B and HIV have similar modes of transmission with one key difference: HIV is much less infectious than hepatitis B.
Though many thousands of patients with HIV have been cared for in hospitals and clinics around the world, only a handful of health care workers have become infected. Where this has happened it has generally been because the standard safety procedures were not followed. These procedures are:
It is sometimes suggested that health care workers with HIV might be a risk to their patients. Extensive follow up of patients cared for by workers with HIV has revealed only one case in the world of a worker whose patients may have been infected. This was an American dentist, and it remains unclear whether he did actually infect his patients and, if he did, how this happened.
Reducing the risk of transmission during and after pregnancy
A woman living with HIV who wishes to become pregnant may have particular anxieties about the health of her baby. The chance of the virus being transmitted to the baby is about one in seven. It can happen before or during birth or through breast feeding. In parts of the world with lower standards of general health, transmission from a woman with HIV to her baby is more likely.
Viral load and mother-to-baby transmission before and during birth
Viral load is the amount of HIV in the blood. If a woman with HIV has low viral load it is less likely that the virus will be passed to her baby than if she has high viral load. However, even if viral load is very low, there is still a chance that HIV will be transmitted.
Among people with HIV who have not had anti-HIV treatments, viral load is highest during the weeks immediately after infection and when they start to become ill. So a woman with HIV might reduce the risk to her baby by becoming pregnant while she is healthy rather than delaying until she has become ill.
Viral load can often be reduced by taking anti-HIV drugs. Research has shown that if the anti-HIV drug AZT is taken by the mother during the last six months of her pregnancy and while giving birth, and given to the baby for a few weeks after birth, the baby's chances of infection will be reduced by up to two thirds. No significant side effects of exposing babies to AZT before and after birth have yet been reported, but the long-term effects are not known. Taking the drug in this way may also affect the mother's own future treatment options.
There is evidence that delivery by Caesarean section will reduce the chance of infection during birth. More evidence is needed before this potentially hazardous procedure can be routinely recommended to pregnant women with HIV.
The breast milk of a woman with HIV contains enough virus to infect a baby during breast feeding. In regions with a poor water supply, using substitutes for breast milk can be a greater risk to babies' health than HIV, and women with HIV are advised to breast feed. In parts of the world where the water supply is safe, women with HIV are recommended not to breast feed.
Talking to health care workers
Many doctors and midwives will be helpful and supportive to a woman with HIV who wants a child. A few are less so. It can be very hard for a woman with HIV to tell her health care workers she is pregnant or wants to be, if she suspects they will try to change her mind. Staff with experience of working with women who have HIV are likely to be the best informed and most supportive.
Towards the future
In time the development of a vaccine may prevent new HIV infections throughout the world. Until that happens we all need to know how to protect ourselves and each other. HIV infection is preventable, but we need to understand how. Often we need support to help us act on our knowledge.
Honest, sex-positive sex education will help prepare young people for adulthood, but it is not always available in this country. Particularly important is a sex education which will help young people to feel confident and good about their sexuality (and this includes young gay men, lesbians and bisexuals), and which gives them information about sexual health which is relevant to them. Confidence and self esteem help everyone achieve a healthy sex life.
Sticking to safer sex is not always easy, and the same can be true for safer drug use. We are all human after all. Even in the UK, people are becoming newly infected all the time.
If you are finding that safer sex or safer drug use is a struggle, why not call one of the Helplines to talk it through. They are there to give support, or just to listen. Many HIV organisations, including the Terrence Higgins Trust, also have counsellors you can talk to face-to-face.
© 1996 -1998 The Terrence Higgins Trust Charity Registration No. 288527
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