What Are HIV-Positive Persons' HIV Prevention Needs?
Why Prevention for HIV-Positive Persons?
Every new HIV infection involves an HIV-positive person. The Centers for Disease Control and Prevention (CDC) estimate that there are 600,000-900,000 people living with HIV in the U.S. Yet very few prevention interventions have been directed to HIV-positive women and men. People who are HIV positive deserve to have interventions to help them stay safe and play an active role in stopping the epidemic.
In the past few years, advances in the treatment and care of HIV-positive persons have helped many people enjoy increased health and longer life. For many, this allows for a renewed interest in sexual and for some, drug using activity. More sexually active and drug using HIV-positive persons means the possibility of more new infections.
Why Haven't We Done More of This?
In the past, prevention efforts had not been directed toward HIV-positive persons for fear of "pointing the finger" or blaming HIV-positive persons for the epidemic. Although AIDS has become less stigmatized in the U.S., in some communities there is still serious stigma experienced by HIV-positive persons. AIDS activists and HIV-positive persons have also feared laws criminalizing sexual risk behaviors and further prosecution of injection drug users (IDUs).
Prevention efforts for HIV-positive persons have focused on protecting one's own health from the possibility of reinfection with untreatable strains of HIV. Few efforts have addressed altruis -- the responsibility of HIV-positive persons to not transmit the virus to others and the opportunity for HIV-positive persons to actively contribute to ending the epidemic. Prevention efforts need to address both issues: taking responsibility for one's own health and the health of one's partners, children, other family members and community.
Why Would Someone Infect Another?
Most HIV-positive persons are concerned about not infecting others and have made efforts to prevent transmission. Yet there has not been much support for HIV-positive persons to gain the necessary skills and tools to adopt new, safer behaviors. Couples where one partner is HIV positive and the other is HIV negative often wrestle with issues such as how to maintain sexual satisfaction and trust. For some couples, the risk of losing commitment and intimacy in a relationship is more threatening than the risk of transmitting HIV.
A precondition of reducing your risk is knowing you're HIV positive and getting help. There are an estimated 200,000-250,000 Americans unaware that they are infected with HIV. It is imperative to help HIV-positive persons get tested before they unknowingly infect others. Finding out HIV status can also allow early access to life-prolonging treatment and services.
Incorrect assumptions and denial of responsibility between partners can lead to risky behavior. Many HIV negative persons are unaware of their partners' status or risk behaviors and may make assumptions that they are not at risk for HIV because they are married, in a relationship, their partner looks healthy, or simply because their partner did not ask to use a condom. HIV-positive persons may make the same assumptions that their partner is also HIV positive because the partner didn't ask about serostatus or suggest using condoms. Likewise, there may be a difference of opinion on who's responsible for keeping safe, the HIV positive person, the HIV negative person, or both.
Disclosure can be a way of beginning a discussion about safer sex or drug use. Yet disclosure of one's serostatus is difficult for many HIV-positive persons, especially women, who may fear stigma, rejection or violence from their partners.
Practicing safer sex with all partners and always using clean needles is one way of preventing transmission without having to disclose status. However, in many communities where this is not the norm, simply using a condom can disclose HIV-positive status, even without saying it.
HIV is a disease that is often mistakenly associated with careless sexual behavior. However, many HIV-positive persons become infected within a loving relationship. In one study of HIV-positive men and women, 41% reported becoming infected by a spouse, significant other, or long-standing friend. Research has shown that people are often more comfortable disclosing and practicing safer sex with partners outside of their main relationship.
What Are Barriers to Prevention?
Often, the same factors that led someone to become infected are also barriers to preventing transmission. Many HIV-positive persons face complex issues that can affect their ability to engage in safer sex or drug-using behaviors. Depression, substance use and abuse, history of violence and abuse and sexual compulsivity are all issues that may need to be addressed. Many of these issues cannot be addressed in a prevention program and may require referral to longer-term counseling or other social services.
Legal, political, and environmental factors can be barriers to HIV prevention among HIV-positive persons. For example, the lack of access to sterile syringes and needle exchange programs, as well as laws prohibiting possession of syringes, hamper the ability of IDUs to engage in safe behaviors. Fear of arrest for carrying drug paraphernalia has been associated with sharing syringes and other injection supplies.
What's Being Done?
In 1998, the CDC funded five Health Departments to create demonstration projects providing primary HIV prevention for HIV-positive individuals. California, Los Angeles, San Francisco, Maryland, and Wisconsin have begun a variety of programs that address a wide audience including: HIV-positive women, men of color who have sex with men, IDUs, youth, female sex and needle sharing partners of IDUs, and incarcerated men and women.
Interventions include: HIV, STD and TB counseling, testing and treatment; referral and linkage to care; prevention case management; HIV-positive peer "buddies"; outreach via social networks; mass media and internet marketing; partner counseling and referral services; skills building; and community level forums and social events.
AIDS Action Committee in Boston, MA, created an ad campaign that targets HIV-positive gay men with messages aimed at opening discussion about transmission and promoting responsibility. Posters with messages such as "Ask. Tell." "Let's stop new infections now." and "If you're positive, think about transmission." were placed over urinals in gay bars and sex clubs. A survey of men leaving the bathrooms found that 70% could recall two or more of the messages.
Couples counseling for sero-discordant couples (where one partner is HIV positive, the other HIV negative) has proven highly effective at reducing new HIV infections. One program for heterosexual women and men provided couples counseling in combination with social support. As a result, condom use increased and no new HIV infections were reported among the couples. Couples counseling can help ease communication and provide support for both the HIV-positive and HIV-negative partner in straight and gay/lesbian relationships.
What Needs to Be Done?
HIV-positive persons are a unique population in that they require both care and prevention, which requires better coordination between these two worlds.
Health care providers need to be trained to deliver HIV prevention, as seroconversion can provide a strong motivation to change risky behaviors.
HIV prevention programs need to address HIV-positive persons and include STD, hepatitis and TB screening and treatment as well as referrals to drug treatment, family planning and mental health services.
HIV-positive persons' partners, children and families must be included with support and education.
We need more effective HIV testing and counseling strategies.
There is currently an unacceptably high number of persons who do not know they are HIV positive unknowingly infecting others. The social network approach (encouraging HIV-positive persons to provide information and outreach to peers who might be positive) is one way to create a more efficient and targeted approach to HIV testing and counseling for those at greatest risk.
There are many things we don't know about the relationship between new anti-HIV drugs and HIV transmission. How much do they affect a person's infectiousness and how does that affect transmission? Is reinfection or super-infection a valid concern? These questions need to be researched, and the answers disseminated widely so that HIV-positive persons can make informed decisions about preventing transmission of the virus.
If you have tested HIV positive, reach out and get some help. If you don't know your HIV status, take the test -- it's free and confidential.
If you need a prevention for positives program to help you reduce your chances of transmitting virus to others, please call the Women Alive Coalition at 323.965.1564. Ask for Gina!