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HIV ProtectionHIV made an enormous impact on the world in the early 1980's.  It scrounged up fear, stigma, and discrimination.  It also brought out compassion, kindness and a drive to help fellow community members.  As researches learned the routes of HIV transmission, the entire world had begun to politicize an infectious disease.  As the world learned how to prevent HIV, there was a collective sigh of relief.  To prevent becoming infected with HIV, people should not share needles and should use condoms for anal, vaginal, and oral sex.  Pregnant women could take steps to reduce the chances of infecting their children.  Screening became mandatory for the blood supply and for blood-products.  It seemed it was only a matter of years until this disease was under control and the crisis ended.

But HIV didn't go away.  There were people that refused to use condoms.  People were fearful or out right against testing.  Effective testing and condom campaigns were utilized and helped slow the infection rates in the U.S.

HIV still hasn't gone away.  People still refuse to wear condoms.  People are still fearful or outright against testing.  Testing and condom campaigns are slowly disappearing as HIV prevention funding dries up.  People are living longer with HIV.  There is a generation that is coming of sexual age since the improvement in HIV medications after receiving an abstinence-only sex education.  And newly reported infections continue to climb.  Why?  What goes into HIV prevention?  How does it need to change?  Will it evolve?
 
Macro Message
 
Starting on a grander scale, the general public needs to be aware of how HIV is transmitted.  HIV education is a process, not an event.  We see messages over and over again reminding us to wear our seatbelt.  School children are taught songs about how to ride in cars safely by strapping on a seatbelt.  Every high school student that has gone through driver's education has seen gory short films about the dangers of not buckling up.

Public health officials have identified a problem and instituted on-going education to promote safe behaviors.  The same can and needs to be done with HIV.  The general population needs to see, time and again, that HIV still exists, that there is no cure, and that they need to protect themselves.  Reminding people of the consequences of unsafe sex is no different than reminding them of how they can shatter their faces on a windshield if they aren't belted in.

Unfortunately, sex and drugs comes with moral baggage.  Even though public health officials know how to prevent HIV, messages are filtered, softened, or eliminated altogether by legislators.  Everyone is entitled to their opinions.  However, when science is providing factual information about how to prevent a life-long, potentially fatal infection, the message cannot be filtered.  People need concrete, factual information to protect themselves.
 
Prevalence
 
Let's say you go to a party at a hotel.  The party is split in to two ballrooms.  In one ballroom, 25% of the people have the flu.  In the other, only 2% of the people have the flu.  Which ballroom do you want to be in?
 
Certain communities have a higher prevalence of HIV than others.  Men who have sex with men are at greater risk not simply because anal sex is a high risk activity - there are more men who have sex with men living with HIV.  In San Francisco, gay and bi men have a 1 in 4 chance of having sex with a man who is HIV-positive - that's 25% of the ballroom.  Other communities are disproportionately affected by HIV, such as black Americans.  Although we're striving to live in a color-blind world, people will date within their culture.  When one particular community has a high prevalence of anything, whether it be HIV, Chlamydia, or H1N1, people in that community are going to be at a higher risk for the possibility of infection.
 
Bulls Eye - Targeted HIV Prevention Efforts
 
With prevalence higher in some communities than others, targeted HIV prevention efforts are essential.  Letting at-risk individuals know that the likelihood for HIV infection is higher in their community emphasizes the importance of safer sex and safer injecting drug skills.  Outreach efforts inform community members of places to access syringes, condoms, safer sex supplies, testing sites, and services for those living with HIV.  They also can empower members of these sometimes marginalized communities.  It's important for a person to feel they are worth protecting.

Mental Health - From Janitor to CEO
 
"Are you worth protecting?"  This may be simple to answer for some.  Others may struggle to answer that question.  Others, still, struggle with their self worth, body image, and mental health.  Just telling someone they're worth it sounds insincere.  Especially if it is coming from an outreach worker who may not know that person very well.   Therefore, encouraging a positive mental health can play a vital role in the prevention of HIV.  Studies have shown how those struggling with depression or poor self-esteem are more likely to engage in risky sexual behaviors that put them at risk for HIV infection.

Emphasize the important of mental health to those in your life.  Let them know that there is no shame in having emotions that are typically viewed by society as inappropriate.  They shouldn't be embarrassed to be depressed, angry, or sad.  Those are valid feelings and each person has a right to them.  Validating experiences and feelings can lift self-esteem, which in turn can encourage empowerment, which in turn could lead to safer behaviors, which in turn could prevent another case of HIV transmission.
 
Prevention for Positives
 
Yes, we want to stop people from becoming infected.  But what happens when someone becomes infected with HIV?  Sex lives don't end just because a person sero-converts.  HIV-positive individuals may lack safer sex and safer injecting drug skills.  Giving them the tools to prevent transmission is an incredibly important part of prevention.

Also, when someone tests positive, they don't magically understand everything about HIV.  Physicians may not provide an education for their patients.  People living with HIV should be offered the opportunity to learn about their disease and what are realistic transmission concerns.

Finally, by managing HIV disease, HIV-positive people are decreasing the risk of infecting others.  By adhering to their medications, they lower the amount of virus in the four fluids that can transmit the virus: blood, semen, vaginal fluids and breast milk.  With less virus in the fluids that can transmit HIV, the likelihood of transmission decreases drastically.  As medications are helping those with HIV live longer, there are more people living with HIV in the population as a whole.  To minimize new infections, prevention for positives is essential.

Train Spotting
 
Everyone has opinions on drug use.  We are each entitled to our opinion.  However, it is helpful to know about a public health concept known as "Harm Reduction".  Harm reduction was created because outreach workers identified that not everyone at risk for HIV is ready to stop injecting drugs or engaging in risky sexual behaviors.  These people are at risk for harm, particularly HIV infection.  Health officials have identified steps that can be taken to reduce the amount of harm/risk that can come to these individuals.

One example of an effective HIV harm reduction strategy has been the creation of needle exchange programs.  A needle exchange program lets drug users exchange used needles for clean ones.  Outreach workers are usually available to give HIV tests, provide HIV education, and make referrals to any services that may be helpful.
 
In the U.S., new HIV infections in Injection Drug Users (IDUs) account for 13% of new infections.  In Minnesota, for example, where needle exchange programs are legal, IDUs account for only 5% of new infections.  In cities where needle exchange programs exist, IDU infection rates are similar to this.  These statistics reflect the effectiveness of needle exchange programs and that, despite moral arguments, confronting the problem instead of ignoring it will make an impact.
 
PrEP + PEP = Sunblock + Aloe Vera
 
There are medications that can be administered within 72 hours after a known HIV exposure that can greatly reduce the likelihood of HIV infection.  This is known as Post-Exposure Prophylaxis (PEP).  It is a month long HIV medication regimen and can be prescribed in an emergency room.  This is not a morning-after pill for HIV.  It is prescribed for known HIV exposures and an assessment will be performed by the prescribing physician in order to determine if PEP is medically necessary or appropriate.  Some things to keep in mind about HIV medications - they are very expensive; in the U.S., a month supply of HIV medications can cost anywhere from $800 to $2,000. HIV medications are very hard on the body and can have serious side effects that disrupt daily life.  It is important educate about PEP so it can be utilized when HIV transmission may have occurred.
 
There is research going into Pre-Exposure Prophylaxis (PrEP), which is a preventative versus reactionary measure to prevent HIV transmission.  The theory is that a person whom continuously engages in high-risk behaviors would take HIV medications on an on-going basis to prevent HIV infection.  However, as of the time of release of this article, there has been no conclusive information about how it shall be administered.  Research is currently indicating this is an effective HIV prevention technique.

I'm Monogamous/I Have Unprotected Sex with a Sex Worker
 
If two people are having sex and neither one of them is HIV-positive, they can't become infected.  Monogamy, just like abstinence, is a method to prevent becoming infected with HIV.  When working in the sexual health field, it becomes obvious very quickly that people have varying definitions of monogamy.  With divorce rates over 50% in the U.S., it may be time to accept that relationships are going to be defined in a variety of ways.

What needs to be taken from that is that whether someone identified multiple partners as cheating, polyamory, open relationships, or sluttiness doesn't matter.  What matters are the behaviors people are engaging in non-monogamous relationships.  HIV prevention workers need to start those conversations.  More and more often, testing staff are giving positive results to people whom believed they were in a monogamous relationship.

You and your sex partners can help prevent the transmission with honesty.  Getting tested together is a great step to open the doors to honesty, but it doesn't end there.  Not all sex happens between two people that are in a long-term relationship.  Honesty is simple to ignore when having a one-night stand.  Honesty can save a life, though - yours or someone else's.  By sharing your risk behaviors with your sex partners, you are respecting them and yourself.  You're showing them that you believe sexual health is important.  You're showing them that you are sex-positive and ready to face the challenges that can arise as a result of sexual encounters.

By looking at HIV as a multi-faceted disease, you can see that there is a lot of work that needs to be done.  However, this isn't overwhelming.  These points have either already happened or are currently happening right now.  Help spread the message about HIV so your generation can be the last to be impacted by it.


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