HIV understandably causes most guys a fair bit of anxiety. Guys who are positive worry about potentially passing on the virus, and negative guys are afraid of getting HIV. Today, whether you are positive or negative, there are a number of ways to significantly reduce the chances of transmitting HIV. Get to know your options and use the ones that work best for you. In some situations, using more than one strategy at the same time may give you more piece of mind. Most important, take control of your prevention plan. Using the prevention strategies that work best for you will give you confidence and reduce stress, and make sex more fun and pleasurable.
Condoms remain one of our most effective prevention methods. When used properly, they are up to 90-100% effective. Condoms not only significantly reduce the risk of transmitting HIV, they also reduce the risk of acquiring other sexually transmitted infections like gonorrhea and Chlamydia. Condoms are also usually easy to find. They can be purchased at almost any drug store, and are often available and free for the taking at many sexual health clinics.
How to use a condom:
Have condoms on hand whenever you think you may need them. Check the expiry date to make sure they are still good to use, and check the wrapper to make sure they are still sealed. If the wrapper is damaged or open, don’t use the condom. Get another one.
When your cock or your partner’s cock is hard, depending on who is going to wear it, tear open the condom wrapper. Don’t use teeth or scissors as you may inadvertently cut the condom. Remove the condom from the wrapper and check which way it unrolls. You may want to unroll it just a little to make sure you have it right side out.
Place the condom over the head of the penis, and then unroll it down over the shaft. Make sure you unroll the condom all the way to the base of the cock. This will make it less likely to slip off.
Add lots of lube to the outside of the condom once it is on your (or his) dick. Use either water-based or silicone-based lube. You can really never have too much lube.
Fuck. It is a good idea to pause now and again to make sure the condom is still in place and hasn’t slipped off or broken. If you are fucking for a while, it is also a good idea to pause and add more lube.
When you are done, be sure to pull out before your (or his) dick gets too soft. Grab the condom at the base when you pull out to make sure it doesn’t slip off. Once out, pull the condom off your (or his) dick and throw it in the trash.
There are dozens of brands of lube to choose from, so experiment a little and find one that you like. The only important thing is that lube should be either water-based or silicone-based. It will be on the label. Don’t use oils or oil-based products as lube; such things as Vaseline, hand or body lotion, moisturizing lotions, baby oil or cooking oil like olive oil. These will damage condoms and cause them to break.
Some dos and don’ts:
Some guys find it difficult to maintain their erection once they put on a condom. If this happens for you, talk to your doctor about Viagra or Cialis to see if they help.
Some guys are allergic to latex and so can’t use usual condoms. Latex allergies usually manifest as skin irritation (redness and itching) wherever the skin comes in contact with latex. Latex-free condoms are available, although they often cost a little more. Polyurethane condoms are made of thin plastic. They may not fit as tightly as latex condoms so pay particular attention that they don’t slip off while fucking. Polyisoprene condoms are made of synthetic rubber. They do have better stretch and so they usually fit better. Non-latex condoms available in Canada include Druex Avanti Bare, Lifestyles Skyn, and Trojan Supra.
PrEP: HIV Pre-Exposure Prophylaxis
PrEP is an effective way for HIV-negative guys to reduce their risk of getting HIV. It involves taking anti-HIV medication, one pill once a day. Each pill contains two medications, tenofovir-DF and emtricitabine. These medications prevent HIV from replicating. The idea is when HIV-negative guys take PrEP and have these medications already in their system, if they are exposed to HIV, the medications will block the virus and prevent infection. Several studies have shown PrEP is very effective, somewhere around 90%. That means of course that it is not perfect, but PrEP does substantially reduce the chances of getting infected, and when combined with other prevention strategies can add an effective extra layer of protection. The medications tenofovir-DF and emtricitabine combined in a single pill is marketed under the brand name Truvada, but is also available in Canada in generic form.
If you think you are at risk of contracting HIV, PrEP may be something to consider. PrEP is a good way for HIV-negative guys to reduce their chances of getting HIV and to take personal control of their sexual risk. PrEP may be worth considering if you don’t always use condoms and:
- you have sex outside a monogamous relationship
- you don’t know the HIV status of your partner or partners
- you have sex when you are drinking or high
- your sexual partner is HIV-positive and you are not absolutely certain he is on HIV medication and has an undetectable viral load.
You might also consider PrEP if thoughts of HIV make you really anxious. Many guys are so worried about HIV that it is all they think about during sex, or they end up feeling anxious for days after sex. In a recent survey of gay guys in Ottawa, 50% reported being stressed about HIV frequently or always during sex, and 60% felt stressed frequently or always after sex. Once they started PrEP, the anxiety almost disappeared. Only 1.7% reported feeling stressed frequently or always during sex, and no one reported feeling stressed frequently or always after sex.
PrEP involves taking one pill once a day. You should take it roughly every 24 hours, either with or without food. It is important to take PrEP every day, that way you will maintain the required amount of medication in your body to prevent HIV from replicating and establishing an infection. Research has shown PrEP is most effective when it is taken daily.
The majority of guys who go on PrEP report no side effects at all. In a survey of guys using PrEP in Ottawa, 8% reported nausea and 6% reported diarrhea in the first few days after starting PrEP. In all but one, these side effects went away after a few days.
It is important to know that PrEP can affect your kidneys. This occurs in about 2% of people taking PrEP. Unfortunately, if your kidneys are in trouble you will not have symptoms, so it is important to check your kidneys regularly with a blood test. If you take PrEP, you will need to see your doctor once every 3 months to have a blood test to check your kidneys and to get an HIV test.
PrEP can also cause a small amount of osteoporosis, or thinning of the bones. For most healthy guys, the amount of osteoporosis caused by PrEP is not significant. If you already have osteoporosis or bone disease, talk to your doctor about this before you start PrEP. If you are concerned, taking vitamin D can be a good idea.
Lastly, if you have chronic active hepatitis B, PrEP gets a little more complicated. If you have a hepatitis B infection, it is a good idea to get your PrEP from a doctor who also has experience treating hepatitis B.
No. PrEP does not protect against any other sexually transmitted infections except HIV. PrEP has no effect on the transmission of gonorrhea, Chlamydia, syphilis, or hepatitis C.
As for all medications, you will need a way to pay for PrEP. The brand Truvada costs about $1200 per month. Luckily, the generic forms are just as effective and are much cheaper at about $250 per month. Most, if not all, insurance companies cover PrEP, so if you have one, check with your extended health benefits program. Most programs cover 80-100% of the cost of the medication meaning you may have to pay up to $50 per month. If you are under 25 years of age in Ontario PrEP is covered by OHIP+. Similarly, if you are over 65 PrEP will be covered by your Ontario senior’s drug plan. PrEP is also on the Ontario Drug Benefits formulary for those on social assistance, and if you have additional high drug costs you can apply to the Ontario Trillium program for assistance with drug payment. PrEP is also covered by First Nations and Inuit Health.
Any doctor or nurse practitioner can prescribe PrEP, but not all are familiar with the medications. Start by talking to your regular healthcare provider or check with your local sexual health clinic. The Ontario Gay Men’s Sexual Health Alliance has compiled a list of healthcare professionals in each part of Ontario who provide PrEP. You can find the list online at The Sex You Want.
PEP: HIV Post-Exposure Prophylaxis
If you are HIV-negative and you think you have been exposed to HIV, PEP is a way to reduce your chances of becoming infected. Sometimes when we are having sex with other guys we get carried away in the moment and forget, or chose not, to use a condom. Sometimes condoms break or slip off, and sometimes we may be drunk or high and condoms don’t enter the picture. If you think you have been exposed to HIV in a way that could result in you becoming infected, you can use PEP. PEP involves taking anti-HIV medications starting as soon after the exposure as possible and continuing for 28 days. Different HIV medications may be used, but you will most likely be prescribed one or two pills to be taken once or twice a day. The idea is to get the medications into your system as soon as possible and allow them to stop HIV from replicating and establishing an infection. Like anything in medicine, PEP is not perfect, but it is considered highly effective.
You should take PEP if you are HIV-negative and think you have been exposed to HIV in a way that could result in you becoming infected. Usually, this means fucking without a condom, either as a top or a bottom, with someone you are not absolutely sure is also HIV-negative. It is essential that you start PEP as soon possible. PEP becomes less and less effective with each passing hour and will not be prescribed if it has been more than 72 hours since the exposure. If you think you have been exposed to HIV go immediately to the nearest hospital’s emergency department.
You can get PEP at the emergency department of any hospital. In Ottawa, you can also get PEP at the Sexual Health Clinic on Clarence St in the Market. Tell the person at the intake desk that you may have been exposed to HIV and that you need PEP. That way they will know a doctor or nurse needs to see you quickly. When you see the doctor or nurse, they will ask you what happened, who you were having sex with, and how long ago the exposure occurred. This will all help determine if PEP is necessary. They will also do some blood tests including an HIV test. A number of different HIV medications can be used for PEP, so the ones you are given may vary depending on where you go to get them. Regardless, you should always be given your first dose right there in the emergency room, and then provided with a prescription to obtain the remaining 28 days of medication. You should also receive a follow up appointment to be seen in a clinic with experience providing PEP. PEP medications are expensive, often costing about $1500. Most insurance companies and extended health plans will cover all or a portion of the cost. If you don’t have a way to pay for the medications, tell the healthcare provider you see. They may be able to help find ways to get some of the cost covered.
Take your PEP exactly as prescribed. That will usually mean taking one or two pills once or twice a day, depending on which medications are used. You will have to take these medications for 28 days. It is important that you take all the doses every day. PEP becomes ineffective if you skip doses or stop taking it.
The medications used for PEP today are generally very well tolerated with very few, if any, side effects. Some people experience some nausea or loose bowel movements after the first few doses. If these occur, they usually go away within a few days. Unfortunately HIV medications have a bad legacy based on the old drugs used in the 1980’s and 1990’s, which were very difficult to take. Don’t let these old stories discourage you from taking PEP if you need it. If the medications you are given do cause side effects, tell your doctor. Today, there are plenty of HIV medications to choose from.
It is important that you follow up with your doctor or a clinic experienced in providing PEP while you are on the medications and for a few months after. Although PEP is considered effective, it is not 100%. It is very important that you do an HIV test after completing your PEP medications to be sure you did not get infected. This test should be done by taking a vial of blood from your vein (not by a finger prick rapid test) 8 weeks after you complete the medications (12 weeks after the HIV exposure). During these 12 weeks you should use condoms during sex. If you are thinking of starting PrEP you should wait until you get a negative HIV test 8 weeks after completing PEP.
Treatment as Prevention and Being Undetectable
“Undetectable” describes the situation where someone living with HIV is taking anti-HIV medications (antiretrovirals) that have effectively reduced the amount of HIV in their blood to levels that can no longer be detected. If someone is infected with HIV and does not take antiretroviral medications the virus is free to replicate and spread through the body reaching levels of a few thousand to several hundreds of thousands of viruses per milliliter of blood. When this happens, HIV is present in bodily fluids, like cum and rectal fluids, and can be transmitted during sex. Antiretroviral medications are very effective at shutting down the virus. They prevent HIV from replicating and keep it inactive. When HIV is “locked down” by these medications, the amount of virus in the blood declines eventually becoming so low it can no longer be detected. This is what it means to have an undetectable viral load, or to be “undetectable”.
When someone with HIV is on effective antiretroviral therapy, and has an undetectable viral load, they do not pass on HIV to their sexual partners. The best data supporting this comes from the PARTNER-2 study, results of which were released in the summer of 2018. The PARTNER-2 study followed 783 gay couples in Europe where one partner was HIV-negative and the other partner was HIV-positive on antiretrovirals with an undetectable viral load. These couples collectively reported 70,743 episodes of anal sex without a condom with no evidence of HIV transmission from the HIV-positive partner with an undetectable viral load to his HIV-negative partner. During the study, 15 of the HIV-negative men did become infected. Each of these HIV infections appeared to be linked to sex with men other than their partner.
These data then indicate that HIV-positive guys on antiretroviral therapy with an undetectable viral load effectively do not pass on HIV to their sexual partners. If you are positive, it is very important that you take your HIV medication every day and don’t miss any doses, and have your viral load checked regularly. To avoid transmitting HIV your viral load must be consistently undetectable. Going on and off your medication will allow the virus to replicate and populate bodily fluids, and also risks development of resistance.
HIV is efficiently transmitted by sharing needles and the works used to prepare drugs for injection. If any blood containing HIV is introduced into a needle or the works, the virus will be passed on to the next person using these articles. If you inject drugs, including recreational drugs or steroids, always use a clean needle. Make sure the needle is in a sealed package that has not been opened. Also, for recreational drugs, keep your own private works for preparing your drugs.