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Home , HIV, Safe sex, Serodiscordant

A 2007 Reproductive Matters. All rights reserved. Matters 2007;15(29 Supplement):67–92 0968-8080/06 $ – see front matter www.rhm-elsevier.com PII: S0 968 -808 0(07 )2 90 34-2 www.rhmjournal.org.uk

Sexual Health for People Living with HIV Kathy Shapiro,a Sunanda Rayb

a Independent consultant, New Delhi, . E-mail: [email protected] b physician, Brighton and Hove Teaching Primary Care Trust, Brighton, UK

Abstract: Sexual health is defined in terms of well-being, but is challenged by the social, cultural and economic realities faced by women and men with HIV. A sexual rights approach puts women and men with HIV in charge of their sexual health. Accurate, accessible information to make informed choices and safe, pleasurable sexual relationships possible is best delivered through peer education and health professionals trained in empathetic approaches to sensitive issues. Young people with HIV especially need appropriate and support for dealing with sexuality and self-identity with HIV. Women and men with HIV need , appropriate services for sexually transmitted , and management of cervical and anogenital . Interventions based on positive prevention, that combine protection of personal health with avoiding HIV/STI transmission to partners, are recommended. HIV counselling following a positive test has increased use and decreased coercive sex and outside sexual contacts among discordant couples. HIV treatment and care have reduced stigma and increased uptake of HIV testing and disclosure of positive status to partners. High adherence to antiretroviral therapy and safer sexual behaviour must go hand-in-hand. Sexual health services have worked with peer educators and volunteer groups to reach those at higher risk, such as sex workers. Technological advances in diagnosis of STIs, microbicide development and screening and for human papillomavirus must be available in developing countries and for those with the highest need globally. A2007 Reproductive Health Matters. All rights reserved.

Keywords: sexual health, HIV sexual transmission, sexually transmitted infections, cervical and anogenital cancers, sexuality education, condoms, safer sex

‘‘Sexual health is a state of physical, emotional, IOLOGY, history, politics, religion and law mental and social well-being in relation to sex- interact to regulate sexual expression in ways uality; it is not merely the absence of disease, Bthat may promote or undermine health, and in dysfunction or infirmity. Sexual health requires many countries these may target or affect people a positive and respectful approach to sexuality living with HIV in particular ways. Poverty, atti- and sexual relationships, as well as the possibility tudes towards sexuality and gender power rela- of having pleasurable and safe sexual experiences, tions, and tensions between individual rights to free of coercion, discrimination and violence. privacy and self-determination and the rights of Sexual rights embrace human rights that are already recognized in national laws, interna- tional human rights documents and other con- *These definitions were elaborated in a WHO-convened sensus statements. They include the right of all international technical consultation on sexual health in persons, free of coercion, discrimination and vio- January 2002, and subsequently revised by a group of lence to the highest attainable standard of sexual experts from different parts of the world. They are not health, and to access to sexual and reproductive official WHO definitions, and should not be used or health care services.’’1* quoted as such.

67 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 partners, families and communities as regards the cordant relationships); access to condoms and practice of safer sex also influence sexual health. lubricants and information on how to use them; The sexual rights of people with HIV are often guidance on other safer sex practices; infor- not recognised or respected. Poor communica- mation on re- with HIV; and regular tion by and with health care providers on sexual health check-ups to treat STIs and opportunis- issues mean that informed choices may be lim- tic infections, cervical and ano-genital ited and services not offered. Certain religious screening, and counselling and treatment for leaders and faith-based organisations emphasise sexual dysfunction.2 or promote only sexual for young Based on the literature, this paper examines and unmarried people in spite of evidence that the sexual health needs of adolescents, young many are having unsafe sex and may have HIV, people, women and men living with HIV and and need information and the means to pro- how these can best be met through health poli- tect themselves and their partners from sexu- cies, programmes and services.5 ally transmitted infections (STIs) and women partners unwanted . In many settings, people with HIV are expected not to have sexual Sexual health and sexuality education for lives, and their sexual health needs and rights HIV positive adolescents and young people may not even be considered. People living with The impact of HIV therapies is particularly note- HIV may be among the least able to access health worthy among HIV-positive who have been services, yet are among those at highest risk for infected perinatally or through products. sexual health problems. They need information Significant numbers of youth now treated in on how to look after their health in ways that adolescent HIV clinics in the USA, for example, put them in charge of looking after themselves have ‘‘graduated’’ into these programmes from and able to protect their partners and families.2 paediatric HIV clinics. Such longevity was unthink- Programmes to improve sexual health for able a decade ago, when most HIV positive chil- women, men and young people with HIV have dren died before their tenth birthday. Further, to take into account a person’s actual sexual people diagnosed during adolescence now sur- relationship(s) in the context of their lives and vive well into their 20s, with many maturing into socio-economic situation, and their need for their 30s.6 information. The concept of ‘‘positive preven- It is critical to understand the developmental tion’’ endorses the right of HIV positive people stages and changes of adolescence in developing to have a healthy sexual life, access strategies outreach and care strategies. Relevant changes to support and protect their sexual health, pre- among younger teens include physiological growth vent and treat STIs and maintain good health and maturation, intense sexual feelings, movement with antiretroviral treatment and other health away from dependence on parents to peers, and care. Positive prevention is also about positive understanding of cause and effect. Girls start their people acknowledging they have a crucial role menstrual periods and boys’ sex organs mature, in controlling the HIV and avoiding and as they get older, youth increase their ability transmitting HIV to others, while also having to take responsibility for their own actions but rights to health and safer sex of their own.3,4 also have periods of self-consciousness and self- Positive prevention requires a supportive, non- criticism, bouts of low self-esteem, mood swings discriminatory environment for people to learn and an increased desire for independence. Being their HIV status, disclose it to partners, access HIV positive complicates being young and con- non-judgemental treatment and care, and receive fronting sexuality for the first time.6 respect from their partners, family, community HIV positive young people are a diverse group, and peers. differing in age, gender, , race To be able to enjoy safer sexual lives, people and ethnicity, educational attainment, economic with HIV have requested sexual health educa- circumstances and cognitive abilities. They expe- tion; help to gain skills to negotiate ; rience differing rates of mental illness, chemical long-term supportive counselling that addresses dependency, social isolation and lack of economic the risk of HIV/STI transmission to regular and opportunity. HIV positive youth are more likely casual partners (both in sero-discordant and con- to be female, men who have sex with men, from

68 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 racial and ethnic minority populations, and from Research shows that school-based sexuality economically deprived groups than their HIV education programmes for youth: negative counterparts. High-risk sexual behavior  reduce stigma and discrimination as well as is the dominant mode of HIV transmission among STIs, HIV and ;9 youth. HIV positive young men are much more  do not encourage early sexual activity in ado- likely to have acquired the through same- lescents or increase the number of their sexual sex contact, including unprotected anal inter- partners;10,11 and course, and in some cultures also sexual contact  can increase knowledge and reduce risk with older women. HIV positive young women are behaviour.12,13 more likely to have been infected through hetero- sexual activity, such as unprotected vaginal and Theliteratureisrepletewithdescriptions anal intercourse, often with (young) men older of prevention interventions aimed at increasing than themselves. High-risk sexual behaviour is knowledge and understanding of sexuality and common among youth, primarily associated with sex-related issues for adolescents and young a culturally prevalent expectation of sexual inter- people – involving schools, peer counselling, action among this age group.6 Yet the adult and drama and the internet. All of them assume that parent world often wish to deny and ignore why the adolescents and young people being tar- young people become HIV positive. geted are HIV negative, however, and there are few evaluations of interventions targeting HIV ‘‘... young people are, at times, abandoned by positive young people. Yet 25% of all new HIV their parents, society and the church to learn infections globally are in adolescents and young by themselves the life skills which sexual rela- people, especially in high settings, tionships require... to wither and die through and children who have had HIV since infancy ignorance, the absence of open, honest and com- need information and support as they become passionate sharing of vital information, and adolescents and young adults. our embarrassed silence and resistance to real- An HIV positive youth at the International ity.’’ (Njongonkulu Ndungane, Archbishop of AIDS Conference in Toronto in August 2006 Cape Town)7 pointed out that the difference between HIV Knowledge is critical for adolescents and young prevention for HIV negative youth and AIDS people to protect their health. Paucity of sexual prevention for HIV positive youth is often not and services tailored to adoles- addressed, and there is almost no one teaching cents and youth at risk, many of whom are out positive adolescents about sexuality with HIV of school and unemployed, contributes to high (Marge Berer, Editor, RHM, Personal commu- rates of STIs, HIV and unintended pregnancy. nication, April 2007). Adolescents need prepa- Young people seek and welcome this informa- ration emotionally and practically for taking tion, as a recent cross-sectional survey of inter- antiretroviral . As regards relationships, there net use among 500 school-going adolescents aged are special disclosure issues – even if adolescents 12–18 years in Mbarara, , shows. The have never had intercourse and may not be ready majority of youth in this rural area of Uganda for it, should they tell a new partner they are expressed the need for such information. Some positive before or after the first ? Thus, there 35% (173) had used the internet at home to find are sexual and reproductive health issues rele- information about HIV and AIDS, and 20% (102) vant to young HIV positive adolescents that need had looked for sexual health information. If to be mapped with them and appropriate pro- internet access were free, 66% (330) reported that grammes developed. they would search for information about HIV/ Young African women with HIV recently pri- AIDS prevention online.8 Youth from homes with oritised non-judgmental, skills-based training less education had less access to the internet and on relationships, sexuality and , therefore to information. Yet young people did and assertiveness training, nego- not appear to be encouraged to access this infor- tiation skills for safer sex, and information on mation while at school; going online at school the safety of different sexual practices.7 In spite was inversely related to looking for HIV/AIDS of national commitments to support adolescent information via technology. sexual health and end the HIV epidemic, these

69 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 needs are still not being met in most countries that focuses on health education, testing and of the world today. counselling, HIV care and follow-up, STI care and Instead, national sexual health programmes for . About 1,700 young people aged young people in a number of African and other 12–25 visit monthly. Every young person need- countries funded under US PEPFAR money or ing STI treatment is strongly encouraged to learn run by faith-based organisations are promoting their HIV status, and 26% of those tested so far only. A condition for receiv- have been HIV positive. The majority of young ing PEPFAR money is that the funds may not people first come for family planning, which be used to physically distribute or provide con- gives an excellent opportunity to discuss condom doms in school settings orformarketingefforts use and safer sex. Follow-up for HIV positive to promote condoms to , nor in any set- youth with low CD4 counts has been increased ting to promote condoms as the primary inter- to once monthly to assure continuing sex edu- vention for HIV prevention.14 cation and support. This has overwhelmed staff workloads but this problem is being addressed ‘‘It is not possible to promote condoms only for high by encouraging more HIV support groups for risk people without stigmatising both the people and young people.19 condoms, and it also jeopardises promoting condom Also in , the UN Development use for contraception. Everything possible must be Programme has initiated three pilot projects that done to reduce negative messages about condoms. involve HIV positive youth, in the provinces of Everyone involved in HIV/AIDS needs to reflect on Limpopo, KwaZuluNatal and Eastern Cape, in their own work in relation to this new climate and partnership with national and provincial depart- ensure that all prevention options are widely ments of health, the Department of Social Deve- available, correct information is given and condoms lopment, and UNFIP, UNICEF and UNFPA. These are available for everyone who needs them.’’15 are pilots for a programme by and for HIV posi- While many young people, both positive and tive youth aimed at involving them in NGOs negative, may welcome programmes that sup- providing community and home-based care and port not having sex, abstinence is hard to sus- support, promoting behavioural change by involv- tain as a ‘‘forever’’ or long-term option. In the ing them in action research on sexual attitudes USA, oral gonorrhoea is higher in young people and behaviours, the acquisition of life skills and who have been taught only about abstinence.16 the relationship between HIV risk and sexual vio- Interviews with ten HIV positive young women lence, and involving them in local employment and men aged 17–24 years in Sweden found situations to equip them with the skills to enable that ‘‘cultures of silence’’ surrounding sexuality them to better manage their status, and to enhance were critical in making them vulnerable to HIV their potential for employment.20 infection, alongside lack of adult supervision Ongoing health maintenance, monitoring of when they were children, naRve views, being in immune function and , providing edu- love, alcohol and drugs, a macho ideal and gender cation about HIV and risk reduction, providing differentials as regards sex affecting both consen- access to treatment, identifying and addressing sual and forced sex.17 psychosocial needs and depression, promoting A rights-based approach in the case of adoles- skills to live independently and to make the cents is based on the recognition of the right of transition to adulthood, treating STIs, providing adolescents to full and accurate sexuality infor- contraceptives and condoms, support for child- mation and education as means to ensure that care, and reinforcing and sustaining safer sex they ‘‘have the ability to acquire knowledge and behaviours are all important elements of youth- skills to protect themselves and others as they friendly services for young people with HIV.21 begin to express their sexuality.’’18 Barriers to health care for HIV-infected young A growing number of NGO-led projects for people include lack of financial resources, mis- young people may serve as models for implement- trust of health care professionals, difficulty ing a rights-based approach for national pro- negotiating the health care system, complicated grammes to adapt and scale up. The Me´de´cins treatment regimens, lack of providers with exper- Sans Frontie`res South Africa Khayelitsha Project tise in both HIV and adolescent medicine, and has operated a youth-friendly service since 2004 concerns about confidentiality and disclosure.

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Laws and institutional policies governing ado- HIV counselling and testing, disclosure of lescents’ rights to confidentiality and consent HIV positive status and partner notification may not even exist. Fear and denial may also The majority of people with the highest play a part. Research in the USA has pinpointed of new HIV infections (adolescents, sex workers, the following components of youth-friendly ser- men who have sex with men, and vices for HIV-positive youth: users) are unaware of their HIV status. They need  Flexible hours, including weekends and eve- access to sympathetic HIV counselling and test- nings, to lessen conflicts with school or work. ing services to learn their and how  Walk-in appointments, to encourage use of to maintain their health if they are positive. Over services. half of new HIV infections in the USA were spread  Accessibility through convenient locations near by HIV positive people who were unaware of their public transport, travel vouchers and transpor- status. Once they knew, they reduced their high- tation assistance for rural youth. risk practices by half.22 In , and  Intensive case management to assist with dis- Trinidad, after learning their HIV status, discor- closure and partner notification, and to link dant couples increased condom use and decreased youth to care, sexual contacts outside the relationship.23–26 In treatment, housing as needed. Rwanda, intensive male-focused counselling and  Active involvement of young people in all testing dramatically increased condom use and aspects of programme planning, operations decreased coercive sex at one-year follow-up, com- and evaluation. pared to those receiving conventional counsel-  Staffing, at least in part, by members of the ling and testing.27 InaZambiastudy,condomuse target population. increased from less than 3% to more than 80%  Culturally competent staff who are sensitive after counselling and testing, and was sustained to youth culture and to racial and ethnic cul- over the 12 months of the study, although there was tures as well as to issues of gender, sexual ori- substantial under-reporting of unprotected sex.28 entation and HIV status. Few HIV care programmes offer sexual and  Services appropriate to those being served, reproductive health services at all, but where e.g. street outreach for homeless youth and they do, providers may not offer sufficient infor- tailored support groups for gay, , bisex- mation for considered decision-making.29 When ual, transgender and questioning youth, sub- care and treatment for HIV and STIs are com- stance users, and adolescent parents. bined with education in suitable settings, directly  Youthful and welcoming de´cor, materials and or through referral, the opportunities for reaching atmosphere. people with HIV are increased with greater impact  Informational materials appropriate to the lan- on reducing further transmission. UNAIDS/WHO guages and literacy levels of the youth served.21 have demonstrated the potential for increasing LARRY TOWELL / MAGNUM PHOTOS Picnic organised by Me´de´cins sans Frontie`res for HIV patients, Peru, 2005

71 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 prevention, treatment and care synergies as more in order to protect the partner and others from risk people get tested in order to access life-saving of death or serious harm, but not those, including antiretroviral treatment, and more people on treat- relatives, who are not at risk of infection.36 ment are brought back to health.30 In and Non-disclosure of HIV status to sexual part- South Africa, introduction of HIV treatment and ners has been a fraught area for health profes- care reduced stigma, increased uptake of coun- sionals as they have witnessed partners of positive selling and testing and disclosure to partners.31,32 people becoming infected out of lack of know- Fear of the consequences of disclosure of HIV ledge. Women have acquired HIV through sexual to a partner may hamper communication around transmission without realising their partners were sexual issues. Disclosure and attempts by positive also having sex with men or injection drug users, women and men to use condoms to protect their thus at higher risk of HIV.37,38 Knowledge of part- partners are often met with anger or disbelief.33 ner status may not protect women who do not A study among French emphasises the have the social or economic independence to with- need to encourage communication and HIV dis- draw from relationships, or the power to refuse closure in HIV-discordant gay couples. Where unprotected sex. Problems arise where disclosure HIV-positive partners had not disclosed their is accompanied by blame, violence, betrayal and status to their HIV negative or untested regular bitterness. ‘‘Shared confidentiality’’, i.e. revealing partners, unprotected sex was more likely. Binge- sensitive information such as HIV status to defined drinking also made inconsistent condom use more groups such as family or close community members likely in HIV discordant partnerships.34 in order to support the affected person, e.g. with WHO and UNAIDS have pointed to the fear home-based care, has assisted families to come to of disclosing HIV positive status to health care terms with HIV through an emphasis on mutual workers in order to receive appropriate and timely benefit and support. Health professionals, peer care; to families and communities in order to get facilitators and family mediators, such as from psychosocial and practical support; and to sexual faith-based organisations, can assist families and drug-injecting partners, to prevent onward to mitigate the impact, especially where benefits transmission of HIV. Several years ago they called accrue with disclosure such as STI and antire- for the promotion of ‘‘beneficial disclosure’’ and troviral treatment.39,40 ‘‘ethical partner counselling’’ as crucial steps to reducing stigma and creating a more open, accept- ing social environment. Criminalisation of those Sexual transmission of HIV, safer sex and who have not disclosed their status and may risk reduction have transmitted HIV is considered as counter- For people with HIV, the importance of safer sex productive. Beneficial disclosure is voluntary, with an HIV negative or one with respectful of the autonomy and dignity of people uncertain status (an HIV rela- with HIV, maintains confidentiality and empha- tionship) is for self-protection from STIs and to sises benefits to both partners. This can be achieved protect the partner from becoming HIV infected. through counselling and testing services, work- Between two people with HIV (an HIV serocon- place policies and community care but only if cordant relationship), the aim is to protect each health workers are trained, supervised and sup- other from STIs and re-infection. In an HIV discor- ported in their work as well. Ethical partner coun- dant relationship, making sure the HIV negative selling involves confidentiality and informed partner or partners, whether regular or casual, consent for disclosure by the person with HIV, remain negative is particularly challenging. with strong professional efforts to persuade them The risk of sexual transmission of HIV increases to notify partners. In recognition of the serious if the HIV positive partner has a high viral load, consequences of partners not being informed and e.g. during in the early stages thereby putting others at risk of infection, WHO/ of HIV infection and during late-stage disease. UNAIDS advise that health care providers may Between these stages the risk of infection is still counsel the partners of positive people without present, but can be considerably lower.41 Con- their consent after an ethical weighing of possible current STIs facilitate HIV transmission through harm.35 The General Medical Council in Britain genital ulcers, of vaginal and anal similarly permits disclosure by a health professional tissue and under the foreskin of the , and

72 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 concentration of HIV in STI-related discharge and encounters seroconversion was more likely to secretions. Women who have unprotected vaginal be explained in terms of pleasure, lack of con- sex and both men and women who have unpro- trol and related to particular sexual settings. The tected anal penetration are more vulnerable bio- ways in which men understood their HIV infec- logically than men who penetrate their partners.42 tion were informed both by the risk discourse Adolescent girls are at higher risk in unprotected of HIV researchers and also by the discourses of penetrative vaginal sex because of immaturity of love, pleasure and control.44 the genital tract. The increased vulnerability of Certain health educators, governments and the recipient of results from the larger sur- faith-based organisations have been inclined to face area of the or relative to the give simple ‘‘do’’ or ‘‘don’t do’’ messages, includ- penis and the longer period during which semen ing ‘‘ABC’’, but the reality is more complex. remains in contact with tissue. Rough, forced sex Decisions based on safer sex information require can cause abrasions and bleeding, enhancing some understanding of biological principles of transmission of HIV and . disease transmission, while many cultures oper- The ability to practise safer sex depends on ate with different belief systems of health confidence, communication and trust in the part- and disease. Behavioural factors include sex ner and the relationship. These characteristics between older, more sexually experienced men may or may not be present; indeed, sex may take and younger women (and vice versa), having place with little or no communication whatso- more than one partner, having multiple part- ever and/or may be coerced. Health care workers, ners (as with selling sex), and frequent partner counsellors and educators need training and change. Loss of self-control leading to unsafe possibly sexuality education themselves in order sex may occur under the influence of alcohol or to address sexual issues with HIV positive people drug use. Sex workers often do not use condoms professionally, in a sex-positive way and with- with lovers in order to differentiate them from out judgment. Discussing sex is taboo in many commercial clients.45,46 Where sex between men cultures, making the delivery of education to or with transgender people is criminalised or health workers and the discussion of safer sex stigmatised, which is still the case in most deve- by them with people living with and at risk of loping countries, the need to hide these relation- HIV very difficult. ships from neighbours and family may lead to Safer sex promotion can only be effective if quick, unprotected sex in places like secluded it considers people’s real-world sexual desires 43 cruising areas, which mitigates hugely against and activities. Case histories of how people in developing steady partnerships.47 Safer sex is diverse HIV serodiscordant relationships have far more complicated to promote and practise in become infected (e.g. both among male factory all these situations. workers in and gay men in the USA) Not having sex at all is of course the safest indicate areas for intervention such as improving path but of no help for those who wish to have perceptions of risk, addressing the link between sex or are forced to do so. Based on biological prin- low self-esteem, loss of control and unsafe sex, ciples of disease transmission, safe(r) sex refers to and teaching ways to show love and intimacy sexual activities that avoid or reduce exchange of that incorporate condom use and other safer body fluids (semen, blood, vaginal fluids), avoid sex practices.39,40 The risk discourses of HIV genital-to-genital contact and reduce risk of STI researchers and educators may be different from and HIV transmission, including re-infection. The those in the narratives of HIV positive people in most effective forms of safe(r) sex are: their own seroconversion. A case-series study of seroconversion in Australia, in which men who  Non-penetrative sex (no penetration of the had seroconverted were asked to give an account vagina, anus or mouth by the penis) including of the occasion on which they believed they were , mutual masturbation, kissing, infected found that the reasons they gave for their sex-talking, and other forms of touch- HIV infection varied depending on the context. ing and stimulation. Within regular relationships, breakdown of nego-  Mutual or polygamy between part- tiated safety, love and intimacy, and fatalism were ners with no pre-existing infection. Protection among the explanations given. In casual sexual depends on each partner being faithful, and

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no partner having a relationship outside the uals (110 women and 25 men) in a sexual rela- couple or circle. tionship with a person with HIV, in a study in  Use of male or female condoms alone, in- Spain conducted between 1990 and 2000.52 Oral cluding for vaginal and and non- sex on a woman is considered even lower risk lubricated male condoms for . than on a man, and avoiding menstrual blood is sometimes suggested.51 Minimising risk can be There are also risk reduction approaches that achieved by use of condoms or other latex or are somewhat safe or safer than others rather polyurethane barriers over the or anus, than ‘‘absolutely safe’’, and their efficacy and avoiding oral sex when the positive partner is acceptability will vary considerably. Evidence likely to have higher viral loads and may be more shows that consistent and correct condom use is infectious, when there is inflammation caused by the most effective risk-reduction strategy. Other common throat infections, allergies or STIs such risk reduction strategies, with differing and in as gonorrhoea, or bleeding gums or sores in the some cases uncertain degrees of efficacy include mouth or throat of the recipient, and avoiding withdrawal, oral sex, male circumcision for HIV into the recipient’s mouth if the giver negative men, maintaining a low viral load 53 48,49 is HIV positive. through antiretroviral therapy and sero-sort- A 2005 study demonstrated the ability of HIV ing (people with HIV seeking relationships with antiretroviral therapy to reduce heterosexual positive partners). transmission of HIV in discordant couples by Withdrawal () has been used 80%48 but the investigators and others have cau- for centuries as a risk reduction method for pre- tioned that even a small increase in sexual risk- venting pregnancy. Since the early days of the taking could cancel this out. Moreover, while HIV epidemic it has also been used by gay men mathematical modelling has also shown that (or the variation of temporary and partial pene- 50 reduced viral load may reduce risk in individual tration without a condom), e.g. in Australia, cases, in settings such as Uganda, with limited for risk reduction. Withdrawal does not protect access to antiretroviral therapy, and because only against other STIs, and its efficacy for HIV risk people with advanced disease receive therapy, it reduction has never been studied. is unlikely to have an impact on the epidemic Oral sex is an exciting alternative to penetra- at population level.49 tive sex for many people. It is difficult to study The is the primary site of infection HIV transmission through oral sex because most for gonorrhoea, and human papil- people engage in other sexual activities as well, lomavirus and has more HIV receptors than the though most STIs other than HIV (e.g. , vagina.54 Cervical barriers such as the diaphragm herpes and gonorrhoea) are transmissible orally. and cervical cap have been in use for decades for The current consensus is that unprotected oral sex contraception. The diaphragm has been shown to is an effective risk reduction strategy compared decrease rates of gonorrhoea, chlamydia and pelvic to unprotected anal or vaginal penetration. The inflammatory disease and results are pending of a UK’s Service estimates clinical trial of the All-Flex diaphragm to prevent that 1–3% of HIV cases may be due to oral sex. HIV transmission.55,56 Newer barrier devices are One American study on the risks of HIV transmis- also now available. sion from oral sex reported that of 122 gay men Anal sex practices are rarely addressed in with HIV, 8% reported oral sex as their only risk sex education on the assumption that they do activity. However, some of the men in this study not happen, or at least not with women, and sex who initially said oral sex was their only risk between men and transgender people may not activity subsequently admitted having unpro- be discussed at all. Yet a review of studies in the tected anal sex. A recent study did not find any USA in 1999 on heterosexual anal intercourse cases of oral transmission of HIV over a ten-year showed in absolute numbers that approximately period in over 100 couples where one partner seven times more women than homosexual men was HIV positive and the other HIV negative.51 had experienced unprotected anal intercourse.57 Over 19,000 instances of unprotected oral sex did Anal transmission of HIV from an HIV posi- not lead to a single case of HIV transmission tive man to a receptive partner, male or female, amongst a cohort of 135 HIV-negative individ- is the highest risk mode of HIV transmission,

74 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 after blood-to-blood transmission. In a number of acquisition of HIV infection among recently of countries adolescents have reported having circumcised HIV negative men and may increase anal sex to avoid pregnancy or to preserve vir- the risk of HIV transmission to female partners of ginity.41 In South Africa, 42.8% of a sample of recently circumcised HIV positive men.66,67 women sex workers had anal sex with their A partially effective intervention that pro- clients. HIV prevalence in this group was 61.3% tects men but not women could result in increased compared to 42.7% in those who did not engage HIV transmission if circumcised men do not in anal sex, controlling for age, number of clients maintain or initiate use of condoms or if they per week and duration of sex work.58 Unpro- have more partners. WHO/UNAIDS advise that tected receptive anal intercourse is ten times ‘‘any decisions about male circumcision must take more risky than unprotected vaginal intercourse into account cultural factors, risk of complica- for acquiring HIV because anal mucosa is more tions, potential to undermine existing protective delicate and easily damaged during penetra- behaviours and prevention strategies and health tion.59 Tearing of rectal tissue, haemorrhoids, system constraints’’.67 and other anal lesions have been expe- Based on the currently available evidence, male rienced by some men who have sex with men circumcision is not recommended for HIV positive and also increase risk.60 men as an intervention to reduce HIV transmis- Vaginal douching may remove natural fluids sion to women; nor is there information on the and such as lactobacilli which main- safety of male circumcision for HIV positive tain the natural environment and pH of the men, especially those with advanced immune vagina. Natural during sexual suppression. Research has not yet been done on arousal facilitates penetration, with or without whether there is any protective benefit of male condoms. Negative associations of natural vag- circumcision for sex between men when one is HIV inal wetness with in some cultures positive, nor in heterosexual anal sex.67 should be addressed. Water-based lubricants and saliva make vaginal and anal sex safer and are especially needed by sex workers and others Condom use for repeated acts of intercourse. They can also UNAIDS, WHO and UNFPA emphasise that make sex more pleasurable. Water-based lubri- condoms are central to all STI and HIV control cants should be used with condoms, especially for strategies.68 The common notion among family anal sex, to prevent damage to anal tissue and planning providers that condoms are only for condom breakage.61 Health workers and women disease prevention because they are less effec- need information on the dangers of inserting tive than other contraceptive methods fails to substances into the vagina to make it tight, dry take into account the potential for increasing the or ‘‘hot’’ with astringents, detergents, bleach, number of protected sex acts when their contra- chillies, bark and other substances.62 ceptive potential is also stressed. Due to success- Recent results from three randomised trials ful social marketing efforts, condom promotion in Africa show partial protection (50–60% in Africa has been a success for single women, reduction in risk) from female-to-male vaginal including for pregnancy prevention, which the transmission of HIV for HIV negative men who main or partial motive of most single women undergo male circumcision.63–65 Consideration of who use condoms even if the risk of HIV/STIs male circumcision is particularly appropriate for is high. The needs of the married and cohabiting women with HIV and their male partners who population have been neglected by researchers are untested or negative. No protective effect of and programme staff alike, despite the fact that male circumcision for women has been shown, more than half of HIV infections in the severe and recruitment for the one trial looking at this of southern and East Africa are occur- issue was stopped early because of higher HIV ring in this group. Yet the barriers to condom incidence among the female partners of circum- by married couples may not be as severe cised men compared to the uncircumcised con- as is often assumed.69 trol group.66 Messages and counselling should Misleading and factually incorrect statements stress that resumption of sexual relations before about condom effectiveness are increasingly complete wound healing may increase the risk found in health education materials supported

75 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 by faith-based organisations opposed to sex out- Company,79 and PATH are also testing a new side and to contraception.7 Christian model of .80 More investment is conservatives in the USA want condom labels needed for mass production, support for advo- to warn of the risk of infections rather than cacy groups who can advise on use, and training their high effectiveness on preventing infection for health workers to promote them. if used consistently and correctly, and state- There is anecdotal evidence from many coun- funded abstinence-only programmes only allow tries that men who have sex with men success- mention of condoms in the context of their fail- fully use female condoms anally for protection. ure rate.70 Deliberate misinformation seriously In a 1998 survey of more than 2,200 HIV posi- undermines prevention efforts, sows confusion tive men in the USA, a majority said they and threatens condom availability and use – were very likely or somewhat likely to use the which in turn promotes HIV transmission. Reality female condom for future receptive and Male latex condoms are 80–95% effective insertive anal intercourse. 54% of those sur- in preventing HIV and most STIs when used veyedactuallypreferredusingtheReality consistently and correctly.71–73 Condoms are condom to the male condom. A redesigned impermeable to infectious agents in genital product may be preferable for anal intercourse81 secretions.58,72,74,75 They reduce the risk of but none has emerged in the decade since. transmission of human papillomavirus (HPV) Difficulties using condoms, which occur mostly and therefore of cervical and ano-genital dyspla- for new users, should be acknowledged and sia and cancer.70,76,77 They also reduce the risk of practical suggestions given on how to overcome transmission of virus-2, although them.82 Men may lose their when put- some transmission can still occur through non- ting a condom on, especially when they first start penetrative sex and through skin not covered by using condoms, and may not persist with them a condom. for this reason (Juliet Richters, National Centre Using a lubricant with male condoms is impor- in HIV Social Research, Sydney, Australia. Per- tant for post-menopausal women, who have less sonal communication, October 2006). It is worth natural vaginal lubrication, and for women sex suggesting that men practise on their own before workers and others who are having multiple and/ trying them with their partners, and the same or rapid intercourse with one or more persons, could be said for female condoms, but trying with which can cause discomfort and even pain a partner and making it a joint learning adven- with condoms alone, because the vagina may not ture may help to sustain use by introducing them produce adequate natural lubrication. Lack as part of sexual intimacy from the start. of stimulation and psychological depression can contribute to vaginal dryness as well. This some- times leads to condom breakage and an increase in Focus on pleasure vaginal tearing, thereby increasing the risk of STI/ ‘‘There is growing evidence that promoting plea- HIV transmission.61 Anal sex should always be sure in male and female condom use, alongside protected by condoms and a water-based lubricant safer sex messaging, can increase the consistent should always be used to prevent friction, as the use of condoms and the practise of safer sex. anal passage does not have its own natural lubrica- This is the ‘power of pleasure’.’’78 tion like the vagina does, and condom breakage.78 Female condoms come with lubrication. Female The emphasis in HIV programmes on disease condoms used consistently and correctly are esti- and disease prevention, , infi- mated to be 94–97% effective against STIs. While delity and difficulties in promoting condoms can they have not specifically been studied for HIV be overwhelming. Being labelled as ‘‘infected’’ prevention, effectiveness is assumed to be com- injures a person’s sense of identity, often making parable.68 Despite limited access and high cost, them feel they have no right to a fulfilling rela- female condoms are becoming more popular with tionship or to being ‘‘normal’’. Most HIV positive some women, who are able to negotiate their use women and men are healthy, and those on anti- with some men.43 Newer versions of female con- retroviral treatment have in large numbers got doms have been developed, including a more their health back. Most are or will be having affordable nitrile version by the Female Health active sexual lives, just as young people with HIV

76 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 want to explore relationships as much as their pb0.001).83 High levels of consistent condom use negative peers. Promotion of safer sex can be (73%) were reported in a 2003 Swiss study of HIV done in a sex-positive way, rather than trying to serodiscordant couples and in the Swiss HIV frighten people. Emphasis on sex as pleasurable, Cohort Study, the level was 88%.84 On the other condoms and lubricants as erotic and non- hand, among 145 HIV serodiscordant couples in penetrative sex as exciting should be used more the USA, 45% reported having had unprotected often to encourage safer sex. The Pleasure Project vaginal or anal sex in the six months prior to has mapped programmes, literature, research and the study. Unsafe sex was associated with training using pleasure as a primary motivational lower educational level, unemployment, African- force, particularly in resource-poor settings.61,78 American ethnicity, practice of anal sex by the Many gay men’s organisations in the US, UK, couple and injection drug use. Consistency of Canada, Australia and other developed coun- condom use did not depend on the sex of the tries have taken a pleasure approach to HIV pre- HIV positive partner or duration of the sexual vention and teach men how to make condoms relationship. The findings suggest that many HIV feel better and integrate them into sex play. The serodiscordant heterosexual couples remain at Australian Federation of AIDS Organisations, for high risk of HIV transmission and may benefit example, created Sex in Queer Places, an inter- not only from safer sex interventions but also active video game that follows a fictional gay from interventions aimed at improving their social man through a variety of sexual encounters (e.g. and economic conditions.85 sauna, dance party) and lets the viewer make a In areas of high HIV prevalence in sub-Saharan set of sexual and drug-use choices. With each Africa, e.g. Zimbabwe, 5–10% of women become choice a dialogue box pops up with health pro- HIV infected during pregnancy and breastfeed- motion and harm minimisation information. ing.86,87 Where a male partner’s HIV positive An electronic booklet that takes a sex- status is known, condom use during pregnancy positive approach to issues about sex for HIV- and can be introduced to prevent positive men is also included (bwww.afao.org. HIV infection of the woman if she is negative auN). Often, the target audience have their own but also parent-to-child transmission to the innovative ideas for eroticising condoms and unborn baby which is a much greater risk when increasing their use.78 the mother is infected while pregnant. Encour- Pleasure and sexiness are often culturally spe- aging men to share this responsibility may cific, so it is vital to tailor pleasure-focused HIV normalise condom use in marriage so that dis- prevention to the needs and desires of target cordant couples continue to use them after the communities. For example, in Mumbai, India, perinatal period. During breastfeeding, addition- the Sambhavana Trust reported that some of the ally, condom use is a safe means of preventing hijra (transsexual) community were inserting the another pregnancy. female condom anally before sex and explaining In a study among homosexual men with a to their penetrative partner that they were using regular partner in France, 285 reported a sero- the female condom as proof of their femininity.78 discordant partner and 193 a seroconcordant partner. Unprotected sex was reported by a higher number of those in seroconcordant (46.7%) than Safer sex in HIV serodiscordant and serodiscordant couples (15.6%). In both kinds seroconcordant relationships of partnerships, unprotected sex was significantly HIV negative partners of people with HIV are more frequent when episodes of unprotected sex at high risk for HIV infection but they are often with casual partners were reported. In sero- not the focus of prevention programmes, espe- concordant couples, those who had more than cially married couples, and condoms are rarely four casual partners were also more likely to prac- promoted to them. In a French study of 575 sex- tise unprotected sex with their regular partner. ually active HIV positive women of reproductive Among sero-nonconcordant couples, binge drink- age who knew the serologic status of their steady ing and absence of disclosure of HIV-positive partners, consistent condom use was six times status to the partner were also independently asso- higher in serodiscordant couples than in serocon- ciated with unprotected sex. Absence of disclo- cordant couples (odds ratio=6.1, 95% CI=0.1-0.2, sure of HIV positive status to the partner was also

77 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 independently associated with unprotected sex. other contraception.93 In the CAPRISA Project The relationship between unprotected sex with both in South Africa, they have stopped counselling casual and regular partners thus appeared to be such concordant couples to use condoms (Per- related to the underlying psychosocial and interac- sonal communication, Salim Abdool Karim, tional factors that may influence sexual behaviours CAPRISA Project KwaZuluNatal, South Africa, of people living with HIV in regular relationships, March 2006). The greater challenge is how to independently of the status of the partner.88 increase safer sex between partners who are not concordant or monogamous. Re-infection in HIV concordant couples The question of whether people with HIV can re- Antiretroviral therapy and safer sex infect each other and whether such re-infection Reports of increasing unprotected intercourse causes progression to AIDs more quickly has been associated with poor adherence to antiretroviral around since the beginning of the epidemic. Con- therapy in the USA and Europe have given rise to ventional advice given to HIV positive concor- fears that being on treatment, ‘‘safe-sex ’’ dant couples emphasises consistent condom use and perceptions of HIV as treatable and chronic for all for the rest of their 94,95 89 will result in increased risk-taking behaviours. lives because of the dangers of re-infection. However a literature review found that the prev- However, information about re-infection between alence of unprotected sexual intercourse was not seroconcordant partners is still extremely limited, higher in HIV positive people on antiretroviral making the evidence for this advice uncertain. therapy than in those who were not, nor in those The main concerns are that dual infection (with with undetectable vs. detectable viral load.96 two or more viral strains, in the case of multiple Regardless of HIV serostatus, however, the likeli- positive partners) may lead to more rapid disease hood of unprotected sex was higher in people who progression and that recombinant drug resistant perceived that receiving antiretroviral therapy or may occur. Re-infection means: i) co- having an undetectable viral load was protective infection with another strain of HIV at the same against transmitting HIV. time or within a month of the initial HIV infection, Encouragingly, some studies have found a or ii) super-infection with a second HIV strain relationship between high adherence to anti- some time after the initial infection has become retroviral therapy and safer sex behaviours: in established. Only 16 cases of re-infection have California HIV clinics with diverse populations, been reported in the literature since the first case 90,91 use of and adherence to antiretroviral therapy in 2002, and as detecting re-infection is tech- N95% and undetected viral load were signifi- nically difficult, the frequency is quite possibly cantly associated with a decrease in unprotected under-estimated. Studies of super-infection have vaginal and anal sex.97 In a London outpatient recently begun. At the International AIDS Con- clinic, HIV positive homosexual men on anti- ference in 2006 Dr Julie Overbaugh reported in a retroviral therapy consistently reported lower plenary presentation on eight potential cases of behavioural and clinical risk factors than men super-infection among a cohort of HIV positive not on treatment.98 A recent study in Uganda women in Mombasa, Kenya, that had occurred found that provision of antiretroviral therapy after an response had had time to 92 along with prevention counselling and partner develop (2–5 years). testing and counselling reduced sexual risk Many women and men with HIV are seeking 99 behaviour by 70% after six months. relationships with positive partners (called ‘‘sero- Antiretroviral ‘‘treatment literacy’’ for both sorting’’) in an attempt to avoid HIV transmis- health care providers and people with HIV is sion to negative partners and having always to essential for treatment to be effective. Treatment use condoms. Given the difficulty of sustaining literacy education should include messages that consistent lifelong condom use, this is a rational include pleasure-based safer sex information response. Condom use between HIV concordant and emphasise: partners may need re-thinking, especially for those who have no STIs, are reliably monogamous and  the benefits of treatment adherence (better if heterosexual and not wanting a child, using health, reducing the need to change treatment

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regimens, preventing development of drug- tance. Herpes is incurable but suppression with resistant virus); daily acyclovir is currently being studied for its  the continuing need for safer sex because effect on HIV prevention.108 Effective STI control although improvements in health (higher CD4 requires interventions that reach sexual net- counts and lower or undetectable viral loads) works with the highest rates of sexual partner do reduce the risk of sexual transmission of change.109–111 Successful interventions combin- HIV they do not eliminate it; ing peer outreach and clinical services includ-  antiretroviral therapy is not a ‘‘cure’’ for HIV, ing STI screening and/or presumptive treatment and have reported marked reductions in STI preva-  there is a continuing risk of other STIs with lence among sex workers in Africa,112–115 Latin unprotected sex. America116 and Asia.117 Sex workers have special service needs for As access to antiretroviral therapy increases STI prevention and detection. Over half of sex in developing countries, while second and third workers, many of whom are HIV positive, have line drugs remain extremely limited, strategies curable STIs but are unable to access health ser- to support adherence and sustained safer sex are vices for diagnosis and treatment, and unable to critical to avoid resistant HIV strains emerging. insist on condom use with clients.111 In success- ful programmes, services are offered at conve- nient places and times, along with other needed Regular screening and treatment for STIs services such as contraception, HIV care and STIs cause considerable morbidity and mortality, treatment, and support for advocacy to prevent and are powerful cofactors that facilitate HIV police harassment and ensure that the rights of transmission and acquisition from 10–300 times women are respected by brothel owners (Box 1). per sex act, especially with dis- Although some programmes were originally ease.100–102 STI treatment can be carried out in intended for female sex workers, male sex work- two ways: i) population-level interventions to ers (who are even more highly stigmatised) have reduce STI prevalence and lower HIV trans- also been attracted to utilise them. Frequent STI mission efficiency, and ii) STI services to address exposure is a real and ongoing hazard of sex the health needs of individual people, with and work that should be addressed through counsel- without HIV, which are usually based on symp- ling, regular genital examination and six- tomatic individuals seeking treatment. monthly screening for syphilis. The conditions Sexual transmission of HIV is most wide- that frequently lead to sex work, especially pov- spread in the same regions as those with poorest erty and lack of economic alternatives, are aggra- STI control, where curable STIs (, vated by HIV infection. syphilis, gonorrhoea and chlamydia) predomi- Repeated STIs challenge the nate. An appropriate strategy includes targets of HIV positive people, reducing their capacity to lower curable STI prevalence, minimise com- for staying healthy. People with HIV need to know plications (which can be more severe in people the risks to their health associated with STIs, be with HIV), and slow further HIV transmission. encouraged to seek treatment early for symp- Thailand and successfully implemented tomsandadvisedonincreasedHIVrisktonega- national-level interventions that resulted in large tive partners. Per sex act, men are twice as likely reductions in curable STIs and helped to reverse to infect women with a variety of STIs47 and the growth of their HIV epidemics.103–105 Key ele- four times more likely to infect them with HIV ments of success included condom promotion, as women are to infect them.122 The common improved STI services and targeting sex workers sequelae of STIs in women – pelvic inflammatory and clients with effective preventive and cura- disease, ectopic pregnancy, congenital infections – tive services. Similar results have been reported and ano-genital cancers and in both from , Kenya and elsewhere.106,107 Once women and men may be aggravated by HIV infec- basic STI services are strengthened, curable tion.123 Other infections of the reproductive tract, STIs can be rapidly controlled and incurable including chronic vulvovaginitis and bac- viral infections (-2) and terial vaginosis, although not sexually transmit- human papillomavirus assume greater impor- ted, are also problems for HIV positive women.

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Extensive, persistent herpes simplex virus-2 women who may have endogenous .125 infection is a sign of late-stage AIDS (WHO Lack of good diagnostic tests for gonorrhoea and clinical stage 4).89 Systematic screening for chlamydia at point of care and appropriate for infection (serologic test for syph- resource-poor settings remain a critical unmet ilis, speculum/bimanual examination with tests need, especially for women..126 Prices of highly for cervical infection, where feasible, and cer- effective single dose treatment for gonorrohoea, vical cancer screening) should be an integral chlamydia, and genital ulcer disease (azithromy- part of routine HIV care for women.124 Ser- cin, ciprofloxacin, cefixime) have dropped in the vices providing HIV testing and counselling, past decade but these and other appropriate antenatal care, prevention of parent-to-child- medicines for treating bacterial STIs continue to transmission and treatment for be available intermittently or not at all in many should develop STI screening programmes that STI programs in developing countries. Poor drug include referral or treatment. Syndromic case supply management, weak health infrastructure management is challenging for women because and lack of political support for STI control con- is over-diagnosed as an tribute to continuing STI epidemics in the same STI, resulting in stigma and over-treatment in populations where HIV prevalence is highest.

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HIV seroconversion is a time of high viral load Large-scale multi-country, multi-site trials of and infectiousness. A person who acquires an STI several HPV are underway.132 A may have been simultaneously exposed to HIV. that is 90% effective against two oncogenic HPV A recent study in found that 2% of men strains, 16 and 18, causing about 70% of cervical presenting to clinics with symptomatic STIs and cancer, has been evaluated and approved in the negative for HIV were found to be in USA and Europe for use in (young) women.133,134 the process of acute HIV seroconversion with There is currently a lack of knowledge of the significantly higher viral loads than those who prevalence of specific HPV types in women and tested positive for HIV.127 HIV testing and coun- menwithHIV.Between1996and2003inthe selling should routinely be offered as part of STI USA, of 202 HIV positive women who were receiv- services; those who test positive should receive ing routine HIV care, 105 were positive for HPV, intensive prevention counselling and support. of whom 52% were positive for multiple types People diagnosed with STIs similarly need inten- of HPV. Women in this study were often infected sive education that they may be in the window with different strains of the virus from the ones period of HIV infection and need a repeat HIV test covered by the new vaccine, which were also asso- in 6–12 weeks, and could pass HIV on to partners ciated with a high risk of pre-cancerous and can- if they have unprotected sex. All people at risk cerous cell changes.135 of STIs through unsafe sex need to use safer sex No data are yet available on the safety and methods consistently. This is potentially harder efficacy of HPV vaccines for people with HIV, for those whose risk comes from their partner’s whether infected perinatally or sexually. Studies behaviour rather than their own. have found that women with HIV have a two- to six-fold increased risk of pre-cancerous cervical cell abnormalities,136–138 and can develop inva- Human papillomavirus, cervical and sive up to ten years younger than ano-genital cancers HIV negative women.138 Progression to high-grade Cancer of the cervix and ano-genital cancers lesions is more rapid, and lesions are more resistant in women and men are a complication of persis- to treatment in the presence of HIV.139–141 tent infection with oncogenic strains of human In women with HIV, lower genital tract can- papillomavirus (HPV). Lower-risk strains of human cers in the vagina and vulva, and cancers of the papillomavirus cause benign genital warts on anus in women who have receptive anal sex are the lower genitalia and anus in both sexes. They also prevalent. Overall, however, increased rates can be severe and persistent in people with of invasive cervical cancer have not been asso- HIV, but eventually resolve spontaneously with- ciated with the HIV epidemic.142 In 1992 the US out treatment. Centers for Disease Control classified cervical Globally up to 80% of newly sexually active cancer as an AIDS-defining illness. This is now men and women may be exposed to oncogenic being questioned since the relationship of cer- strains of HPV, but most develop only transient vical cancer to declining immune function, as infection. In a small percentage of women, HPV determined by CD4 cell count and responsive- infection progresses to cervical intraepithelial neo- ness to antiretroviral therapy, is unclear.143 plasia (CIN), a pre-cancerous condition that either In the context of population-based cervical regresses or progresses to invasive cancer.128 control programmes, WHO recom- intraepithelial neoplasia (AIN) caused by HPV mends that women with HIV be offered cervical occurs with the same frequency in men who have screening at the time of HIV diagnosis and sex with men as cervical cancer does in women thereafter ‘‘at the same frequency and with and is probably higher among those with HIV.129 the same screening test as women not infected A study of over 100 women with CIN and their with HIV’’.124 Once screened, a woman with male sexual partners indicated that consistent an abnormal test should be followed up and/or condom use can speed up regression of HPV- treated. HIV positive women with cervical dys- associated lesions, clearance of HPV in women plasia also have a higher incidence of other and regression of flat penile lesions in men, pre- lower genital tract cancers; they, and men with sumably by blocking repeated transmission and HIV, should be screened on a regular basis by re-infection between partners.130,131 visual inspection of the genitalia for abnormal

81 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 tissue or lesions, which should be biopsied, fol- cervical cancer). It would also include integrating lowed up and/or treated as well. screening into HIV care and sexual and repro- Since the HIV epidemic, the incidence of AIN ductive health programmes where there is access in men who have sex with men is increasing. to treatment. Ideally, HIV positive women and men Screening in HIV positive and HIV negative men should receive cervical and ano-genital screening who have sex with men for anorectal malig- and treatment along with contraception and STI nancies or dysplasia is cost-effective if the inci- services from a combination of enhanced public dence is sufficiently high. Treatment options range sector and research-focused clinical services.155 from watchful waiting for asymptomatic grade-1 Women and men with HIV have real concerns AIN to excision or radio(chemo)therapy for ano- about the impact of cervical and ano-genital dis- rectal carcinoma.144 ease on their health, which services should do All available screening methods, cytology, their best to address. But it is unrealistic to expect HPV DNA testing and visual inspection, are complex multi-level services to be set up for appropriate for people with HIV. As most HPV them in the absence of national guidelines and infections resolve spontaneously by age 30–35, services, particularly for cervical cancer preven- HPV testing before that time is not useful as tion for the general population. Screening is not a screening test.146 High grade pre-cancerous helpful if proper diagnosis, follow-up, treatment lesions (CIN 3) require treatment but this is com- and care for abnormalities are unavailable; it plicated by poor outcomes, especially for women is only through well-planned provision of ser- with CD4 counts below 200. However, women vices at the central level that people with HIV with HIV should be offered treatment and fol- will benefit.145 lowed closely for complications, recurrence or per- sistence of lesions.145 Low-grade abnormalities (CIN 1 and 2) do not require treatment, but women Addressing sexual dysfunction with HIV need to know they require closer follow- The sexuality of men and women with HIV is up because of risk of rapid progression. diminished by the fear of infecting others and Evidence on the impact of antiretroviral therapy being infected, as well as guilt, anger and ill- on HPV disease in people with HIV is mixed.146 health resulting in negative physical and psycho- Cancer incidence data in North America, Europe logical effects on sexual desire. Men with HIV and Australia showed no significant change in are not uncommonly concerned about sexual incidence rates for cervical cancer but the number dysfunction, including loss of , problems of cancers was very small.147–149 Regression of with and ejaculation, which may be cervical lesions as immune function improves related to illness or opportunistic infections, cer- has been noted in several studies.150,151 Other tain antiretroviral drugs or other medications. studies have showed a dose–response relation- Poor treatment adherence and sexual dysfunc- ship between decreased immune function and tion have also been reported.156–158 Men with increased severity and persistence of CIN.152,153 sexual dysfunction have also commonly reported Early data suggest that most anal high-grade recreational drug use, co-infection with hepa- lesions do not regress after an individual begins titis B and C, anxiety and depressive illnesses, antiretroviral therapy, but may take several years peripheral neuropathy and lipodystrophy.159 to show a comparative difference with HIV nega- Health care providers can provide some reassur- tive men and women.154 Given these data, it is ance that improvement in health will address important that those who are eligible have access some sexual dysfunction. Treating STIs, address- to antiretroviral treatment. ing concerns and providing simple behavioural Integration of cervical and ano-genital cancer interventions could increase positive men’s con- control into sexual health programmes for people fidence. Health staff need skills in sympathetic with HIV would include giving information on and knowledgeable responses to such problems, primary HPV prevention as part of sex education in particular to raise these issues in counselling to young people with HIV who are not yet sexu- so that men with HIV continue to comply with ally active, and for women, alertness to persis- their treatment. tent vaginal discharge or spotting unresponsive Retrospective analysis of clinic notes of women to treatment (possibly the only symptom of early with HIV attending an HIV clinic in London that

82 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 offered a sexual dysfunction service for men of stigma. Like women, men often feel stigmatised with HIV found that about half the clinic’s when their only option for care is a designated STI cohort of women patients reported sexual prob- clinic. A study in India, for example, found that lems, most commonly from contextual causes, men preferred going to a ‘‘male clinic’’ which pro- or were not satisfied with sex in the preceding vided more than STI care.156 Programmes have to 12 months. A survey by letter of HIV clinical fit in with people’s working times, discard puni- centres in the UK found that 60% had rarely or tive approaches, ensure confidentiality and use never asked women patients with HIV about alternative settings, ranging from community- sexual functioning.160 based groups, social and sports facilities to work- places, drinking spots and bars.167 Peer education and social networking approaches are highly Policies, programmes and health services suited to young people, injecting drug users, sex There are increasing calls for men’s sexual health workers and men who have sex with men.168 to be better addressed for their own sake as well as Developing countries rely on sexual health that of their partners and families.161,162 Although research and therapeutic interventions often this may slowly be changing among some men developed in better-resourced environments. As in many cultures, men mostly still hold the power these interventions become more widely available, to make decisions about pregnancy, contracep- international and national programmes will need tion, safer sex and when to have sex and with to incorporate them in ways that are responsive to whom, and their choices may be based on limited HIV-affected people. Programmes have to become knowledge. Peer pressure and cultural norms and more people-centred, more courageous and flexi- expectations, such as pressure to have early sexual ble, and less punitive and conservative, always experiences, for which they may not be prepared, focusing on public health interventions with having multiple partners and even expressing known effectiveness. sexual violence163,164 serve to limit and under- Current developments in HPV vaccination and mine HIV prevention efforts. screening could eventually transform cervical and Lack of knowledge of reproductive , ano-genital cancer prevention, but the relevance including the of sexual response, to people with HIV needs to be clarified. As fertility, the , biological vulner- regards STIs more generally, in 2006 the World ability to HIV/STIs their effects on pregnancy, Health Assembly endorsed the Global Strategy contribute to poor attention to sexual health, for the Prevention and Control of Sexually Trans- dissatisfaction with sex and failure to realise mitted Infections for 2006–2015.169 Although it reproductive goals.165 Sexual health education is cast almost entirely in the mode of preven- is more targeted at women through health talks, tion of HIV and does not deal with STIs in people posters and leaflets when they attend family living with HIV, it does underline the impor- planning clinics and antenatal care, or with tance of having quality, up-to-date drugs always children for immunisation. Women educate each available and well-equipped STI services able to other through social networking. Men are also carry out both diagnosis and treatment, which interested in receiving scientifically-based infor- are critical for maintaining the health of people mation directly from clinics, rather than through living with HIV. their wives or partners.166 Cervical barriers and female condoms have been Men tend to use services where health educa- available for many years but are still not widely tion is not the norm, such as STI clinics, workplace available because of funding shortages and low clinics, private or informal health services when political will, despite widespread support and clinic hours clash with work. They also tend to calls for women-initiated methods. Microbicides prefer the private sector, where they are less likely include a range of topical products (they can be to be ‘‘scolded’’ by staff for having STIs and where gels, creams, films, or suppositories) that are under they have more privacy. Services for women that development. They are intended to interrupt HIV include men as partners, such as antenatal care, by transmission in both semen and vaginal secretions, their nature exclude young, single men and men and to reduce the risk of some STIs when applied who have sex with men, and other marginalised vaginally or rectally prior to sex; some may also groups,whose concerns areusually hiddenbecause prevent pregnancy. Research has been ongoing for

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a number of years, but there have been setbacks, Interventions that are currently available need most recently the discontinuation in early 2007 of more intensive lobbying. National policies that the Phase III effectiveness trials of cellulose sulfate clearly state the scientific and public health ratio- because of safety concerns. Several other Phase III nale for promoting and distributing condoms in trials of vaginal microbicides evaluating the HIV/STI programmes need far greater encour- effectiveness of products to prevent vaginal trans- agement from international public health, sexual mission of HIV to women are ongoing or due to health and HIV/AIDS agencies and donors. Far start, and advocates have stressed the importance greater support for condom social marketing of continuing this research. Further studies will be efforts is also needed. Promotion of consistent, needed of effectiveness for preventing transmis- correct use of male and female condoms for ‘‘dual sion from HIV positive women to HIV negative protection’’ against pregnancy and infection needs male partners and for safety and effectiveness for also strengthening, particularly among hetero- anal sex. Another promising line of research is sexual couples affected by HIV. Condoms should chemoprophylaxis which, if successful, would be universally available, free or at low cost, along involve an HIV negative person taking an anti- with measures to decrease barriers to their use. retroviral to interrupt HIV transmission during and People living with HIV need more confidence after sex. None of these potential products is likely that their sexual health and rights will be to be available in the coming few years.170–172 respected. To this end, governments must be encouraged to develop policies, laws and guide- lines that protect confidentiality and informed consent as well as stating clearly the limited circumstances in which partner disclosure may take place without consent. Advocacy by civil society organisations to implement policies, strat- egies and legislation already in place is essential for governments and leaders to show they are accountable for the protection of women and men living with HIV. Policies developed at national and regional level by governments, local experts and civil society in conjunction with young people, men and women living with HIV have demonstrated effectiveness. Examples are 100% condom and STI policies in southeast Asia;103 treatment lit- eracy and advocacy in South Africa, Brazil and many developed countries; integration of cer- vical cancer screening into sexual and repro- ductive health services in Zimbabwe; peer education in India, , Kenya, Thai- land, Mexico and Dominican Republic. Evidence shows that coordinated approaches linking strat- egies for antiretroviral adherence to support for practising safer sex and reducing risky sexual behaviours, and programmes that address the broader sexual health concerns of HIV positive men and women can all help to sustain health gains for people living with HIV. HAYDEN HORNER / IRIN PLUS NEWS HIV conference in Kenya told that African Conclusion HIV programmes must include the gay In many ways the challenges faced by people community, May 2007 living with HIV in achieving sexual health are

84 K Shapiro, S Ray / Reproductive Health Matters 2007;15(29 Supplement):67–92 the same as for everyone living in resource-poor and dignity, taking into account the diversity settings, and depend on good health services of sexual relationships and partnerships, and and systems. The added vulnerability of women people’s different needs at different stages in and men with HIV because of stigma, social vul- their lives, starting in adolescence. Involvement nerability and illness needs to be addressed in of people with HIV as active partners in develop- ways that are supportive and enabling rather ment of policy, programmes and services will than discriminatory. This paper argues for the encourage ownership, enhancing quality of care need for appropriate health services and tar- within both resource-rich and resource-poor envi- geted education, advocacy for the development ronments. At the same time, advocacy and activ- of enabling policies and support for positive ism will remain essential to guarantee that new prevention for people with HIV. Investment is technologies and therapies are accessible for HIV needed in training health workers to provide positive people in developing countries, especially services within a professional ethos of respect those countries with a high prevalence of HIV.

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Re´sume´ Resumen La sante´ge´ne´sique, de´finie en termes de bien- La salud sexual, definida en te´rminos de bienestar, eˆtre,estmenace´eparlesre´alite´s sociales, culturelles se ve afectada por las realidades sociales, culturales et e´conomiques des femmes et des hommes yecono´micas que afrontan las personas con VIH. se´ropositifs. Il faut donner aux femmes et aux Un enfoque en los derechos sexuales pone a dichas hommes se´ropositifs la maıˆtrise de leur sante´ personas en control de su salud sexual. La mejor ge´ne´sique. Les pairs et les personnels sanitaires forma de suministrar informacio´n exacta y accesible forme´s a` des approches empathiques sont les para propiciar una toma de decisiones informadas mieux a`meˆme de transmettre des informations y relaciones sexuales seguras y placenteras es exactes pour permettre des choix e´claire´s et des mediante la educacio´n por pares y profesionales relations sexuelles suˆres et agre´ables. Les jeunes de la salud capacitados en tratar los asuntos se´ropositifs ont spe´cialement besoin d’e´ducation delicados con empatı´a. En particular, la juventud sexuelle et de soutien pour vivre leur sexualite´ con VIH necesita una educacio´n sexual y apoyo et leur identite´ par rapport au VIH. Les femmes adecuados para lidiar con la sexualidad y etleshommesse´ropositifs doivent disposer de autoidentidad con el VIH. Las personas con VIH pre´servatifs, de services adapte´s de prise en necesitan condones, servicios adecuados para las charge des IST, des dysfonctionnements sexuels infecciones de transmisio´n sexual, la disfuncio´n et des cancers de la sphe`re anale et ge´nitale. sexual y el manejo del ca´ncer cervical y anogenital. On recommande des interventions fonde´es sur Se recomiendan intervenciones basadas en la la pre´vention positive, qui prote`gent la sante´ prevencio´n positiva, que combinen la proteccio´n personnelle tout en e´vitant la contamination de la salud personal con evitar la transmisio´n de des partenaires. Le conseil apre`s un test positif ITS/VIH a las parejas. Gracias a la consejerı´a sobre el au VIH a augmente´ l’utilisation du pre´servatif, VIH despue´sdeunapruebapositiva,haaumentado et a diminue´ les rapports sexuels force´s et les el uso de condones y disminuido el sexo forzado y contacts sexuels exte´rieurs chez les couples los contactos sexuales exteriores entre parejas se´rodiscordants. Le traitement du VIH a atte´nue´ discordantes. El tratamiento y la atencio´n del VIH la stigmatisation, et encourage´lede´pistage et la han reducido el estigma y aumentado la aceptacio´n re´ve´lationdelase´ropositivite´ aux partenaires. de las pruebas de VIH y la divulgacio´n del estado L’observance du traitement antire´troviral doit seropositivo a las parejas. La terapia antirretroviral y aller de pair avec un comportement sexuel plus el comportamiento sexual ma´s seguro deben ir de la suˆr. Les services de sante´ge´ne´sique ont collabore´ mano. Los servicios de salud sexual han trabajado avec les e´ducateurs pairs et les groupes de con educadores de pares y grupos voluntarios para be´ne´voles pour atteindre les populations les plus alcanzar a aquellas personas que corren un riesgo expose´es, comme les professionnel(le)s du sexe. ma´s alto, como las trabajadoras sexuales. Los Les progre`s technologiques dans le diagnostic des avances tecnolo´gicos en el diagno´stico de ITS, IST, la mise au point de microbicides et le de´pistage desarrollo de microbicidas y la deteccio´n sistema´tica et la vaccination contre le papillomavirus doivent y vacunacio´n del virus del papiloma humano deben eˆtre disponibles dans les pays en de´veloppement et estar a la disposicio´n de los paı´ses en desarrollo y pour ceux qui en ont le plus besoin. laspersonasma´s necesitadas mundialmente.

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