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

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Sexual Health for People Living with HIV Kathy Shapiro,A Sunanda Rayb A 2007 Reproductive Health Matters. All rights reserved. Reproductive Health 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, India. E-mail: [email protected] b Public health 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 sex education and support for dealing with sexuality and self-identity with HIV. Women and men with HIV need condoms, appropriate services for sexually transmitted infections, sexual dysfunction and management of cervical and anogenital cancers. 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 condom 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 vaccination 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-infection 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 cancer 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 abstinence 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 pregnancy. 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 youth who have been services, yet are among those at highest risk for infected perinatally or through blood 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 epidemic 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, sexual orientation, 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 safe sex; 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 unintended pregnancy;9 youth. HIV positive young men are much more do not encourage early sexual activity in ado- likely to have acquired the virus 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
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