Protecting yourself

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Co-infection
Hepatitis
Hepatitis B
Hepatitis C
Other sexually transmitted infections
Re-infection

Having HIV may lead you to think that there’s no need to worry about protecting yourself during sex any more. You may also think that as long as you have sex with other men who are also HIV positive then you can forget the condoms when you fuck or get fucked. This is a strategy used by quite a few HIV positive gay men so that they don’t risk passing HIV onto HIV negative men, and also so they can get the closeness, intimacy and sensation associated with sex without condoms. This strategy of seeking other HIV positive men to have unprotected sex with is known as serosorting, and we talk more about this in the section on your sexual partners.

However, there are still very good reasons for protecting yourself even though you’re already HIV positive. If you have unprotected sex you could be putting yourself at risk of co-infection with another sexually transmitted infection (STI) and re-infection with a different strain of HIV. It’s a good idea to be aware of the risk of both co-infection and re-infection so that you can make an informed choice about whether to use condoms or not when you have sex.

Co-infection

Co-infection is having another infection as well as HIV. If you fuck without using condoms you could be at risk of getting hepatitis and other sexually transmitted infections (STIs), and we talk about these below.

Hepatitis

Hepatitis is a general term referring to inflammation of the liver. There are six known Hepatitis types; A, B, C, D, E and G. The most important ones to be aware of are Hepatitis B and C and we go into more detail about these below.

Hepatitis B (Hep B)

Hepatitis B is a serious illness caused by a virus that attacks the liver. You can get Hep B in a similar way to HIV – by fucking without condoms or by sucking cock. Although sucking cock carries a low risk for passing on HIV, this is not the case for Hep B. Hep B is much more infectious than HIV. At some London HIV clinics up to 6% of gay men with HIV also have Hep B.

There is a vaccine available that can protect you against getting Hep B, and everyone who has HIV really should make sure they are vaccinated. The vaccine is available free from your HIV or GUM clinic, and is the best way to protect yourself, but it doesn’t work for everyone. The vaccine works better if your CD4 count is high and your viral load is low. Also, immunity after vaccination may not last for life, so you should have regular blood tests to check that your immunity is sustained, and you will probably need boosters every so often. Ask at your HIV or GUM clinic when you go for your jab.

About a third of people with HIV who get Hep B will not be able to get rid of it without treatment. Of this third, only 20-40% will respond to Hep B treatment. Those who don’t respond to treatment will go on to develop chronic (long-term) Hep B infection putting them at a high risk of developing liver disease and liver failure (which would be fatal without a liver transplant).

Alpha-interferon, a drug used to treat Hep B, can cause side effects such as high temperature, joint pain, weight loss, nausea & depression. Alpha-interferon can also cause low white blood cell and / or platelet count (known as thrombocytopenia).

Other drugs currently used to treat Hep B are 3TC, FTC and tenofovir (which are also anti-HIV drugs) and Adefovir, which can have side effects such as headache, stomach pain, nausea and diarrhoea.

The damage Hep B does to your liver could also mean that you have a greater risk of side effects from your anti-HIV drugs, especially those associated with liver side-effects such as AZT, ddI, ritonavir, indinavir and nevirapine. If these side effects become too severe, it could mean that you have to change to different anti-HIV drugs. This would reduce your choice of anti-HIV drugs.

If you are not vaccinated against Hep B, you can reduce the risk of getting it by fucking with condoms or not getting cum up your arse or in your mouth.

Hepatitis C (Hep C)

Hepatitis C is a serious illness caused by a virus passed on through infected blood that attacks the liver, however it is much harder to treat than Hep B. There is no vaccine available to protect you against Hep C.

It used to be the case that Hep C infection was mainly seen in intravenous drug users who had been sharing needles, and in people given blood transfusions with blood products infected with Hep C. However recently there have been a growing number of cases of Hep C infection in HIV positive gay men. There are a number of ways that Hep C can be transmitted. These are:

Sharing needles for injecting drugs including steroids with someone who has Hep C.
Being fisted by a man with Hep C who has cuts or sores on his hand and isn’t wearing a glove.
Being fisted by a man who has just fisted another man with Hep C and who hasn’t put on an unused latex glove or thoroughly washed his hands.
Using a dildo or other sex toy that has just been used on a man with Hep C and which hasn’t been thoroughly cleaned, or had a new condom put on it.
Sharing a pot of lube with a man with Hep C, as lube can become contaminated with blood.
Sharing a drug snorting straw, banknote or bullet with someone with Hep C, as small specks of infected blood could be on the straw, banknote or bullet.
There has been a lot of debate about whether Hep C can be passed on through fucking without condoms with a man who has Hep C. Recent studies suggest that it can.

The Royal College of Physicians estimate that 4-8% of gay men have Hep C. However, up to 90% of people with Hep C do not know they have it. About 75% of people who get Hep C will not be able to get rid of it without treatment. The standard treatment for Hep C is Pegylated Interferon (also known as peg-interferon) and Ribivarin. Peg-interferon can cause side effects such as high temperature, joint pain, weight loss, nausea & depression. Alpha-interferon can also cause a low white blood cell count and a low platelet count (known as thrombocytopenia).

Hep C treatment can also reduce your HIV treatment options. Ribivarin should not be taken with anti-HIV drugs ddI, d4T or Tenofovir, as this can cause potentially fatal side effects such as pancreatitis (where the pancreas becomes inflamed and the digestive enzymes leak into the abdominal cavity where they can cause severe inflammation and damage to the surrounding tissues) and lactic acidosis (where there are high levels of a substance called lactate, a by-product of the body processing sugar, in the blood). Ribivarin can also cause anaemia and so should not be taken with the anti-HIV drug AZT.

Only 20-50% of men who have HIV and Hep C will respond to Hep C treatment. The rest will go on to develop chronic (long-term) Hep C infection putting them at a high risk of developing liver disease and liver failure (which would be fatal without a liver transplant). People with HIV can progress to this stage much faster than people without HIV.

Having Hep C can also mean that your HIV treatment may not be as effective as it otherwise would be. People with HIV and Hep C who start HIV treatment may see a smaller rise in their CD4 counts than people with HIV alone.

The damage Hep C does to your liver could also mean that you have a greater risk of side effects from your anti-HIV drugs, and metabolic disorders such as insulin resistance and diabetes.

You can reduce the risk of getting Hep C by:

Using a new sterile syringe and needle for injecting steroids or recreational drugs.
Making sure the man fisting you is wearing an unused latex glove. If you don’t have any latex gloves, make sure the man fisting you doesn’t have cuts or sores on his hands and has washed his hands thoroughly if he has just fisted someone else.
Using a new condom on your dildo if it’s been used on someone else.
Using your own drug snorting straw, banknote or bullet.
Using a condom when you fuck or get fucked.

If you need more information or support about Hepatitis, speak to your doctor or health adviser at your clinic. Alternatively you can contact The British Liver Trust (www.britishlivertrust.org.uk, 01425 463080) or the UK Hepatitis C Resource Centre (hepcentre.org.uk, 020 7378 5495)

Other sexually transmitted infections (STIs)

STIs such as syphilis, gonorrhoea, herpes, genital and anal warts, chlamydia or LGV (a type of chlamydia), can be more severe, progress faster and be harder to treat if you are HIV positive and your CD4 count is low. This is because having a low CD4 count means that your immune system is weaker than it otherwise would be, and is therefore less effective at fighting infections. Some STIs can also lead to more serious complications if left untreated.

For example, having a low CD4 count means that attacks of herpes can be more frequent, more severe and last longer, and LGV can progress much faster and cause extreme swelling and ulceration of the genitals.

The number of cases of syphilis seen in gay men has risen dramatically over the last few years. Syphilis can be harder to cure, more severe and progress more quickly if you have a low CD4 count. It is also highly contagious in the primary and secondary stages. More information about the different STIs can be found on our sex and sexual health site.

As having some STIs can make it easier for someone to get HIV, it is probable that having one of these STIs could make you more susceptible to re-infection, which we talk about later on this page. Some STIs can also increase your HIV viral load, making it more likely that you could pass on HIV to sexual partners.

Condoms can provide protection against some STIs, but not against all of them. However, most STIs are much easier to treat if they are diagnosed at an early stage.

Some STIs show no symptoms, so if you are sexually active then the best way to be sure you haven’t picked up an STI is to have regular free sexual health check-ups at your HIV or GUM clinic.

Re-infection

Re-infection (also known as superinfection) is being infected with another strain of HIV in addition to the one you already have.

We know that re-infection can happen, and we also know that sometimes when it happens it can have a negative impact on a person’s health. However, research so far suggests that re-infection with another strain of HIV is probably not very common, although no one can be certain of this. Research also suggests that re-infection is probably more likely to happen in the first three years after you got HIV, if you are not on HIV treatment, or if you are taking a treatment break.

Re-infection happens in exactly the same way as original (primary) HIV infection – mainly by fucking without condoms, but also by sucking cock, although oral sex carries a low risk of HIV transmission and therefore carries a low risk for re-infection.

If you are re-infected with a strain of HIV which is resistant to one or more anti-HIV drugs, your HIV treatment options could be reduced. This would mean that finding a combination of drugs that will be able to reduce your viral load to an undetectable level could be much harder.

If you are re-infected with a more aggressive strain of HIV this could cause a sudden rise in your viral load and a drop in your CD4 count, putting you at more risk of an HIV-related illness.

If you are concerned about re-infection, you can reduce the risk by using a condom when you fuck.