Twice Bitten

By Mira Schwirtz

The virus knows no social boundaries. This means that top or bottom, infected or not, having unprotected sex with men or with women puts you at risk.

If you're HIV-positive and keeping healthy, you're probably well aware of your life's checkpoints: keeping your viral load below 50, your T-cell count above 500 and swallowing the scores of pills you have to take every day.

There is, however, one shadowy area where perhaps you'd like to feel less restricted — your sex life. If your partner is also HIV-positive, you might assume you can skip the condom or dental dam. But unfortunately, for safety's sake, that's just not the case.

This year, an HIV-positive patient in Canada was found to have developed a second strain of HIV through having unprotected sex. The patient's second infection, or "superinfection," proved resistant to the antiviral drugs he was taking and his health quickly deteriorated.

This newfound risk for "superinfection" puts an unwelcome new face on the epidemic that many in the United States had hoped was coming to a close. Doctors worry that they will see an increase in such cases, and are alerting their HIV-positive patients to protect themselves.

"For many people [who are] already HIV-positive, their primary, or only, interest is in treatments," wrote Rick Sowadsky, a communicable disease specialist from TheBody.com. "They don't think they have to learn about transmission. Actually, learning about it is more important than ever."

For people with HIV, any kind of infection comes with risks. If you have HIV, contracting a sexually transmitted disease or another strain of HIV could worsen your condition, explained Dr. Karen Perkins, an OB/GYN at Baltimore's Mercy Medical Center.

Re-infection can make you resistant to the drugs you take. And with a limited number of drugs available, you don't want to limit your options, Dr. Perkins cautioned.

Even "curable" sexually transmitted diseases can be dangerous, said Dr. Perkins, because they can be more difficult to treat in people with compromised immune systems. They can also make you susceptible to opportunistic infections like Kaposi's Sarcoma or other air-borne diseases such as tuberculosis or pneumonia.

While the science regarding HIV transmission has changed, for the most part, public thinking has not. Until people begin to realize the chances they're taking, doctors will likely begin to see more "superinfection" cases.

When it comes to HIV, oftentimes the biggest challenge is thwarting misinformation. Until recently, experts were unaware that there was any risk in unprotected sex between HIV-positive partners. HIV-positive people who worried they'd never have sex again were routinely counseled to seek out positive partners.

Myths about HIV transmission are rampant. Many people, for example, still mistakenly believe that they are safe from infection, so long as they stay "on top."

Today, experts maintain that transmission of the AIDS virus can occur whenever a person comes into contact with infected bodily fluids. The virus knows no social boundaries. This means that top or bottom, infected or not, having unprotected sex with men or with women puts you at risk. The question is: how much?

"If you're talking about the hierarchy of risk, for sure, any kind of anal sex is very high risk because it is the most efficient point of transmission," said Dr. Cynthia Gomez, researcher at the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco.

The possibility of contracting HIV through unprotected vaginal intercourse is also great, Dr. Gomez warns. And while lower on the list, oral sex is risky, too. Without knowing for certain your partner's HIV status, there are no guarantees. And contrary to what some people believe, people don't wear their HIV-status on their sleeves.

"A lot of the young men and women I treat think they can tell if someone is HIV-positive by looking at them. That's where their freehandedness in not using a condom comes from," said Perkins.

Even if you are equipped with all the right information, subconscious denial or emotional needs can lead anyone to take chances. After all, sex is more complicated then, well, sex.

"A lot of it is companionship, self-esteem, a validation of a person's identity," said Dr. Robert Hays, a research psychologist at CAPS. "Especially for HIV-positive people who can feel isolated, not using a condom is a calculated risk."

Clearly, dealing with complex emotional situations demands more than the mandate "practice safe sex" has to offer. Health professionals say the problem must be solved at the root, through longer-term counseling.

Rather than opt for the fleeting, Russian roulette of a one-night encounter, many counselors encourage clients to understand what sex really means to them and what emotional impulses lead them to put themselves at risk.

"It's very important that the deeper problems are addressed. We need to really understand the things that contribute to safe sexual behavior. We're getting more sophisticated in saying how can we get people to practice safe sex when they're depressed or when alcohol is involved," said Dr. Gomez.

For many, the allure of sex is not only physical, but emotional pleasure. "Sex without condoms comes to mean freedom and enjoyment," Hays said.

To respond to these complex needs, said Steven Gibson, program director at the Stop AIDS Project in San Francisco, "we talk about alternative tricks of the trade."

Some of those alternatives can include: exploring ways to eroticize latex barriers, masturbating with a partner, or use of (clean or protected) sex toys. For safer anal sex, Gibson says, some couples use condoms originally designed for vaginal intercourse, sometimes called "condoms for women."

In spite of the challenges, there are indications that people are, in fact, minimizing their risk.

"I think people, especially as they get older, are being safer," said Dr. Perkins.

"A lot of guys do a fantastic job of protecting themselves," said Steven Gibson. "And that's because they have changed their sexual behavior."

Mira Schwirtz is a freelance writer and journalism teacher based in the San Francisco Bay Area.

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