29.2.2 Strategies to minimise HIV transmission
Having established that PLHIV can still transmit the virus to uninfected individuals or to other PLHIV, we shall now discuss ways that PLHIV can minimise the risks of HIV transmission via the sexual route.
What are the most widely known strategies for prevention of HIV transmission through the sexual route?
These are known as the ‘ABC Rules’. ‘A’ stands for ‘Abstinence’, which means refraining from premarital sexual intercourse; ‘B’ stands for ‘Be faithful’, which means maintaining faithful relationships with a long-term partner; and ‘C’ stands for ‘proper use of Condoms’, which means correct and consistent use of condoms in sexual relations (Study Session 25).
Abstinence
Abstinence is certainly a choice for PLHIV with the aim to eliminate the risks of transmitting HIV to uninfected people or other PLHIV. However, it is still possible for PLHIV to engage in a rich and satisfying, active sex life, and we will discuss this topic in the context of the ‘B’ (maintaining faithful relationships) and ‘C’ (safer sex practises) rules.
Maintaining faithful relationships
In general, maintaining faithful relationships is an effective measure for individuals to reduce the risk of HIV infection. Remember the linear relationship between HIV transmission and the number of sexual partners that is; the higher the number of partners, the higher the risk of HIV transmission (Study Session 25). This particularly applies to PLHIV — the more partners they have, the more likely it is that they transmit the virus to other people and/or that they become re-infected.
However, for the ‘B’ rule to be effective, both partners need to be confirmed as HIV negative. It is not sufficient to maintain a faithful relationship in order to prevent HIV transmission where PLHIV are concerned, whether their partner(s) are HIV negative (as it would lead to HIV infection of a previously uninfected person) or HIV positive (as it would lead to re-infection of a person living with HIV).
Safer sex practises
In this context, it is critical that you stress the importance of consistent and correct safer sex practises to PLHIV (whether they have opted for faithful relationships or for multiple sex partners).
What are the safer sex alternatives to unprotected penetrative sex?
Non-penetrative sex practices, or penetrative sex with a condom (Study Session 25).
Thus, to reduce the risk of HIV transmission or re-infection, sexually active PLHIV should be advised to ALWAYS engage with a partner using either non-penetrative sex practises, or penetrative sex practices with a correctly used condom. If condoms are correctly used they can prevent the transmission of HIV by more than 98% (the remaining 2% reflects incorrect use of condoms). Refer to Study Session 25 for information on the correct use of condoms. In this context, safer sexual practises are also beneficial in the prevention of other sexually transmitted infections (STIs), a topic that will be further discussed in Study Session 31.
Engaging the sexual partners of PLHIV
When providing information to PLHIV about general and specific issues on prevention of HIV transmission via the sexual route, it is also important to engage their partner(s) in the discussion, whether they know their HIV status or not. This is important so that all partners involved play an active role in the prevention of HIV transmission (or re-infection). However, you should discuss with PLHIV the benefits (e.g. good adherence to ART) and/or problems of disclosing their status to their partners before they decide to do so.
Biruk and Hiwot are a young married couple in your community. Biruk is HIV-positive, so for the duration of their marriage they have engaged in safer sex practises to reduce the risk of HIV transmission to Hiwot (who has remained HIV-negative). They now want to have a baby. What issues would you discuss with them?
You should make sure that they understand that unprotected penetrative sex will greatly increase the risk of HIV infection for Hiwot. This may have consequences for the health of Hiwot and for the health of the child, should she become pregnant. If they are still intent on having a baby, refer them to the nearest health centre for further care and support.
Finally, you should also advise PLHIV (and their partner(s) and close family) on issues related to HIV transmission via contact with blood-contaminated objects. PLHIV and their close family should be particularly attentive to sharing common objects that may have been contaminated with blood. These include utensils such as needles, razor blades and toothbrushes (Figure 29.1).
It is also important to emphasise that PLHIV should never give blood for transfusion, as this could result in HIV transmission to other patients that receive their blood or blood-related products.
29.2.1 Re-infection with HIV