Preventing HIV Transmission in HIV- Discordant Couples
1. Women, put the condom on your husband or partner with your hands, your mouth or whatever it takes to make it be one of the most exciting parts of the sex act. Make it fun! Get over your embarrassment and you may be alive to have intercourse for many more years.
2. In advance, talk, negotiate and make a commitment together. Don’t just “do it”. Talk about your plan. Negotiate this plan carefully. Honestly discuss what it would mean for the uninfected person to die. That’s not fun. Remember that hope is not a method of preventing the spread of STDs.
3. Commitment to condoms – every single time – is a very effective (not perfect) step toward the prevention of HIV transmission. Agree to use outercourse or abstinence whenever condoms are not, for whatever reason, going to be used. Many of the ways of having fun sexually are far less likely than vaginal intercourse to lead to the transmission of HIV.
4. Terminate a relationship or stop having intercourse in that relationship if it is clear that the uninfected person is exposing himself or herself to the life-threatening risk of sex without consistent condom use.
5. Monogamy is moral. This is a message that resonates in most societies, and although it is not the pattern that is going to prevail in all marriages or in all long-term relationships, it is certainly worth discussing in all relationships. Monogamy is clearly a help in preventing initial infection of either partner with HIV. Monogamy in discordant couples is going to prevent the introduction of other sexually transmitted infections that may increase the risk of HIV transmission.
6. Male or female condoms must be available to be used. Female condoms may be the answer for millions of women unable to get their husbands or trusted long-term partner to use male condoms consistently AND those same women may be unable for a variety of reasons (often having to do with the status of women in a given society), to leave that relationship. The availability of adequate numbers of condoms, both male and female condoms, is a huge challenge. It is a challenge to each couple. It is also a challenge to high schools, universities, health organizations and social marketing systems. It costs less than $5.00 to produce 100 male condoms – enough for 2 acts of intercourse weekly for an entire year. Programs that make men and women return to clinics repeatedly for 3 to 12 condoms are providing inadequate supplies. This still happens in 2009 and is a disgraceful public health short-coming. Returning repeatedly to ask for condoms may also be extremely embarrassing and inconvenient.
7. Repeated testing of the HIV-negative person in a relationship may provide reinforcement for a couple to continue using condoms…leading to verbalized or unstated comments such as: “Fantastic, I’m still not infected after 4 years of very pleasurable sex – always using a condom. This is really working and it’s worth the effort.”
8. Accurate education must be available – not the typical biased inaccurate rubbish about the effectiveness of condoms promulgated by many abstinence-only sex education programs. Currently the message should be that all 3 components of the ABC approach are excellent ways to prevent new HIV infection:
A = Abstinence
B = Be Faithful
C = Condoms, and one can say that if a discordant couple has intercourse condoms are the most effective approach to preventing transmission of HIV – from 87% - 90% effective over time. Said another way, heterosexual relationships are 87% to 90% less likely to transmit HIV if condoms are used consistently and correctly.
9. Just why don’t our laws reflect the importance of this issue? Put the reproductive organs of HIV-positive people (and the rest of their bodies) into jail if they fail to inform their wife, husband or trusting long-term partner, that they are HIV-positive, or if they refuse to use condoms every single time. Jail may not be enough; however, I am one of those who oppose capital punishment. People who are HIV-positive and knowingly have intercourse with others without using a condom are killing other people. This must not be considered acceptable behavior. Schools, medical facilities and the media must speak with a united voice in opposition to this destructive behavior.
10. Finally, take this challenge seriously. I will take a crack at saying that we must
encourage condom use with passion using sentences inspired directly by Stephen King’s passionate words about writing:
You can approach preventing the transmission of HIV in HIV- discordant couples with nervousness, hopefulness, or even despair - the sense that you can never do it perfectly even if you do all you know you should do. You can come to this challenge (as the couple, or as the clinician caring for the couple, or as the purveyor of public health) with your fists clenched and your eyes narrowed, ready to kick ass and take down names. You can come to it because it is personally so important to you and to the person you love and your children and/or parents or you can do it because you want to change the world. Let me say it again- don’t come to the challenge of preventing HIV transmission in HIV-discordant couples lightly. Come with passion.
I’m not asking you to come reverently or unquestioningly; I’m not asking you to be politically correct or to cast aside your humor (God, we know you have a sense of humor when it comes to the area of sex!). This isn’t a popularity contest, it’s not the moral Olympics, and it’s not church, the synagogue, or the mosque. It’s the prevention of what has been called the worst epidemic in history. It’s an infection that causes pain, ostracism, chronic infections, cancer and death. It’s emotionally and economically extremely debilitating. If you can take it seriously, then we can do business. If you can’t or won’t take the prevention of infections using condoms seriously, it’s time for you to do something else in public health or medicine.
Wash your hands after you sneeze, maybe.
Key Words: condoms, discordant couples, prevent, HIV, talk, negotiate, commitment, STDs, sex, transmission, outercourse, abstinence, health organizations, testing, education, Stephen King, effectiveness
King, Stephen ON writing –“A Memoir of the Craft” POCKET BOOKS, a division of Simon & Schuster, Inc. New York 2000.
Posted 7-7-2009, Updated 7-9-2009, Updated 7-20-2009