Preventing Transmission through Sex, Drugs, or Pregnancy Safer Sex

The risk of HIV transmission by sexual contact can be reduced in three ways: (1) reducing the viral load is a theoretically effective method that will probably help reduce transmission but will never be completely ef­fective, because the risk is always relative and never zero; (2) treatment with drugs against HIV after initial exposure works for health care workers with occupational exposures, but the drugs must be taken within hours, and we have no proof that such treatment will also work with sexual exposure; and (3) “safe sex,” based on extensive theory and scientific data.

One good way to prevent transmission of HIV during sexual inter­course is to use a barrier against body fluids—that is, use condoms. Con­doms should be used during vaginal, oral, or anal sex to prevent expo­sure not only to HIV but also to all other sexually transmitted diseases, including gonorrhea, syphilis, herpes, and chlamydia.

The Food and Drug Administration inspects condoms for leakage: ten ounces of water are poured into the condom, and the condom is pressed and rolled along blotter paper. If more than 4 per 1,000 con­doms leak, the entire manufacturer’s lot must be destroyed. The major problems with condoms, however, are not that they leak, but that they are used inconsistently, they break, or they fall off. Surveys show that fewer than 10 percent of Americans use condoms regularly for sexual intercourse. An estimated 2 to 5 percent of condoms tear during use, usually because they are used improperly, not because they are flawed.

The usefulness of condoms in reducing HIV transmission has been established by two studies of discordant couples.

1. Use latex or polyurethane condoms. They are less porous—that is, they are less likely to have minute holes through which the virus can pass—than condoms made from animal skins. The latex and polyurethane varieties are also substantially less expensive. Con­doms manufactured by large companies—Ansell, Inc., Carter­Wallace, Circle Rubber Company, and Schmid Laboratories — are generally more reliable than those from small companies that are sold in novelty shops.

2. Reduce the risk of breakage by leaving the condom in the pack­age until used. Condoms should be stored in a cool and dry place out of direct sunlight. With appropriate storage, most condoms re­tain their durability for up to three years. Condoms that are in dam­aged packages or show such signs of age as brittle texture, sticky surface, or discoloration should be discarded. Open the package carefully to avoid tearing the condom. Maintain an adequate sup­ply of condoms.

3. The use of lubricants is encouraged, but oil-based lubricants (like Vaseline, Crisco, baby oil, cooking oil, and skin moisturizers) will dissolve latex and leave microscopic holes and should therefore be avoided. The preferred lubricants are water-based (like K-Y Jelly). Many condoms are supplied with such lubricants as oil, glycerine, or surgical jelly. The lubricant should be placed on the outside of the condom and inside the partner.

4. In 1994, Consumers’ Guide evaluated 37 brands of latex con­doms, 6,500 condoms in all, with air inflation tests that measure breakage potential.

5. Fewer than 1 percent of people are allergic to latex and experi­ence irritation or burning. This allergy is most common in medical personnel who have extensive contact with latex gloves, catheters, masks, etc. Many of the allergic reactions are actually reactions to the lubricants, spermicides, or materials used in manufacturing; changing the brand of latex supplies is therefore effective. For true allergies to latex, the next best alternative is condoms made from polyurethane (like the Avanti brand).

6. The spermicide nonoxynol 9 rapidly kills both HIV and sperm. It also kills other microbes that cause sexually transmitted diseases like gonorrhea and chlamydia. Nonoxynol 9 is available as spermicidal creams, jellies, or contraceptive sponges. Nonoxynol 9 was once widely advocated to reduce HIV transmission but has fallen into dis­favor because it apparently can cause vaginal irritation and tiny abrasions that actually increase the chance of becoming infected. Current research is now in hot pursuit of other vaginal microbicides that do the job without the irritation.

7. The condom must be put on before any sexual contact, oral or genital or anal. The tip is placed over the erect penis. If the condom has a reservoir tip, first squeeze out the air; if the condom has no reservoir tip, leave about a half-inch space for semen, then squeeze the air out. Unroll the condom down the entire length of the penis.

8. Condoms should be used for vaginal or anal sex and for fellatio (oral sex performed on a man). Rubber or latex dams placed over the woman’s genitals should be used for cunnilingus (oral sex per­formed on a woman). Latex dental dams are available in dental sup­ply stores. There is now a female condom for vaginal intercourse. The female condom looks like a tunnel with two rings at the ends; one ring fits high in the vagina and the other is external.

9. If a condom leaks or breaks, both partners should wash their gen­itals with soap and water. A spermicide may also be useful for pro­tecting against HIV transmission, but it should be applied rapidly. Douching is not recommended for women because it can force se­men up through the cervix. When accidental exposure to HIV has happened, some health services provide a one-month course of anti­HIV drugs. Remember, however, that the drugs must be taken with 48 to 72 hours of exposure, and preferably within 1 to 2 hours. Fur­thermore, the drugs cause many side effects; the cost of the drugs is $500 to $1,000 for the month’s supply, and no one has any evidence that the drugs will prevent transmission.

10. Avoid contact with the menstrual blood of any woman with HIV. Menstrual blood also contains HIV. Use a condom.

Any method of birth control that allows pregnancy will also allow transmission of HIV. Some methods of birth control—rhythm or the pill, for example—prevent pregnancy but allow transmission of HIV.

The alternative to condoms is to have sexual contact that does not exchange body fluids at all. This kind of contact includes body-to-body rubbing, acting out sexual fantasies, or mutual masturbation using dis­posable latex gloves.

The basic principle of safer sex is to avoid getting the body fluids of a person with HIV infection into the body of another person. That can be accomplished by a barrier—condoms, latex dams, latex gloves—be- tween the body fluids of the person with HIV infection and the other person, or by sexual contact or play that does not involve body fluids at all. For specific safer sex practices, and for alternatives to sex, see the booklet put out by the Gay Men’s Health Crisis (GMHC), 129 W. 20th Street, New York, N.Y. 10011, 1-212-807-6655.

Avoid Injection Drug Use

The obvious way to avoid transmitting HIV during injection drug use is to stop using drugs that are injected. Many people who use drugs, how­ever, are unable to curb this habit. Some people who would like to stop using drugs may have difficulty finding programs—such as methadone clinics or detoxification centers—that are available. Those who find it impossible to stop using drugs by injection should avoid sharing needles, avoid sharing works, and, of course, practice safer sex.

Anyone who can’t avoid sharing should clean the needle and works.

Table 1. Percentage Who Accidentally Become Pregnant in One Year Using Various Birth Control Methods

Source: Adapted from Robert A. Hatcher et al., Contraceptive Technology, 16th rev. ed. (New York: Irvington Publishers, 1994), 113.

Clean needles are often available from needle-exchange programs, which seem to reduce HIV risk without changing the frequency of drug de­pendency. Another alternative, available in 48 states, is to ask physicians to prescribe needles and syringes and pharmacists to dispense needles and syringes.

1. Use full-strength household bleach.

2. Pour the bleach into a glass, immerse the needle and syringe to cover completely, and then draw the bleach up to fill the syringe. Bleach should probably be left in the syringe not less than two min­utes. The two-minute period is absolutely critical.

3. Discharge the bleach and repeat the process.

4. Rinse the syringe by filling and discharging water twice.

5. Alcohol is an adequate substitute for bleach.

The drawback to these ways of preventing transmission of HIV is that using any drugs at all reduces a person’s inhibitions. With reduced inhibitions, people are much less likely to practice safer sex and to avoid sharing needles and works, in spite of good intentions. Other substances that reduce inhibitions carry the same danger. This applies to mind­altering drugs that are not necessarily injected, such as alcohol, cocaine, crack, amyl nitrate (poppers), marijuana, barbiturates, and ampheta­mines (speed).

Think Hard about Pregnancy;

Avoid Breast-Feeding

Getting pregnant—as of course people wish to do—without risking transmission of HIV can be done with artificial insemination if the sperm comes from an uninfected man; or if the man’s viral load is undetectable, then possibly with sperm-washing. Nevertheless, women with HIV in­fection may wish to avoid pregnancy. The probability of transmission of HIV to the baby, if the mother takes drugs to reduce HIV, is about 7 per­cent. This probability varies with the mother’s viral load: if her viral load is high at delivery, the probability of transmission is also high; but if her viral load is under 1,000, then the risk of transmission is under 1 per­cent. Women with higher viral loads have the option of delivering the baby by cesarean section, which reduces the risk of transmission to less than 2 percent. In this case, the cesarean section must be done before the delivery date, at 38 weeks, and before the membranes rupture (before the water breaks). Any woman considering pregnancy or considering an abortion to terminate a pregnancy absolutely must discuss these issues with an obstetrician versed in HIV infection.

To avoid pregnancy, the most reliable method is tubal ligation, or having your tubes tied. The birth control pill is also extremely reliable, 98 percent effective. The rate of failure with condoms is 10 percent, so condoms are considered unreliable. To prevent transmission of HIV in­fection and other sexually transmitted diseases, use condoms. To prevent transmission and pregnancy, use condoms plus the pill.

If abortion is desired, it is best performed during the first fourteen weeks of pregnancy, when it is considered most safe. Abortions during the period of fourteen to twenty weeks are offered by some specialized clinics, but hospitalization is usually required and the risk to the mother is somewhat greater.

A woman who chooses to continue the pregnancy needs to tell her obstetrician about her HIV infection. In fact, the standard policy is now to give HIV tests to all pregnant women, because the risk of transmit­ting HIV to the baby can be reduced so effectively with drugs that con­trol HIV and with deliveries by cesarean section. The original study demonstrating the benefit of treatment showed that AZT could reduce the rate of transmission from the mother to the baby from 25 percent to 8 percent. Subsequent studies showed that AZT plus additional drugs could reduce the transmission rate to the baby to 2 to 3 percent. It was then recommended that all pregnant women with HIV infection who de­cide to continue the pregnancy take standard HAART.

The following are principles for HIV care during pregnancy: (1) The mother should usually receive treatment with multiple drugs, which in­clude AZT because it works. (2) The HIV drug to avoid during preg­nancy is efavirenz. (3) The goal of therapy should be to get the viral load as low as possible, both for the mother’s health and for reducing trans­mission to the baby. (4) Consider cesarean section at 38 weeks an op­tion if the viral load is not reduced to less than 2,000. (5) Drugs used to control HIV are often difficult for pregnant women to take because of side effects, especially gastrointestinal problems. Furthermore, different concentrations of HIV drugs are used during pregnancy. Consequently, the pregnant woman with HIV infection needs an obstetrician who spe­cializes in HIV infection.

The safety of the drugs used for HIV infection in pregnant women has been studied for ten years through the HIV Drug Registry, which keeps track of the experiences of pregnant women with all antiretrovi­ral drugs and records the side effects to the unborn child. So far the only unsafe drug found is efavirenz, which causes birth defects in about one in fifty infants exposed to the drug during the first trimester, the first three months of pregnancy. As a result physicians are now warned not to prescribe efavirenz to any woman who is pregnant or likely to become pregnant. Other HIV drugs appear to be safe, but the track record on some of them is still sparse. Obstetricians who specialize in HIV infec­tion stay aware of all the numbers.

The woman who chooses to continue the pregnancy also needs to tell her pediatrician about her HIV infection. The pediatrician will then give the appropriate preventive treatments—usually including AZT for six weeks—to the child. The pediatrician will also know what to look for during the child’s medical evaluations, will increase the number of visits, and will decide whether to change the schedule of childhood vac­cinations. Many pediatricians do not feel competent to care for children with HIV infection. Nor do many pediatricians know which tests for telling whether the child is infected are currently in vogue; the standard blood test for HIV infection will not give valid results until the child is 15 months old, but alternative tests, including the viral load test, are now commonly used. It might be best to ask your pediatrician to refer you to a pediatrician with a specific interest in HIV infection. You should get this reference immediately, because beginning the treatment early might be critical to the treatment’s success.

The woman who continues the pregnancy should also plan not to breast-feed her baby. HIV is found in breast milk, and the baby could also be infected by breast-feeding (see above, page 39).

Women who are already pregnant should take the test for HIV. This testing is for the sake of both the mother and the child. Some obstetri­cians offer such tests to all pregnant women, some offer the test only to those considered at risk for HIV infection, some do not think of HIV in­fection at all unless reminded, and some states have laws requiring that HIV tests be offered.