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Sexual health

“Healthy sexuality is more than just practicing safe sex – it involves healthy relationships, self esteem, and feeling good about the decisions you make.” 
Ministry of Health Promotion and Protection. Government of Nova Scotia

The decision to begin having a sexual relationship is a complicated one.  And what exactly is meant by sexual health? Well it includes things like how to protect yourself from sexually transmitted infections (STIs), how to protect your partner from HIV transmission, how to prevent pregnancy until it is planned, and how to work on negotiation skills so you and are partner feel comfortable with your decisions.

There is a lot of information on the web about sexuality.  Some of it is reliable, some isn’t.  There are several sites listed in our resources section that you can visit for more detailed information about sexuality.

Healthy relationships and disclosure

Relationships

Because you and your partner are unique people, every relationship will be different.
Some keys to healthy relationships:

  • You and your partner feel good about the decisions you are making together. 
  • You can have fun with and without each other, and you can always be yourself. 

Disclosure

You have thought about having sex and you know you have to disclose your status, but when? And how?  Disclosing your HIV status to sexual partners can be emotionally challenging. Unfortunately, it’s not something that is just going to disappear the longer you put it off.

You are not alone.  Other people have been there and have gone on to have relationships. Some people choose to disclose early on so they don’t waste their time with someone who doesn’t want to deal with HIV. Others wait until there is a sense of trust and connection in the relationship before disclosing. It’s entirely up to you when you disclose.

Sharing your status involves opening up and changing the relationship and sex life. Although it may lead to better intimacy, there are other reactions which people fear:

  • You could be rejected
  • Your partner will accuse you of being unfaithful
  • Your partner could leave you
  • Your partner will not want to touch you

But these are not reasons not to tell. You need to plan when to have the conversation and the timing needs to be right. Disclosure should happen at a time when you are both comfortable and in an environment where you can be open and honest. Under no circumstances should you disclose in the following situations: right before you are going to have sex, when you have been drinking or taking drugs.

If you feel you can’t disclose to someone, whether they are a partner or a more casual contact, then you shouldn’t have vaginal, anal or oral sex with them.

If you don’t feel comfortable getting in touch with previous sexual partners, Public Health can notify them anonymously. 

In Canada it is now the law that you must inform your partner of your status before having sex. You may face criminal charges if you knowingly keep your HIV status from a sexual partner. Disclosure is one way of protecting yourself and your partner. To find out more information about legal cases related to disclosure visit www.aidslaw.ca.

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Deciding: when is it right to start having sex

Decisions about being intimate are individual.  Nobody can make these choices for you. Here is a checklist of questions to think about before you make your decision.

  1. How comfortable do you feel about becoming intimate with your boyfriend/girlfriend? How comfortable is your partner?
  2. Have you disclosed your HIV status to your partner or do you have a plan in place to make this disclosure before you have sex?
  3. Are you feeling pressured or is this decision mutual?
  4. Have either of you ever had sexual contact before? If so, perhaps you need to check for STIs – remember, some STIs will have no signs or symptoms.
  5. Protection – do you have condoms and lubrication? If not, who is going to get them?
  6. Contraception – what options work best for both of you? Remember, it’s best to use condoms AND lubrication AND contraception.
  7. Timing – where and when do you want to have sex?
  8. Wants, needs and limits- Have you talked about what kind of things you are okay to do, what things you don’t like and what you would like to try?
  9. Consent – before you have any kind of sex, it is important to make sure that your partner has agreed. Either of you can say no at any time.  Part of this consent is disclosing your HIV status.

Safer sex choices

Safer sex is about keeping yourself healthy while also preventing the spread of HIV. Most sexual activity carries some risk of spreading sexually transmitted infections. To reduce the risk, make it more difficult for blood or sexual fluid to get into your partner’s body.  Pay attention to your body and your partner’s. Cuts, sores, or bleeding gums increase the risk of spreading infections. Rough sexual activity also increases the risk. Even small injuries give STI germs a way to get into the body.

There are many different kinds of sex that you and your partner may want to try.  Kissing, touching, watching each other masturbate and sharing sexual fantasies are all very safe activities. 

It is important to remember to use a barrier to prevent contact with blood or sexual fluid. To learn more about barriers check out the Contraception and Protection.

Even if you and the person you are going to have sex with are both HIV positive, it is still important to use safer sex practices.

Masturbation

Masturbation is anything you do to give yourself sexual pleasure.  It usually involves touching your genitals, and often includes sexual fantasy.  Masturbation is the safest form of sex there is.  You can try things out in your mind and with your body without involving anyone else. 

  • Masturbation does not “use up” anything (other than some energy).
  • People often masturbate alone, but this can also be an activity with a sexual partner. It is safe as long as no bodily fluids come into contact with mucous membranes or an open wound or sore.
  • Lubrication isn’t just something to use with a partner—many people will use a lubricant when they masturbate.
  • You don’t need any special equipment to masturbate, but some people use sex toys.  Sex toys made from silicone can be boiled to disinfect them.  If you have other sex toys, it isn’t a good idea to share them.

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Contraception and protection

We talk about contraception and STI protection together because there is some overlap.

Contraception  is anything that stops a woman from getting pregnant.  Many contraceptive methods do not protect against STI.  These methods tend to work better as birth control than things like condoms, which is why we recommend using both a barrier and non-barrier form of contraception.

STI protection is all about creating a barrier that stops one person’s bodily fluids (blood, saliva, semen and vaginal secretions) from getting onto or into someone else.  There are some barrier methods of contraception that don’t work as STI barriers, so stay away from them.  They can give you a false sense of security.

Barrier methods  protect both you and your partner from sexually transmitted infections.  Even if you are both HIV positive, you can give each other different strains of the virus.  And getting another STI is not a good idea.

Contraceptive choices

Here are descriptions of various types of birth control and anything we know about the relationship between them, antivirals or HIV.  For more detailed information, check out the sites listed in our resources section

Oral contraceptives (the pill): a contraceptive suitable for most healthy women, regardless of age, and can be used long-term. With proper use, the pill is very effective.

There are some concerns that using the pill may not be as effective when a woman is also taking antiretroviral therapy.  It is important to consult with your Family Doctor, HIV Specialist, or gynaecologist to make sure starting that any antiviral therapy you might be taking won’t lower the effectiveness of the pill.

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The contraceptive patch sticks to a woman's skin and continuously releases hormones into the bloodstream to prevent unplanned pregnancies. You put a new patch on once a week and can shower with it on.  Like the Pill, the Patch is very effective at preventing pregnancy.

Because the patch is a medication like The Pill you should talk to a doctor about possible interactions with medications you are currently taking before you begin using it.

The vaginal ring is a soft, flexible, clear plastic ring that you insert into your vagina where it remains for three weeks. The ring is as effective as The Pill in preventing pregnancy. 

You or your partner might hear about a ring that is being developed that researchers hope will fight off the HIV virus.  Remember, this is not the same as the vaginal ring. You should check with your doctor to make sure using the vaginal ring with any medication you are currently taking is safe and effective.

Injection: like the pill and the patch, the injection is a hormonal birth control method.  It is a shot you get every 12-13 weeks. It is 99.7% effective in preventing pregnancy.

Some studies have shown that using this type of birth control can change the immune system which is important to consider for people living with HIV. So talk with a doctor about this and also possible interactions with medications before getting a shot.

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The Intra-uterine System (IUS) is a small device placed into the uterus  by a doctor.  The IUS releases a small amount of a hormone and is the most effective form of birth control available.  It also lasts for five years before it needs to be replaced.  Most women’s periods stop when using the IUS.

There are also Intra-uterine devices that don’t release hormone.  They are not recommended for use with women who have HIV, and in fact aren’t a great choice for any woman, given an increased risk of infections.  They are also associated with increased menstrual bleeding.

Barrier methods

The male condom is a tube with a closed end that is rolled over the penis to prevent secretions, including semen, from entering the vagina, mouth or anus.

Condoms are either made of latex, polyurethane or polyisoprene. If you aren’t allergic to latex, latex condoms are the best ones to use because they are cheaper and more easily available.

Using condoms with water-based lubricant will help prevent the condom from breaking.  Most lubes taste terrible so un-lubricated condoms work best for oral sex.

The female condom is a polyurethane baggie-like object inserted into the vagina before sex. The baggie holds in the semen, preventing it from entering the vagina.  It tends to make funny noises.  Because it isn’t tight fitting, semen can drip out and be in contact with the woman’s skin.

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Take the "Do you know you contraceptives?" quiz

Sexually Transmitted Infections (STIs)

Have you ever wondered if there are different considerations about STIs for people infected with HIV? Well the answer is yes! 

First, because your immune system is already weakened by HIV, you are at an increased risk of contracting an additional STI.  Second, because some STIs cause open wounds/sores/ulcers on the genitals, this creates an opportunity for the virus to exit your body and enter your partners.  Third, because of your weakened immunity, the seriousness of an STI can be much greater for you.

There are important considerations in protecting your partner as well.  Because STIs are infections, the body will mount a response to the infection by sending extra helper cells (CD4+ cells) to the genitals.  The CD4+ cells are the ones that HIV attaches itself to.  If your partner has an STI and you are not using a barrier method there are more cells for the virus to attach itself to-this will increase the risk of transmission.

For more specific information about the STIs explained on this site visit ww.sexualityandu.ca/teens/sti.aspx

Bacterial infections

Gonorrhoea and Syphilis

  • Being infected with a bacterial STI can make you more infectious to your partner because breakdown of the skin or mucous membranes can let more virus get into the vagina, urethra or on to the penis
  • Also because your immune system will be trying to fight off the new virus, it can get tired and may have a weaker response to the HIV.
  • Syphilis can show up in many different ways in your body, which can make it hard for doctors to diagnose.
  • Gonorrhoea can cause Pelvic Inflammatory Disease (PID)

Treatment:  Bacterial STIs are treated with antibiotics.  People with HIV are treated the same as those who are not infected.

Other Infections

 Chlamydia,

Even though Chlamydia is actually a very small parasite that lives inside cells, the stuff above about bacterial infections is true for it too.

Chlamydia can cause Pelvic Inflammatory Disease (PID)

Trichomonas

  • Trichomonas or “trich” is a relatively common STI that can make  intercourse painful, although some people don’t even know they have it.
  • The worst thing about trich is that bacteria and viruses can become “hitchhikers” on it, and be carried farther than they could travel on their own.  So a woman can get much sicker from gonorrhea or Chlamydia than they would have without the trich.
  • Important implications of trich for somebody with HIV
    • There is research that shows that trich can increase the spread of HIV in two ways. First, your uninfected partner is more likely to be infected with HIV if s/he has trich.   Second, if you have trich,  this can increase the amount of HIV in your sexual fluids
    • Someone with HIV may not be able to fight off infections very well, so there is a bigger chance of getting sick or having symptoms from trich
    • An infection with trich increases your susceptibility to other STIs both at the time of infection and later

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Viral infections

Genital Herpes

  • For someone who is infected with HIV an infection with genital herpes can be troublesome; each one can worsen the effects of the other. 
  • When the virus that causes herpes is active it can increase HIV replication (increased viral load).  This can lead to a weaker immune system which will have a negative impact on the immune system’s ability to fight the herpes virus.
  • People infected with both HIV and the herpes virus may have longer, more frequent, and more severe outbreaks of herpes symptoms.
    Treatment: It's more difficult to treat genital herpes if you also have HIV. In some cases the herpes virus can become resistant to the medicines used to treat herpes viruses.

Hepatitis B virus

  • Hepatitis B is the leading cause of chronic liver disease
  • As many as 10% of people living  with HIV in the world also have Hepatitis B.
  • HIV and Hepatitis B co-infections cause a number of severe consequences including:
    • more liver-related illness (morbidity)
    • more deaths (mortality)
    • faster reproduction of the Hepatitis virus because of a weakened immune system.
  • Another dangerous complication is that at times as the immune system recovers through the use of antiretroviral therapy it overreacts to the Hepatitis infection and actually makes the liver disease worst. This is called immune reconstitution inflammatory syndrome (IRIS) and can be very dangerous.
  • The damage that is caused to the liver from Hepatitis can also lead to toxic levels of antiretroviral drugs as the liver is not working well.  This is called hepatotoxicity.

Human Papilloma Virus (HPV)

  • HPV is the most common sexually transmitted infection. 
  • It can cause wart-like growths on the genitals. There are many types of HPV, and some types do not cause growths. 
  • HPV can cause pre-cancerous changes in the cervix.  Women with impaired immune systems are more likely to go on to develop cancer than other women.  
  • Women with HIV and HPV co-infection are five times more likely to develop cervical cancer from HPV than HIV negative women.  Treatment of HPV-related cancer is often difficult to treat and, in women with HIV,  the cancer often re-occurs.
  • The risk is not just for women!   HPV has been shown to be the cause of other anogenital cancers (anal cancer) in men who are infected with HIV.
  • Protecting yourself from HPV infection is very important.  In addition to using barrier protection, for women regular pap tests or HPV tests can catch the virus. HPV testing is also recommended for men who are HIV positive.
  • For some extra information on HPV check out www.hpvinfo.ca
  • There is now a vaccine that can protect you against the HPV infection. You may want to speak to your doctor about getting this vaccine. You might have gotten this shot at school.  If you didn't, consider talking with your doctor or nurse about getting the shot.