Positive Life NSW

Asha Persson discusses findings from the second phase of the Straightpoz study, which explores the lives of people living heterosexually with HIV in NSW, including heterosexual partners.

The first phase of the Straightpoz study found that unprotected sex was quite common among serodiscordant (positive/negative) couples. Other research also suggests that a significant proportion (between 20 and 60 percent) of HIV positive heterosexual men and women practise unprotected sex with their negative partner, with no apparent gender differences. Yet there is little research on the dynamics and meanings of sexual practices among serodiscordant heterosexual couples. Against this background, the second Straightpoz phase aimed to gain further insights into serodiscordant sexuality through a deeper exploration of sexual strategies, sexual negotiations and the topic of this article: the study participants’ understandings of ‘safe sex’.

Many participants said they were aware of safe sex messages but did not practise safe sex before their HIV diagnosis or before meeting their positive partner. Their explanations for this tended to be gendered and indicative of the marginality of HIV in heterosexual society. A common theme among the positive men was that they ‘didn’t give it much thought’ at the time. Invoking conventional discourses of masculinity, they described themselves as ‘young’ and ‘reckless’, or as ‘having a good time’ and feeling ‘invincible’ or ‘bullet-proof’. Tobias said: ‘I knew you could catch STIs but that was something that happened to other people, really’.

Others had not considered safe sex to be a personal concern at the time because they had been in an assumed monogamous relationship. This theme was more common among the women, both positive and negative. They explained that they had practised unprotected sex with their partner or husband, believing the relationship to be safe, which for some turned out not to be the case. Several women also mentioned the difficulties of adhering to safe sex because, as Sabrina put it, ‘you know what men are like’. Others described how their understanding of safe sex had mainly centred on avoiding pregnancy. This theme was common among older participants and those who were diagnosed early in the epidemic, but was not exclusive to them. Several themes converge in this quote by Zoe who was diagnosed in the late ‘90s:

Okay, before I tested positive, me, only thing I was worried about is getting pregnant. And I was on the Pill … I learnt about, you know, safe sex and condoms, and stuff, at school. But I don’t know … the guy that gave [HIV] to me never ever used, wouldn’t use condoms ... You think that nothing will happen to you. You don’t even think. I never thought that I would get HIV for it. You know? It just didn’t come to mind.

For most participants, understandings of safe sex shifted with their HIV diagnosis or upon meeting their positive partner. A desire to prevent transmission of HIV was the norm among the participants, irrespective of their HIV status. Nearly all now interpreted safe sex to mean the use of protective barriers to prevent exchange of bodily fluids, with an emphasis on condoms with any penetrative sex. But this textbook definition did not necessarily carry the same meanings and implications for all on a personal level. Yet regardless of their own sexual practice, almost everyone expressed unequivocal views on condoms, including Angus who had practised both protected and unprotected sex with negative partners who were aware of his HIV status: ‘That’s all there is to it in my eyes. There shouldn’t be any “do this or that” ... Penetration occurs; stick the condom on. That’s it.’ Maria who always had protected sex with her positive partner, said: ‘There is no alternative to safe sex. You have to have a condom. That’s it.’ Victor who had had protected sex with casual partners and sex workers, stated:

There’s only one thing and it’s called a condom. And it’s all I really understand. I don’t believe there’s any more to safe sex than that. That’s the only understanding I have. I really wouldn’t want to be prone to listening to anything else, anyone else’s opinion.

Others similarly emphasised condoms, but would add other elements to this interpretation of safe sex, including lubrication, checking hands, mouths and genitals for cuts, being ‘clean’, and ‘knowing your partner’. Several positive participants also mentioned disclosure as a key aspect of safe sex. But others strongly rejected the obligation to disclose to casual partners as unreasonable and as irrelevant to sexual safety if they used condoms. In addition to condoms, some described a broader repertoire of safe sex, including foreplay, the use of sex toys, and mutual masturbation. However, many were uncertain about the safety of oral sex, particularly the specific safety of each different direction of cunnilingus and fellatio between a positive and negative partner.

Participants obtained safe sex information from several sources, most commonly from HIV doctors or other health workers, followed by the Internet, Talkabout, and brochures at HIV or sexual health clinics. Only a few, mostly negative partners, had obtained safe sex information from GPs, but complained that they ‘don’t have a clue what they’re talking about’, as Alice stated: ‘They told me it’s 100% that I’ll catch HIV’. Some had received safe sex education in prison or rehab.

Some said they found current safe sex information too ambiguous. Others felt that it only addressed the physical nature of HIV and sex, but not the emotional complexities involved in negotiating serodiscordant sexuality ‘on an ongoing basis, day-to-day, for the rest of your life’ (Olivia, positive). Many did not keep up with safe sex information because, as one woman put it: ‘everyone knows that safe sex is condoms’ (Sabrina, positive). But the pervasive emphasis on condoms among participants did not always translate into practice:

I think I pretty much basically know what one is supposed to do, or what one is not supposed to do. But do people follow this? I mean it’s down to what happens between the two people in the bedroom, isn’t it? (Denise, positive)

Among both positive and negative participants who had consensual unprotected sex with a serodiscordant partner, there was often a discrepancy between their definition of safe sex and their own sexual practice. However, they did not necessarily consider their sexual practice as unsafe, although a few did, with most relying on mutually agreed alternative risk-reduction strategies. Such strategies included withdrawal, putting a condom on before cumming, abstinence or condom use during menstruation or when the positive partner was sick, no anal sex and an undetectable viral load. These strategies were seen as reasonable precautions against the risk of transmission in light of current knowledge. A partner’s ongoing HIV-negativity often reinforced the sense that the right balance had been found between safety and acceptable risk:

My attitude is, well, hang on a minute. I’ve been with this guy for five years and I still haven’t got it. It can’t be all that risky. And secondly, it’s not easy to get. You’ve really gotta be serious about it if you want to get it, because it’s such a fragile virus. It doesn’t survive well outside the body. (Claire, negative)

It is interesting to note that, although the interviews were conducted prior to the controversial Swiss consensus statement, some couples who practised unprotected sex were already drawing on similar understandings of undetectability and reduced risk, with the one difference being that they believed an undetectable viral load made a positive partner less infectious, rather than non-infectious as claimed in the Swiss statement. Lydia said: ‘I’m lucky at the moment, touch wood, because my viral load is undetectable and my count is good, so there’s even less risk of passing it along’. Similarly, Mahmoud stated: ‘[A]t the moment because of my T-cells and my viral load is undetectable, so I’m pretty safe, you know’. Olivia had recently started to have unprotected sex with her negative husband in an attempt to conceive:

The first couple of times that happened I was stressing out. Like I was saying, “Look, you know, I’ll take you into the clinic and you can get some pills. You’ve gotta take ‘em for a month.” And he’s like, “Look, the risk’s low. You’re undetectable. I know the score. Stop worrying.”

Several participants said they had been informed by their doctor that an undetectable viral load made sex safer, although no doctor had endorsed it as a substitute for protected sex. It should be noted that in all couples that practised unprotected sex, the positive partner was on treatments and had an undetectable viral load. However, not all positive partners who were on treatments and had an undetectable viral load had unprotected sex. Nor did any couple state that undetectability was the reason for their decision to have unprotected sex. Indeed, it was difficult to ascertain to what extent undetectability was a driver of unprotected sex or to what extent it worked to reassure couples that what they were already doing was relatively safe.

Couples who had unprotected sex also emphasised monogamy as an important part of safer sex, another key aspect of the Swiss statement. Monogamy was seen as important primarily to avoid ‘picking anything up from anybody else’, as Claire (negative) explained in reference to other STIs that could increase the risk of HIV transmission. But a few also alluded to monogamy as safe in that it contained both HIV and intimacy within the couple. As positive partner Mahmoud said: ‘Just me and her. No-one else. That’s it. And that to me is safe sex’. Or as negative partner Gabriel, put it: ‘There’s only the two of us. And we basically do what we want to do’.

Many who had unprotected sex also referred to the perceived low incidence of heterosexual transmission. Positive men tended to state that vaginal sex was far less risky than anal sex, while positive women and negative men tended to emphasise that the risk of transmission from a woman to a man was particularly low: ‘Basically a heterosexual relationship between a male and a female where the female’s positive, it’s very, very, very difficult for the virus to be passed onto the male partner’ (Gabriel, negative). Donna, who is positive, summed up several themes:

I think that the likelihood is very, very, very remote ... And a health care professional, a professor, has said he would deny it if ever confronted, but that’s what he believes also. So with that knowledge, with the knowledge that there’s longevity now, with the precautions that I take with regards to my health, I don’t have herpes and I don’t have anal sex, so consequently, if I’m lubricated, then there’s a very, very, very slim chance of contamination. And sixteen years [of unprotected sex] with my [negative] partner proved that … Or whether it’s just luck, whether we’re playing Russian roulette, I don’t know.

As hinted in this quote, while couples who practised unprotected sex would rely on a range of risk reduction strategies, no one was confident that their sexual practice was completely safe and some were deeply conflicted. Because of their limited contact with other people living heterosexually with HIV, most couples operated in a kind of social vacuum with little sense of how their sexual practice compared with that of other serodiscordant couples. Zoe, who is positive, stated: ‘I have no idea, with other couples, how they are, I don’t know. I haven’t really discussed anything with anybody … I don’t know how it fits with how others do it’. Many were curious, including Corey who practised unprotected sex with his negative partner:

I hope that somewhere in your research you document what other couples do … To think that I’m a freak, or we’re freaks, or we’re somewhere around average … It would be great to know what is normal and average.

Many speculated that unprotected sex was probably more common than expected, because of ‘the heterosexual aspect of it’, as positive partner Lydia put it. Interestingly, irrespective of their own sexual practice, many emphasised that other serodiscordant couples should practise protected sex. That some did not do so themselves is no doubt indicative of the many complex emotions and gender dynamics that are at play in serodiscordant intimacy, as described in the recently available Straightpoz report.

Asha Persson is a Research Fellow at the National Centre in HIV Social Research

1. All personal names have been changed. The Straightpoz study is a qualitative longitudinal study exploring the experiences of people who live heterosexually with HIV in NSW, including HIV-negative partners. The study is conducted by the National Centre in HIV Social Research, UNSW, in collaboration with the Heterosexual HIV/AIDS Service NSW (Pozhet). The Straightpoz study report, Volume 1, is available for download on: http://nchsr.arts.unsw.edu.au/pdf%20reports/Straightpoz.pdf The Straightpoz study, Volume 2 is also available for download on: http://nchsr.arts.unsw.edu.au/pdf%20reports/Straightpoz2.pdf
2. Vernazza, P., B. Hirschel, B., Bernasconi, E. (2008) Les personnes séropositives suivant un TAR efficace ne transmettent pas le VIH par voie sexuelle. Bulletin des médecins suisses, 89(5). http://www.pinktherapy.com/downloadables/1cpc/4threwrite.pdf