1. Ceri Evans Senior Sexual Health Adviser West London Centre for Sexual Health Chelsea and Westminster Hospital Foundation Trust

2. use condoms

5. Listening to what people say is the first way forward

6. Condoms…. create a barrier prevent intimacy caused erectile dysfunction loss of desire A reminder that HIV is part of a relationship and can’t be ignored.

7. Often unprotected sex is a sign of intimacy and trust in a relationship where both people are negative – using condoms because one person is positive may psychologically suggest that the relationship is not to be trusted How much risk is each partner willing to take? This will vary with each couple and needs to be addressed if one of the partners is not to feel that they are under pressure

8. What type of safer practices will be used (if any)? – in MSM will the positive partner always be receptive? If unprotected receptive Vaginal Intercourse/Anal Intercourse, will the positive partner not ejaculate? Problems may occur in the relationship if both partners are not fully informed/educated or agreeable to a risk. What if one partner wants unprotected sex more than the other? How divisive will this be? Who will be there to support both parties?

9. The key to all of this is being informed, being educated, being supported and being able to make a choice – whether that is to use condoms – or not

10. Case Studies MSM couple 1 positive 1 negative been having unprotected anal sex (active and receptive) for many years based on undetectable load and high CD4 count. They had worked this out for themselves before the Swiss Statement. Very happy with the arrangement

11. Positive man very anxious around unprotected sex as he feels that if his negative partner became positive he would never forgive himself – feels could not cope with the knowledge he had infected someone he loved even though the negative partner was fully aware of risks and willing to take them.

12. Case Studies Heterosexual couple man positive, wife negative. Both partners fully aware and informed of transmission issues However, female negative partner not keen on having unprotected SI with her husband despite the fact he had undetectable VL and CD4 of 745. She is highly anxious about becoming infected despite her husbands keenness to have unprotected sex and assurances of neglible rate of transmission. She started avoiding sex as she felt she was being emotionally pressured (“if you loved me you would”) and felt a total lack of desire. Husband described himself as feeling neglected, unloved and unclean

13. We must also be aware that there are relationships which are not equal, where emotional and psychological coercion happens. We know that there are relationships where people are not totally honest with each other. We must be sure that we offer dedicated support to people making these vital decisions – the Swiss statement is very clear that there needs to be stringent individual and couple counselling for those who are going to stop using condoms

14. For those not in stable, equal relationships, it is possible that there is very little alternative to advising condom use as prevention. Treatment as prevention will only have an effect, if, as has been suggested in some papers, everyone who tests positive starts on treatment immediately, regardless of their CD4 count.

15. Even then, this depends on the treatment being effective, people taking their treatment without fail, people not being resistant to treatment, people keeping appointments for regular VLCD4 counts. Even so there will be a significant minority who will not keep to this who will ensure that it is still not safe to have unprotected sex with anyone you meet

16. MSM has current BF of 6 months who is HIV +. Having unprotected AAI. Uses reasoning that not only has BF got high CD4/low VL, but client is the active partner in sex and is also circumcised. All well and good – an informed decision made by the both of them on facts and figures. He believes that he is unlikely to become HIV + from this situation.

17. However, client also goes onto describe that he has also had 30 casual male sexual partners in the past 3/12, mostly unprotected active anal sex. He only uses condoms if the sexual contact insists on it, which he says is rare. He tested HIV negative, although was still well within the window period. The client still believes that he is unlikely to get HIV from this situation as he thinks that the people who insist on condom use are the people who have HIV, therefore the people who have unprotected SI are all negative.

18. The key to all of this is being informed, being educated, being supported and being able to make a choice – whether that is to use condoms – or not