Safe sex choices. In a time when biomedical HIV prevention strategies are dominating the social dialogue, we look at the increasingly broad selection of sexual health strategies available without losing sight of traditional methods that have undoubtedly helped reduce the impact of the HIV epidemic
The unprecedented impact of HIV prevention tools like PrEP reducing new HIV transmissions in Australia is popular in media and health promotion messaging right now. We’re also experiencing a time of awakening to scientific, evidence-based confirmation that people living with HIV who maintain an undetectable viral load cannot transmit the virus.
But today, not everybody across Australia is aware, ready, or willing and able to embrace biomedical choices as highly effective HIV prevention strategies. Most importantly, everyone should feel confident in choosing options that work for them. Taking action and choosing one or a combination of sexual health strategies is far better than choosing none.
And let’s be clear. Debating the effectiveness of different strategies is absolutely important. Choosing to actively protect yourself and other people is what really prevents new HIV transmissions from occurring. So here’s some information to help you decide how you can be part of the solution.
Biomedical HIV prevention strategy
PrEP stands for Pre-Exposure Prophylaxis. PrEP involves using prescription medicine that, when used as advised, is highly effective at preventing someone who does not have HIV from acquiring HIV. For more details, check out Introducing PrEP – the little blue pill making a big impact.
VicPrEP was the first demonstration project in Australia to offer PrEP to more than 100 Melbourne residents in 2014. The Australian Therapeutic Goods Administration (TGA) approved PrEP for preventing HIV in May 2016. Even prior to TGA approval, some doctors were prescribing PrEP to people who could benefit from it. Clinical studies in Victoria, New South Wales, Queensland and most other states and territories began enrolling participants from around March 2016.
Can be used by:
Only people who are HIV negative.
PrEP can be safely used in conjunction with condoms to maximise protection against HIV and help reduce the chance of acquiring STIs — this is important as PrEP does not protect against other STIs.
Sexual health tests:
Part of a managed PrEP program includes comprehensive sexual health testing at least once every three months.
Frequency and duration of use:
Daily PrEP involves taking one pill every day. On-demand PrEP involves using PrEP according to a carefully timed dosing schedule for shorter periods of time. PrEP can be used as an ongoing strategy for as long as someone chooses. Discuss how to start or stop using PrEP with a doctor.
Usage trends and population uptake:
There are an estimated 18,000+ people now using PrEP in Australia.
“Taking action and choosing one or a combination of sexual health strategies is far better than choosing none”
Prescriptions are available from doctors across Australia. Although any doctor can prescribe PrEP as part of a managed sexual health program, not all doctors may be aware of it.
From April 1, 2018, PrEP is available on the PBS (Pharmaceutical Benefits Scheme — the list of government subsidised medicines available to people with Medicare). This means that anyone who has a valid script for PrEP will be able to buy it in any Australian pharmacy for no more than $41.00 per month, or $6.60 with a concession. Community organisations PrEP’D For Change and PAN (PrEPaccessNOW) provide support and information on how to access PrEP across the country. For people with or without Medicare, personal importation options to buy PrEP online with a prescription from a doctor start from around $20 per month. For anyone in financial hardship, PAN offer a community assistance coupon scheme for free PrEP.
PrEP offers extremely high levels of protection against HIV. PrEP can only offer protection against HIV when used as advised. It has been reported that PrEP can reduce the transmission of HIV by up to 99 per cent. PrEP does not protect against other viruses or bacterial infections, such as STIs. Most common STIs are easy to detect and straightforward to cure. This is why three monthly testing and, if necessary, treatment of other STIs is so important when someone chooses PrEP as an HIV prevention strategy. Although becoming increasingly popular since its arrival, PrEP may not be suitable or desirable for everyone.
Places around the world that have introduced large scale access to PrEP among gay and bisexual men have observed significant reductions of new HIV diagnoses. New South Wales recently announced a 39 per cent decrease in new HIV transmissions. ACON announced that PrEP is considered one of the contributing factors for this unprecedented drop. The volume of new HIV transmissions reported for the period in NSW is the lowest since 1985 when HIV surveillance first began.
Type: Physical barrier device used as an HIV and STI prevention strategy.
Description: A condom is a physical sheath-shaped device used to cover the penis during sex. Using a condom can help reduce the transmission of HIV and other STIs.
Introduced: Condoms were first acknowledged to prevent the transmission of HIV close to the start of the HIV epidemic in the early 1980s. It took a few years to discover that the virus was passed on via bodily fluids. As a result, gay and bisexual men quickly adopted them. They were pioneering community activists in promoting condom use. It was the only known means of protecting against HIV at the time. Throughout most of the 1980s, before treatments became available, acquiring HIV was likely to result in premature death. Using a condom was directly associated with staying safe and alive. Despite the prevalence of other STIs long before the HIV epidemic, condoms were not typically used for sex between men. They were predominantly considered a means to prevent pregnancy.
Can be used by: People who are HIV negative or people who are HIV positive. As condoms are only used to cover the penis, they are only worn by the insertive partner — the top.
Condoms can be safely used in conjunction with PrEP to maximise protection against HIV and other STIs. Although using HIV treatment medicine to maintain an undetectable viral load means there is no risk of transmitting HIV, condoms can still be used. Using condoms can also help reduce the chance of acquiring or transmitting STIs.
Sexual health tests: A sexual health test every three months is important because condoms may not be used consistently every time. Condoms are not typically used for oral sex and they do not always fully cover affected areas, allowing the possibility of acquiring or transmitting STIs such as syphilis. Testing for HIV and STIs at least four times a year is part of an effective safe sex strategy.
Frequency and duration of use: One condom for every occurrence of sex. A fresh condom should be used with every sexual partner. Condoms can be used as an ongoing strategy to reduce transmission of HIV or other STIs.
Usage trends and population uptake: According to the Centre for Social Research in Health (CSRH) Annual Report of Trends in Behaviour 2016, condom use continues to play an important role in gay men’s sexual risk reduction practices. However, while consistent condom use still remains the most common behavioural risk reduction strategy among HIV negative men, the proportion of HIV negative men reporting consistent condom use has decreased significantly, from 34 per cent in 2006 to 26 per cent in 2015.
“Choosing to actively protect yourself and other people is what really prevents new HIV transmissions from occurring”
We must chose right thing
Accessibility: Condoms can be purchased in some supermarkets, service stations, pharmacies, restroom vending machines, or online. Some LGBTI venues, sexual health clinics and HIV/AIDS organisations provide condoms and lube for free or at low cost.
Personal cost: Condoms vary in price between free to upwards from around $5 for a pack of 10. Some non-latex condoms, or custom-made condoms may cost more.
Considerations: When used correctly, condoms offer protection against HIV and can help prevent some STIs. However, condoms do not always cover affected areas of skin, there is the possibility of them slipping or breaking and they are not typically used for oral sex. If a condom is not being worn, it cannot offer any protection against HIV or STIs. Condoms can only be effective when used correctly every time. Although condoms are a useful tool, they might not always be to hand and not everyone enjoys using them.
Special mention: Use of condoms by gay and bisexual men has prevented millions of HIV transmissions and saved countless lives since the beginning of the HIV epidemic in the early 1980s.
More information: Contact your local sexual health clinic, local HIV/AIDS organisation or visit websites like Top2Bottom for further information.
Type: Biomedical HIV treatment program with additional benefits as an HIV prevention strategy.
Description: Use of prescription medicine to manage HIV in people living with the virus. Using an effective HIV treatment program is important for people living with HIV to remain healthy. When an HIV positive person is taking treatment, the amount of HIV in their body, also known as viral load, can effectively be reduced to a level that is undetectable. This doesn’t mean they are cured or free of HIV; it simply means their treatment has suppressed the virus. People living with HIV who maintain an undetectable viral load cannot transmit the virus to sexual partners.
Introduced: Zidovudine (AZT) was the first effective antiretroviral medicine introduced in 1987. From around March 1996, HAART (highly active antiretroviral therapy) became the new standard for treating HIV using a combination of different classes of HIV medicines. In 2018 there are well over a dozen HIV treatment medicines available for use in Australia, with new and improved medicines in ongoing development and production.
Can be used by: Only used by people who are HIV positive.
Combination approach: Although using HIV treatment medicine to maintain an undetectable viral load means there is no risk of transmitting HIV, condoms can still be safely used to further reduce any concerns of transmitting HIV. Using condoms can also help reduce the chance of acquiring or transmitting STIs.
Sexual health tests: Part of a managed HIV treatment program includes sexual health testing at least every three months.
Frequency and duration of use: Treatment regimes may vary between taking one and multiple pills every day. HIV treatment must be used on an ongoing basis to ensure someone’s health and wellbeing is maintained. Regular monitoring of viral load from a specialist clinician will help ensure the treatment continues to be effective at suppressing the virus to undetectable levels with no risk of onward transmission to other people.
Usage trends and population uptake: According to data from the Kirby Institute, it is estimated that there were 28,180 people living with HIV in Australia in 2018. Of these, 89 per cent were receiving antiretroviral therapy, and 95 per cent of those on treatment had an undetectable viral load. The percentage of people receiving antiretroviral therapy in Australia has gradually increased over a period of three years: 86 per cent in 2015, 87 per cent in 2016 and 88 per cent in 2017. The percentage of people with a suppressed viral load has also gradually increased over the same period: 91 per cent in 2015, 92 per cent in 2016 and 94 per cent in 2017. Over the past few years in New South Wales, treatment uptake has continued to increase with 95 per cent of people living with HIV now on treatment, many of whom started their treatment within six weeks of being diagnosed.
“People living with HIV who maintain an undetectable viral load for six months or more do not transmit the virus”
Accessibility: Only doctors trained as specialist S100 prescribers under the Australian Government’s Highly Specialised Drugs program may prescribe HIV treatment medicine. A list and map of S100 prescribers for all states and territories is available from the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM).
Personal cost: For people with Medicare, HIV treatment medicines are available on the Pharmaceutical Benefits Scheme (PBS) — the list of federal government subsidised medicines. The current maximum charge for a PBS listed medicine is $41.00, or $6.60 for people with a concession. Residents of New South Wales are able to access HIV treatment medicine for free.
Considerations: Although various highly effective treatment options exist, there is currently no cure for HIV. Most people living with HIV who are on treatments which suppress the virus will reach an undetectable viral load; however, a very small number will not achieve this. Even in this small number of cases, the virus may still be suppressed to very low levels which will result in a greatly reduced risk of onward transmission of HIV to sexual partners compared to not being on treatment.
Special mention: HIV treatment is proven to extend and improve quality of life for people diagnosed with HIV. Furthermore, after following 358 couples over four years in Australia, the Kirby Institute’s Opposites Attract study concluded that condomless sex with a person living with HIV who has sustained an undetectable viral load is a form of safe sex. Another study, PARTNER, reported its phase one results showing there were no HIV transmissions following an estimated 58,500 acts of condomless sex between mixed HIV status couples where the HIV positive partner had an undetectable viral load. And on September 27, 2017, the United States Centers for Disease Control and Prevention (CDC) made an announcement stating that: “…people who take ART [Antiretroviral Therapy] daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”
More information: Contact your doctor, local HIV/AIDS organisation, or community groups like The Institute of Many for support and further information. Information on how to access HIV care and treatment is available from the National Association of people with HIV Australia (NAPWHA).