The Ins and Outs of Gay Sex (20 page)

Besides your physician, whom you choose to tell about your HIV status is an entirely personal matter—except where a sexual partner is concerned.
If you are planning to engage in high-risk sex (anal intercourse or oral sex), your partner has a right to know you are positive.
Jerking off and other low-risk sexual practices are safe, and you may keep your status secret if you must.
If someone chooses not to have sex with you because you are HIV positive (and that’s what the Centers for Disease Control recommends), then move on.
Just as you have a choice about whom you sleep with, so should your partner—and it must be an informed choice.

If you are HIV positive, you have a responsibility to protect your partners—even if they don’t want it.
The guy who’s blowing you may beg you to come in his mouth or ask you to fuck him even though you don’t have a condom.
Even if you don’t ejaculate, there still is a risk you can pass HIV during unprotected penetrative sex.
Sure, you
can oblige him, but how would you feel if he catches HIV from you?
Increasingly, it’s not just a moral concern;
more than half the states in the United States have already enacted laws making it a criminal offense to knowingly infect another person with HIV.

It is never easy to find out that you are HIV positive.
I always counsel patients to be careful whom they tell.
Some men deal with the news by telling everyone, hoping somehow to minimize their anxiety.
This is not the way to do it, and in the end you usually find that you’ve told people whom you shouldn’t.
Sure, many will want to help, but others will view it as just another bit of good dish.
Friends or loved ones may have a very difficult time dealing with the fact that you’re HIV positive—especially parents.
Often they have a very limited understanding of HIV and are far less prepared than you to deal with the news.
Of course you’ll want to tell them, but it may need to be a gradual process of education and understanding.

Some men react in just the opposite manner and tell no one.
This is also not the way to deal with the problem.
Find someone you can trust, someone caring who will help you handle it.
Don’t be afraid to unburden your heart, but pick your confidants carefully.

All sexually active gay men should be tested periodically for HIV.
Not only does knowing your HIV status allow you to pass the information on to others, it also has important treatment implications.
Frightening is the only word for the Centers for Disease Control estimate that a quarter million people do not know they carry HIV!
You may argue that your only sex is safe sex and that the test would just add an unnecessary layer of stress.
If your sex is so safe, then why fret over test results?
Unless you’re in a genuinely monogamous relationship, all sex should be safe no matter what your partner’s HIV status is
presumed
to be.
(Shocking, but people do lie!
) Even safe sex bears a minimal risk of
transmission.
If you have any STD—even if it’s just a penile wart—get tested.
People with one STD have a much higher risk for also having HIV.

The start of what you hope will be a lasting relationship is an ideal time for both you and your partner to be tested.
Not only because you should know each other’s status, but also because with time, and presumed monogamy, partners tend to relax their safe-sex vigilance.
I cannot tell you how many patients I have tested, all panic stricken because they just learned that the man who’s been coming in their mouth or ass is suddenly HIV positive when all along he had sworn he was negative.
But before you go for testing with your new partner, examine
all
issues carefully—not just how you will deal with your own results, but how it will impact your relationship if only one of you is negative.

I also advise periodic testing for partners in monogamous relationships.
An anniversary or birthday is a good time, because it becomes routine and doesn’t raise suspicions of infidelity in one partner or the other.
(See
Chapter 10
.
) A small but significant number of HIV-negative men in monogamous relationships abandon safe-sex practices and become positive.
This is obviously because one partner (or both) isn’t really monogamous or because one didn’t know he was positive when the relationship began.
(Don’t act so surprised!
)

He still had that boyish cast to his face, but his blue eyes looked beyond me.
“Your T-cells just fell below three hundred,” I said, but he made no effort to respond.
I tried to catch his gaze.
“It’s definitely time to begin treatment.”

He shook his head.
“I’m still over two hundred.
That’s not AIDS.”

“You don’t want to get AIDS,” I emphasized.

His jaw tightened and he leaned forward.
“I feel great—not sick at all.
Like this I go whole days without thinking I have HIV.
If I start the medication then with every pill I swallow—five, six times a day—I’ll be reminded.
Reminded I’ve got it.”

HIV treatment is one of the most rapidly changing and constantly evolving areas in medicine, but
medications should never be viewed as an alternative to safe sex.
I am appalled by men who don’t seem to care that they became HIV positive because drugs will keep them healthy.
As little as one year ago most physicians advised treatment only when your T-cells fell below 200.
New research now supports treatment as soon as your viral load reaches 5,000 to 10,000 copies per milliliter or your CD4+ counts fall below 500.
Some physicians even advocate treatment as soon as you become positive, irrespective of other parameters.
But no doctor should give you medication based on an anonymous test performed outside of his or her office (from a home test kit or clinic).
If this is how you found out you had HIV, prepare to be retested to document your results officially.

Many reasons support an aggressive treatment regimen.
We know that as the disease enters a clinically latent phase where you feel well and the viral load in your blood may be low, virus hides in potentially great numbers in your lymph nodes.
Treatment during this period kills hidden virus, reduces your viral load, and, it is hoped, decreases your ability to infect others.

Research has shown that although HIV multiplies rapidly in CD4+ cells, its genes aren’t always copied correctly.
An improperly copied gene translates into a potential mutation.
While most mutations have no effect, some destroy the virus and others are potentially more dangerous in that they make HIV resistant to medications.
If aggressive therapy thwarts viral reproduction, then it also decreases the chance of a resistant mutation developing.

You may already be infected with virus strains resistant to certain medications.
One drug may kill some of your virus but allow resistant strains to multiply freely.
Then you end up with an infection of more resistant virus.
Doctors saw this happening frequently in the late 1980s when only AZT was available.
When HIV is hit with three drugs at once, patients have a much higher chance of killing all their virus because the incidence of resistance to all three medications is much lower.
Sure, some virus survives, but then your doctor will switch medications to try to wipe those out as well.
Unfortunately, we are seeing strains of HIV emerge resistant to most, if not all, medications.

Once you swallow that first set of pills, you are probably committed to lifelong treatment—an emotionally and physically taxing proposition, given possible dietary restrictions, time constraints mandated by these drugs, and their side effects.
Fortunately, dosing regimens are getting simpler, with the general trend being one of higher doses taken less frequently.
Nevertheless, it is crucial that you adhere to your medication schedule.
If you lack the resolve to stick to your regimen, you’re better off doing nothing until you develop that resolve.
Skipped or improperly taken medication does not kill virus and may help resistant strains multiply.
By the time your doctor wonders why your T-cell counts are falling and your viral load is rising, it may be too late.
You may never recover no matter what medications you try.

Although collectively called antiretroviral agents, currently three classes of approved medications are used to treat HIV:
nucleoside analogs, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors.
A fourth group, the somewhat confusingly named nucleotide analogs, is a new class of medications.
At this writing, adefovir, the first drug in this class, awaits FDA approval.

Nucleoside analogs were the original class of medications
developed to combat HIV.
Zidovudine (AZT or Retrovir, as it is commonly called) was licensed first, and now there are many others.
Even though AZT was shown to be active against HIV in the laboratory in 1985, it was not approved by the FDA until two years later!
Nucleoside analogs resemble normal DNA building blocks.
The virus mistakenly incorporates these drugs into its DNA, and the defective virus produced cannot survive.
Bone marrow suppression is the most dangerous side effect produced by some of these drugs.
You can become severely anemic or your white count can drop.
Other nucleoside analogs cause a peripheral neuropathy—a fancy name for tingling, burning, or numbness in your hands and feet.
It varies in severity and usually goes away when the medication is stopped.
(See
Table 5.
2
for the other drugs in this class and common doses.
)

Protease inhibitors have shown great promise, and drug combinations containing them dramatically improved survival rates since their introduction in the fight against HIV.
Saquinavir (Invirase), in December 1995, was the first FDA-approved protease inhibitor, but others quickly followed.
(See
Table 5.
2
.
) Protease inhibitors prevent T-cells from making the virus’s outer protein coat.
So even if the viral RNA is manufactured correctly, it has no place to go.
Gastrointestinal upset, including diarrhea, nausea, and vomiting, is a common side effect of some protease inhibitors.
Thankfully, doctors can prescribe other medications to combat these side effects (Imodium, Compazene, etc.
), which usually lessen with time.
Crixivan can cause kidney stones.
Men also complain about strict dietary restrictions some of these drugs require for effective absorption.
Some are taken on an empty stomach, while others need food for proper absorption into the bloodstream.
It is almost as vital to know the dietary restrictions your protease inhibitor requires as it is to know the dose.
Be sure to ask your doctor.

TABLE 5.
2
COMMON ANTIRETROVIRAL MEDICATIONS AND SUGGESTED DOSES