Positive Life NSW

STIs are an important health issue for people with HIV. Once common among gay men, sexually transmitted infections declined in the 1980s and early 1990s as the result of the focus on HIV prevention, but they have returned – in epidemic proportions – among gay men across the developed world in recent years and among HIV positive gay men in particular.

STIs can have serious health implications, particularly if not treated. Syphilis in particular can have a severe impact and be harder to treat in HIV positive people. Having an STI can increase the risk of passing on or getting HIV and it can also make managing your HIV more difficult. If you are sexually active and HIV positive, testing for STIs should be an important part of maintaining your health and well being, as well as the health and well being of your partners.

This fact sheet has been developed from a series of interviews and discussions with HIV positive and negative gay men on their experiences of testing for STIs. It looks at why it is particularly important for gay men with HIV to test for STIs.

Place of STIs in gay men’s lives

For some, HIV has been the major health challenge with other STIs seen as more easily manageable. This is how John and Bob put it:

John: I think while we are being told that there are more STIs and we keep on reading it and seeing the campaigns, a lot of gay guys just accept the fact that they’re going to get a dose of something sometime in their life and it’s quite easy to fix.

Bob: I think it’s changed in that it’s linked to sexual practice. There’s more barebacking going on because there’s a perception there’s a cure out there for all STIs including HIV. I’m positive and it amazes me the number of negative guys who say they will bareback.

Many gay men feel they know more about HIV than other STIs, and for HIV positive men, the primary focus of their health care management and monitoring has been HIV. Tim and Peter explained:

Tim: Guys have a broad knowledge of symptoms they can link with a number of STIs but I don’t think anyone really knows anything specific that they could pinpoint if they needed to or wanted to. Gay men know more about HIV.

Peter: HIV is the one that seems to always get the spotlight: even GPs are focusing on that and not other STIs. As far as the doctors are concerned, the slightest little hiccup in our health is related to HIV not to an STI.

Some men recall a time when gay men regularly and routinely tested for STIs.

Robert reflected: What happened to the old belief that everybody, especially gay active men should be tested for STIs every three months? I remember that used to be drilled into you back in the 70s, 80s: every three months go and get tested. It was part of our initiation into gay life. I’ve been positive for 24 years and I was brought up in the old school, when HIV first came out to assume that everybody’s positive. I’ve got to take some sort of responsibility here. When I have sex I’ve got to be sexually responsible.

Why test for STIs?

For some men, testing for STIs is routine while others respond to symptoms or risk events. Starting a new relationship could be another reason.

Peter: What would prompt me to have a test for STIs is having symptoms. It depends on the circumstances I suppose … for me it’s always been a symptom. […] Regular testing would make STIs a lot easier to deal with.
While many had a general understanding of STIs, they reflected on having limited knowledge of the important details around STIs. Examples include common symptoms of STIs, the way STIs are passed from person to person, available treatments and what happens during testing.

John: We don’t know a lot about symptoms like Chlamydia. I wouldn’t know the difference between syphilis and gonorrhoea and I think the general public really has no real knowledge. How much do we need to know and how do you simplify that. What about the guys who have no symptoms but have an STI?
I think everybody who is sexually active needs to be aware of the increases in syphilis and other STIs, and how to prevent getting it or passing it on.

Screening at least one to two times a year for STIs during a visit to your HIV doctor is one way to minimise your health visits.

Remember you need to specifically ask for tests for STIs.

What to ask for?

With gonorrhoea and Chlamydia ask for a urine sample, anal swab and throat swab. With syphilis and hepatitis A & B ask for blood tests (if you have not been vaccinated or are already immune).

The more partners you have the more often you should be tested. Every three to six months is a guideline.3

Some men feel more comfortable separating their sexual health care from their HIV care by going to a Sexual Health Clinic. These are free of charge and confidential. A Medicare card is not required and you do not have to use your real name. However, it is a good idea to let your HIV doctor know what medications you are on. Talking about your situation may result in you receiving more appropriate treatment and advice.

Tony on the other hand is more comfortable talking to his HIV doctor:
Doctors should be encouraged to offer tests to patients more often. My current doctor is very good. He suggests a full checkup anyway. With my previous doctor I had to ask for a test. It would be good if doctors were more proactive in suggesting a test and without making you feel like you are a bad guy because you are positive and having sex.

It is important to find a doctor with whom you can discuss important aspects of your life.

Barriers to testing: Why would you put off testing?

Testing for STIs is not as regular or as widespread among HIV positive men as it probably should be.4 Fear of being labeled irresponsible may be one reason why people with HIV avoid testing.

For some, getting an STI is seen as being sexually irresponsible and is therefore a likely barrier to testing.

As David asserted: My doctor does an STI check up regardless. But I’ve got a knowledgeable doctor in a gay practice. There are barriers that have to be overcome before people will willingly go and get a checkup. There’s the social stigma and embarrassment for some. Guys in relationships are probably not very likely to go to their local doctor to have a test. You need to be assured that the whole thing is totally anonymous.

Not knowing what is involved in testing and treatment is a major barrier:

Robert: I think also people probably need to be reassured in what’s involved in the tests. I wonder how many people are not keen on blood tests. And if you think you can go in and have something really simple like a urine sample or swab it may make the decision to test easier.

Tim: Guys need to know that most STIs are easily cured. It’s not some huge prolonged treatment to clear these things up. Often it’s just one jab or tablet and it’s gone with the exception of syphilis of course.

There are many reasons why gay men put off testing. Discussion group participants summarised the following:

• I feel fine so I must be okay.
• I can’t see the symptoms so they’re not there.
• If I use a condom I don’t have to worry.
• My doctor does my bloods regularly he will tell me if I have an STI.
• STIs are difficult to get.
• I choose my partners carefully.
• I can’t get an STI from oral sex.
• I don’t sleep around.
• I don’t want to be judged.
• I’m positive anyway so what’s the big deal?

STIs and HIV

There are extra health risks with having an STI when you are HIV positive. The symptoms of some STIs can be more serious if your immune system is already challenged with other infections. For people with HIV, STIs manifest differently and the treatment can be different. For example, with syphilis, you may get more complications like neurosyphilis. Neurosyphilis can involve significant brain damage if left untreated.

Les: The symptoms can be mild or non-existent and you don’t even know you have an STI until the effects become more serious [and more difficult to treat].

Even if you are asymptomatic (show no symptoms) STIs can still be passed on to your partners. This is a good reason why regular testing should be included in your routine health maintenance.

There is scientific evidence that a person with an untreated STI, particularly involving ulcers or discharge, is much more likely to pass on or get HIV during sex.

What about the type of sex?

Your risk of STIs is affected not only by the number of sex partners, but the type of sex you are having. Some sexual practices are riskier than others for STIs (e.g. unprotected anal sex, oral sex).

Oral sex may be a choice made between poz-neg partners to prevent passing on or getting HIV. Unless there are co-factors present (e.g. cuts or sores in your mouth) that may contribute to HIV transmission, oral sex is considered relatively safe for HIV. Oral sex, however, can spread other STIs such as gonorhoea and syphilis in the throat.

The more partners you have, the more often you should test for an STI, however regular STI testing should be a part of every sexually active gay man’s health management.

John: You only need to have sex once with a guy in an unsafe environment or have unsafe sex to get an STI. Anybody who has any form of sex is at risk. Guys who sleep with two people a year might not focus on a message that says if you’re more promiscuous it increases your chances of an STI.

STIs are important in poz-poz sex

Some HIV positive men have made the decision not to use condoms when they have sex with another positive man. Poz-poz sex does not prevent the passing on of STIs, in particular syphilis – and may actually increase the risk.5

This is what James said: I had always been safe with other men after my HIV diagnosis up until about a year ago. Because the other person was positive we came to an agreement to have unprotected sex: our choice, but one that I feel needs to be discussed with your partner. […] I didn’t want to get STIs like syphilis.

For most gay men, using condoms are the best way to look after their sexual health and the sexual health of their partners.

STI testing as part of everyday life

Discussion group participants expressed a need to “normalise” STI testing.

Max explained: We need to normalise testing. It should be like a mammogram or Pap smear for women. They’re so public nowadays: ads are on prime time television. Testing should be like another part of life, daily life. […] It’s on your list of things to do for the week.

10reasons to test for STIs

Getting an STI check-up is a good idea because:

1. STIs are at epidemic level among gay men and positive gay men in particular.
2. STIs increase the risk of passing on HIV.
3. STIs can be more serious for people with HIV.
4. Having lots of sex partners means the risk of getting an STI is even higher.
5. Any sexually active man can catch an STI.
6. The type of sex you are having is risky (e.g. fucking without a condom).6
7. Positive men who bareback together may be at a higher risk of getting an STI.
8. You may have experienced unusual discharges, rashes, itching and pain during sex or when pissing.
9. STI symptoms are not always obvious and frequently there are no noticeable symptoms.
10. It is important to look after your health and that of your partners.

Concerns about STIs should not discourage you from having a healthy and satisfying sex life. Using condoms is the best way to look after your sexual health but they are only part of the equation. If you are sexually active it is a good idea to get regular tests for STIs. The more partners you have the more often you should be tested. Every three to six months is a guideline.

Getting information and support

It is important to find a doctor with whom you can discuss your sexual health.

• Sexual Health Info Line Mon–Fri 9am–5.30pm Freecall 1800 451 624
• Sydney Sexual Health Centre (02) 9382 7440
• Livingstone Road Clinic and The Sanctuary Sexual Health Clinic Free and confidential medical and couseling services; Sexual health checks; HIV testing and counseling; Hepatitis A and B vaccinations (Clinics at Marrickville, Newtown, Camperdown, Canterbury and Rozelle). (02) 9560 3057 for clinic times.
• Albion Street Centre Gay Men’s Sexual Health Hotline Freecall 1800 009 448
• Positive Life NSW. A non-profit community organisation representing the interests of people living with HIV in NSW. (02) 9361 6011 or Freecall 1800 245 677 or visit www.positivelife.org.au
• AIDS Council of NSW (ACON) A health promotion organisation based in the gay, lesbian, bisexual and transgender communities with a central focus on HIV/AIDS. (02) 9206 2000 or Freecall 1800 063 060
• Gay and Lesbian Counseling Service of NSW (GLCS) A telephone counseling & information line operates 7 days a week from 5.30pm to 10.30pm. In the Sydney Metropolitan Area or from outside of NSW, call (02) 8594 9596: Outside of Sydney Areas call: 1800-18-GLCS; (1800-18-4527)

For regional NSW HIV/AIDS and related services:

• Contacts: A Directory of Services for People Living With HIV. Available from Positive Life NSW. T (02) 9361 6011 or Freecall 1800 245 677

For more information on:

• Testing, symptoms, treatment and prevention visit www.whytest.org
• STIs & HIV visit www.plwha.org.au (Health Promotion Factsheet 11 What you need to know about syphilis & Words to say it campaign fact sheet: Sexually transmitted infections: a guide for people with HIV)

Contact Positive Life NSW for other fact sheets in our series:

1. Managing side effects –efavirenz
2. Boosting your energy
3. Getting started on combination therapy;
4. I want to return to work
5. Living with body shape change
6. Positive pregnancy
7. Clinical trials
8. A night with tina – methamphetamine & HIV
9. HIV and your mouth
10. The dynamics of disclosure
11. What you need to know about syphilis
12. Changing horizons: living with HIV in rural NSW
13. Surviving the Centrelink DSP Review
14. Growing older – living longer with HIV

References

1. The more common STIs are syphilis, gonnorhoea, Chlamydia, herpes, Hep A and B. While not considered an STI, recent evidence suggests that there is a risk of passing on Hep C during sex where there is a risk of blood-to-blood contact (e.g. sex when you have cuts or lesions, during unprotected anal sex, and sexual practices that may involve bleeding or broken skin).
2. All names have been changed.
3. Sexually Transmissible Infection in Gay Men Action Group, July 2005. Sexually Transmitted Infection Testing Guidelines For Men Who Have Sex With Men.
4. Volk J E, Prestage G, Jin F, Rawstorne P, Grulich A E. “Sexually Transmitted Infections in A Cohort of HIV Positive Gay Men in Sydney”, Australasian Society for HIV Medicine, (ASHM) Conference, Hobart 2005. Paper
5. Prestage, G. “Positive Men and Sexual Health”, Talkabout, 142, Dec 2005–Jan 2006, pp.9–10.
6. Sexual contact includes fucking, sucking, touching, fingering or kissing/licking a dick or arse.

Produced by the Health Promotion Unit of Positive Life NSW.

Copyright © 2006 Positive Life NSW. This information may be copied for personal or organisational use provided you acknowledge Positive Life NSW.

Funded by NSW Health.

This fact sheet was produced with the assistance of an unconditional grant from Gilead Sciences Pty Ltd.

This is only an extract of the text from this fact sheet; use the links at right to obtain the full content.