What will it change?
Reduce overall risk
Knowing HIV exists, the harm it can cause and how to reduce risk: Some knowledge is relevant to all Africans who are sexually active, or will be in the future. NAHIP agencies make no presumptions about individual Africans’ pre-existing knowledge about HIV in relation to their age, number of years in the UK, or country of origin. Nor do we assume that all recent migrants have little understanding of HIV, as HIV education is widespread in many African countries. Also some Africans migrating to the UK have previously lived in North American or other European countries.
In order for people to reduce their risk they need to know about HIV, how it is transmitted and how they can prevent it. Basic aspects of HIV transmission knowledge include:
- Awareness of the existence of HIV.
- Understanding how HIV is and is not transmitted.
- Knowing that the presence of untreated STIs makes HIV transmission more likely.
- Understanding that HIV can be treated but not cured.
- Knowing that HIV treatment is freely available for people legally residing in England.
- Knowing that it is not necessary to run the risk of HIV exposure in order to have a child.
- Understanding that taking measures to prevent HIV transmission, having an HIV test and receiving medical treatment are compatible with religious faith and prayer.
Earlier studies have found low levels of sexual health knowledge among African people living in England (Fenton et al. 2002, Chinouya & Davidson 2003, Chinouya et al. 2003). More recently, Bass Line respondents (Hickson et al. 2009) demonstrated relatively high levels of basic knowledge about HIV, how it is transmitted, and the existence of HIV medication. However, they were less aware that taking medication before becoming ill could help people with HIV to stay well. Particularly lacking though was an understanding of the extent of HIV prevalence among Africans in England.
People need to know the most effective ways to reduce HIV risk. As long as sexual assault remains a reality there is no way to eliminate sexual HIV risk. However, it is usually within someone’s power to minimise risk by avoiding sex altogether. The second most complete way of minimising risk is by having non-penetrative sex (that is, avoiding vaginal, anal and oral intercourse). However, engaging in any sexual activity increases the chance that sexual force may be used by a partner, or that desire will overcome harm-reduction strategies. Use of condoms during intercourse reduces the risk compared with having unprotected intercourse, but condoms can break. Establishing HIV concordancy and negotiating unprotected intercourse in a monogamous relationship carries the risk of a partner having unsafe sex outside the relationship and bringing HIV into it. Withdrawal before ejaculation during unprotected intercourse reduces the risk for the receptive partner but still carries a risk of HIV from pre-ejaculate and of the insertive partner mis-timing withdrawal.
Someone for whom sex is very valuable will be willing to accept a greater level of risk than someone for whom sex is unimportant. Therefore, health promoters cannot choose for people the level of HIV risk they are able to accept. Health promoters can help people with the knowledge, the will and the power to minimise their HIV risk while engaging in the sexual activity that best suits them.
The motivation to reduce the risk of transmission: Simply knowing about HIV is not enough to cause people to reduce risks. They also need to want to avoid HIV transmission. The vast majority of Africans do not want to be involved in HIV transmission (Hickson et al. 2009) but when faced with an opportunity to have sex, many believe that the beneﬁts outweigh the potential risk of infection. The motivation to reduce risk is a consequence of people’s assessment of the beneﬁts and costs of acting to reduce risks and whether they think it is socially acceptable to do so. The beneﬁts and costs of acting to reduce risk vary, depending on whether someone has HIV or not.
We therefore want all Africans in England to know whether they have HIV infection or not. The only way to know is by having an HIV test. We therefore want to meet Africans’ needs related to testing for HIV. Not testing for HIV is related to low self-perceived risk (Erwin et al. 2002, Hickson et al. 2009) and to low motivation to reduce HIV transmission risks. In order to increase the likelihood of HIV testing, sexually active African people will require knowledge of HIV, how it is sexually transmitted, and the availability of effective treatments.
People who do not know their HIV status need to be assured that testing for HIV will not result in discrimination or loss of privacy, and they will need to know where trusted services can be accessed. They also require an understanding of the meaning and potential impact of HIV test results, including knowledge of the window period when a recent infection may not be detected. People testing for HIV also need to know that a negative test result does not mean that they are immune to HIV, and that subsequent sexual exposures will require future HIV testing in order to establish whether infection has occurred.
We recognise that having an HIV positive diagnosis does not automatically give African people the knowledge, the will and the power to ensure that their subsequent sexual behaviour never exposes their infection to others. The majority of people with HIV do not want to pass it to someone else but often need support to avoid doing so.
People without HIV need to perceive themselves as being at risk from HIV in order to take action to avoid it. This means knowing that it is not possible to identify people with HIV based on appearance, lifestyle or social standing. Assumptions are made about the ability to select partners that are unlikely to have HIV, and this is linked to a belief in the ability to distinguish between partners that will be ‘safe’ and those who will be ‘unsafe’ (Mayisha II Collaborative Group 2005). We therefore want people to:
- Understand that 1-in-20 black Africans in England have HIV, making this the ethnic group with the highest prevalence by far.
- Recognise that the low rate of HIV-related deaths in England relates to treatment success, and is not an indication that there is no HIV in this country.
- Know that there is no way to distinguish between people who have HIV and those who do not, other than through an HIV test.
In the UK fewer than twenty people with HIV have been prosecuted and imprisoned for passing on their infection during sexual activity where their partner was unaware of infection. However, African people with HIV need to be aware of particular sexual situations that could result in a prosecution being brought against them.
Many people expect that someone with HIV will disclose this before having sex. However, this does not always occur, both because a third of the Africans with HIV are not aware of their infection, and because the stigma associated with HIV makes it very difﬁcult for people to be open about their HIV diagnosis. Those who have never tested, those who have tested HIV positive, and those who have tested HIV negative are likely to make different types of assumptions about the HIV status of their sexual partners. Lack of awareness of the potential for HIV sero-discordancy is one reason people give for having unprotected intercourse.
Having a community ethic that includes care and compassion for our sexual partners means we are more likely to want to protect them, as does having a sense of social responsibility
- Care for their sexual partners and to know that reducing risks protects their partners and children as well as themselves.
- Believing that we are able to make a difference to our risk (‘self-efﬁcacy’).
- Self-esteem and hope for the future that makes reducing risks worthwhile.
- Awareness that motivation to manage HIV risk can be compromised or challenged in new settings (such as returning home for a visit).
- Freedom from anxiety and depression (and the multiple causes of these).
People need to be able to choose to take preventative actions without being chastised or rejected by their partners or peers. People are more likely to act to reduce risks if they believe people they admire also act to reduce risks. In other words, we want people to believe their peers recognise the value of abstaining from sex, having non-penetrative sex, using condoms, testing for HIV and using PEP.
The power to act to reduce HIV transmission risk: All people who wish to reduce their HIV risk require physical autonomy and freedom from sexual force. Autonomy relates to the ability to direct one’s own activities. In order to be able to choose not to have sex when the opportunity arises, or to choose to have a particular kind of sex, people need to be free from sexual force and have control over their own bodies. Normative expectations and gender roles can limit sexual autonomy. Men and women need to exercise respect for themselves and for others by understanding that ‘no always means no’.
Those who are trafﬁcked into this country as cheap labourers or to work in the sex industry are usually deprived of the right to refuse sex, as are many of those subjected to domestic violence. Other factors related to vulnerability to sexual force are: poverty; social isolation; lack of legal rights (as in the case of undocumented migrants); and involvement in illegal activity (see the Africans in England section)
In order to take risk-reduction action, people need to express what they want clearly and without bringing harm to others. Being able to communicate to partners the desire for safer sex or no sex makes risk-reduction much more likely. Assertiveness is a key HIV prevention need. Pressure to conform to others’ expectations inﬂuences communication and sexual decision-making. What is often regarded as ‘feminine’ sexual propriety undermines womens’ capacity to encourage their male partners to use condoms, as well as leaving them ill-equipped to negotiate about if and how they have sex. Alongside this, the common idea that ‘masculinity’ is demonstrated by dominance leads to the belief that strong men should disregard sexual negotiation. Men who conform to these values often measure their self-worth by the number of sexual ‘conquests’ they have achieved. Where alternative forms of masculinity and femininity are developed and advocated by African men and women, they will be more able to choose to refrain from sex or to engage in sexual activity based on negotiation. The development of alternative expressions of masculinity and femininity has a close connection to reducing homophobic attitudes, as these are frequently bolstered by strict norms about how men and women ‘should’ behave. Rather than regarding the power to dictate if, how and when sex will happen as being in the domain of only one partner, new models of relations between men and women will help people to regard sexual power as shared.
One of the ways people lose the will to reduce risks and the power to do so is through being drunk or on drugs. African people who identify that they lack control over their alcohol and/or drug use require clinical and psychological support. Drug and alcohol support services that are tailored for African men, women and young people will help to increase uptake and to sustain long-term success particularly where speciﬁc cultural and religious norms prevent participation in counselling interventions and openness about substance use (Johnson et al. 2006).
HIV-related stigma has a signiﬁcant impact on HIV prevention need. People with diagnosed HIV who experience stigma can struggle with low self-worth and hopelessness as a result (Dodds et al. 2004). This can reduce their capacity to use support services, and it can also reduce their motivation to protect sexual partners from transmission. Concerns about discrimination and rejection can mean that those with diagnosed HIV tend to be very selective about disclosing their HIV status (Weatherburn et al. 2009). This keeps the realities of HIV, including the potential to live well with the infection, relatively unknown among many Africans in England.
Stigma associated with HIV can lead to an understanding of people with HIV as ‘others’ who are ‘untrustworthy’, ‘unclean’ and ‘unsuitable’. This leads to a strong desire to be distanced from the illness, and therefore disassociated from those attributes. This very practice of distancing stops individuals from recognising that people like themselves and their sexual partners can have the virus. This in turn reduces the likelihood of recognising the risk of transmission, a need for testing, and acting to reduce risks (Chinouya & Davidson 2003, Mayisha II Collaborative Group 2005)
People who decide to avoid (or postpone) any sexual activity in order to reduce their HIV risk require little beyond the basic set of needs outlined above. In particular, declining a sexual opportunity requires the will to do so, as well as the power to follow through on that intention.People who choose not to have sex for the sole purpose of reducing HIV risk need to know that there are very low risk sexual activites that they can choose to engage in should they wish to.
Penetrative vaginal intercourse is commonly represented among Africans as the ultimate aim of ‘having sex’. Any other kinds of sexual activity are either seen as ‘messing about’ or as a prelude to intercourse. However, neither anal nor vaginal intercourse is compulsory when sex occurs.
People need to know this and to know that other means of sexual satisfaction can be pursued. People also need to know that unprotected intercourse is not the only means of achieving conception, and that conception is not the only way to become a parent (see more on this in the conception section).
Being able to discuss, learn, and talk to partners about non-penetrative sex requires comfort with the idea that we all have a right to choose from a range of sexual activities on our own and with partners. It also requires comfort with the idea that sex is pleasurable, and that there are more means of gaining sexual pleasure than through intercourse. Alternatives to intercourse include:
- Self-masturbation (stimulating yourself sexually - alone or with others).
- Manual stimulation of a partner’s genitals (including penis, vagina, clitoris and anus).
- Fellatio (stimulation of a male partner’s genitals using the mouth).
- Cunnilingus (stimulation of a female partner’s genitals using the mouth).
- Use of sex toys (alone and with others).
People choosing to engage in sex without intercourse need to know that HIV can be acquired orally by ‘licking out’ a woman, ‘sucking’ a man to ejaculation, and can be passed on by sharing vibrators and sex toys (used by an infected partner immediately followed by an uninfected partner).
Many people choose to reduce their HIV risk by using male condoms when they have intercourse. Far fewer people use female condoms, although these are perceived as a means of offering women greater control over HIV risk.
There are a number of needs related to condom use. For instance, choosing to use a male or female condom with a sexual partner requires knowing about condoms and being able to access them, and perceiving a risk of HIV transmission during intercourse.
There are high levels of dislike of condoms among African men and women in England (Mayisha II Collaborative Group 2005), with discomfort and genital irritation given as common explanations. People are more likely to choose condoms if they are accurately informed about their value, and if they are aware that they can access more than one type or size of condom. Many attitudes towards condoms are based on negative assumptions about what they are like and a predisposition to reject their use. People need to know that they prevent pregnancy and protect against other STIs as well as HIV, and that some sexual partners are impressed by men and women who use them. Recognition that the use of condoms is an act of care and respect will help to reduce the likelihood that their introduction into a new or existing relationship is regarded with suspicion (Mayisha II Collaborative Group 2005).
In order to use condoms correctly, people need: access to (male and / or female) condoms; the skills and conﬁdence to use them; and an understanding of which behaviours make them more likely to break or come off during intercourse. For more information on this topic, please see the KWP Briefing Sheet
All of the following make male condoms more likely to break or come off:
- using a oil-based lubricant,
- not using additional water based lubricant,
- using saliva as a lubricant,
- putting lubricant inside the condom before putting it on,
- using a condom that is past its expiry date,
- unrolling the condom before putting it on the penis,
- tearing the condom with jewellery or ﬁngernails,
- using a condom that is either too large or too small for the penis (considering both length and circumference),
- having intercourse for over half an hour without changing the condom.
In the case of female condoms, the risk of failure can be reduced by ensuring that users know where and how to insert them, and that they do not use the female condom at the same time as a male condom. Most of the other behaviours listed above that make male condom failure more likely do not apply to female condoms, as they are not degraded by the use of oil-based lubricants and they have a long shelf-life.
The costs of purchasing condoms (especially female condoms) can be prohibitive, and embarrassment can be another problem. Condoms are freely distributed by HIV organisations and in many healthcare settings. However, awareness of condom distribution programmes may not be widespread among sexually active Africans. People also need to be aware of and able to access male condoms in a range of shapes and sizes, and made from a range of materials (ie. non-latex) so that they are able to ﬁnd a type that best suits the needs of both partners. They also need to be aware that some spermicides used on male condoms can irritate and inﬂame vaginal and anal tissues, thereby increasing the likelihood of discomfort, cystitis (in women) and HIV transmission (Niruthisard et al. 1991, Phillips et al. 2000).
New HIV infections cannot occur when two HIV negative people have unprotected intercourse or when two HIV positive people do so. Once a couple are sure that they have the same HIV status, they can have unprotected intercourse without a new infection occurring. However, sex often takes place prior to any discussion about sexual history. Couples who wish to conceive without risking HIV transmission need to establish if they are both HIV negative before engaging in unprotected intercourse. For those couples where one or both partners have HIV, other ways of conceiving are possible (see below). If people are choosing to have unprotected intercourse (either because of sexual or emotional desire, a desire to conceive, or both), we want them to know whether they have HIV or not.
In order to determine whether or not they have HIV, people need to be able to access and use HIV testing services. Choosing to be tested requires knowing what is involved in taking an HIV test, and being aware of the likely outcomes of a negative or a positive diagnosis. Once an individual or a couple have decided that they would like to take an HIV test, they need to know where to access testing, and have the capacity to overcome anything which stands in the way of following through (such as transport, fear of being seen at a clinic, etc.). One-in-eight of all respondents to the Bass Line 2008-09 survey wanted to take an HIV test (or were not sure about it) but they did not know where to get one. A number of recent intiatives have sought to improve the extent to which African people find HIV testing to be more accessible, including guidance on the matter to be issued by the National Institute of Health and Clinical Excellence (NICE), as well as interim results from a pilot study (HPA 2010) of expanded HIV testing opportunities undertaken in eight cities.
If two people who know they are HIV negative choose to have unprotected intercourse, they need to be conﬁdent that neither will bring HIV into the relationship by having unprotected intercourse with others. This needs negotiation and agreements about whether sex can occur outside the relationship, what type of sex that is, and what happens if one of the partners breaks that agreement.
Generally, men take the lead on using condoms or not in longer-term relationships (Mayisha II Collaborative Group 2005). This suggests that many women would beneﬁt from increased assertiveness to protect themselves. Key values in relationships are trust and faithfulness (Mayisha II Collaborative Group 2005), which are often underpinned by religious beliefs. However some people with HIV, especially women, acquired the virus from a partner whom they believed to be monogamous. People choosing to have unprotected intercourse in relationships they believe are HIV concordant need to know that this happens.
People with and without HIV need to know about the existence of other STIs and about where and how they can be tested for STIs. They also need to be aware of the beneﬁts and costs of testing for other STIs and to be able to do so. Meeting these needs will help to reduce time people have undiagnosed and untreated STIs, thereby reducing the likelihood that another STI is present when sexual HIV exposure occurs.
HIV is present in the semen of men with HIV infection. If men having insertive unprotected vaginal or anal intercourse withdraw the penis prior to ejaculation, then there is less likelihood of transmission from the insertive to receptive partner than if they do ejaculate.
People considering this risk-reduction tactic need to know that on many occasions where men intend to withdraw they ﬁnd it impossible to do so and end up ejaculating into their partner. They also need to know that HIV can be transmitted through pre-ejaculatory ﬂuids (pre-cum).
We do not propose that withdrawal before ejaculation is a foolproof means of avoiding HIV transmission. However, for some people, in some situations, it may be their only option, which is certainly better than none. For others, withdrawal may be used in combination with a number of other tactics, in order to further decrease the likelihood of HIV transmission or acquisition.
For a variety of reasons, people without HIV may engage in unprotected intercourse with a partner they know has HIV or who may have. Such situations include sexual assault, condom failure, the heat of the moment, and ﬁnding out a partner is HIV positive after sex.
In such circumstances people may beneﬁt from post-exposure prophylaxis (PEP). In order to take PEP people need to know about it, to appreciate the costs and beneﬁts of taking it, and to be able to access it and take it correctly. They will also need to be aware that the sooner PEP is taken after exposure (no more than 72 hours) the more likely it will be effective. They may require the skills to communicate this urgency to reception and non-specialist staff in clinical settings (Dodds et al. 2006).
Many people think that unprotected vaginal intercourse is the only way to conceive and that HIV transmission risk is therefore a necessary part of trying to conceive. However, there are other ways to conceive that can reduce the risk of HIV transmission which people with HIV and their partners can explore in consultation with their HIV clinician. This is particularly critical in light of research evidence that demonstrates that female-to-male and male-to-female HIV transmission is more likely during pregnancy (Mugo et al. 2010).
This plan focuses on preventing the sexual transmission of HIV. We do not address mother-to-child transmission, re-infection, or super-infection between two individuals with HIV. Information and guidance on those topics can be found elsewhere (see for instance Audit, Information and Analysis Unit 2007, Fakoya et al. 2008).
People who want a child and who also want to avoid the sexual transmission of HIV need to know that these aims are not mutually exclusive. No one should have to choose between having a child and risking HIV infection. NAHIP aims for couples who have determined that they want to conceive, to undertake HIV tests and to share the results of their HIV tests with each other. If both partners are HIV negative, they will need to negotiate a monogamous relationship if unprotected intercourse is to be on-going. Where the female partner has HIV, access to recent advances in pre-natal treatment, delivery, and post-natal care mean that the likelihood that her child will acquire HIV is below 1%. Where either the woman or man has HIV, there are a number of options to protect both partner and any future child.
Adoption: Any couple considering conception and wanting to minimise HIV transmission risk needs to know of the possibility of adoption. The option of adoption will be reduced for those who are unstable ﬁnancially, whose immigration status is unresolved, or who are in ill-health. The successful uptake of this option will also require that the peers and family members of potential adoptive parents have a positive regard for adoption and the beneﬁts it brings.
Sperm-washing for HIV positive men: Where a man is diagnosed with HIV and his partner is not, the man’s semen can be treated in a way that separates his sperm from other seminal ﬂuids that carry HIV. This is achieved by placing semen in a centrifuge which separates the sperm from the seminal ﬂuids. The man’s partner can then be inseminated with his sperm, either by intrauterine means, or by using in vitro fertilisation treatment, where the woman’s egg is fertilised by male sperm in a laboratory, and the resulting embryo is implanted directly into the woman’s uterus. Sperm-washing services should be made available and accessible for all people living with HIV in England who require them. Sperm-washing requires signiﬁcant ongoing contact with clinical professionals. This process does not eliminate the risk of HIV transmission, however it signiﬁcantly reduces the likelihood that transmission will occur.
Self-insemination for HIV positive women: Where a woman is diagnosed with HIV and her partner is not, she should receive instructions on how to carry out self-insemination of her partner’s sperm at the time in her cycle when she is ovulating. If a condom is used during intercourse with her partner to the point of ejaculation, she can later inseminate herself with semen collected from the (non-spermicidal) condom using a syringe. As there is no transfer of ﬂuids from a positive to a negative person using this technique, it does not carry any risk of HIV transmission.
Suppressing viral load for both HIV positive men and women: Those who will not or cannot access the options listed above might consider conﬁning unprotected sexual intercourse only to a period when the positive partner’s viral load has been undetectable for six months or more. Effective ARV treatment regimes can signiﬁcantly reduce the viral load (the amount of virus that is present in the blood) in a person with diagnosed HIV. In a sero-discordant partnership, the partner who is diagnosed with HIV is likely to have access to information about his or her viral load if they are in regular contact with clinical services.
Now that the Treatment As Prevention (sometimes called Treatment 2.0) paradigm is a key element of the global response to the epidemic, the matter of undetectable viral loads in infectivity are influencing couples’ conception choices. In 2008, the Swiss Federal Committee for HIV/AIDS asserted that those who maintain an undetectable viral load for six months or more without any other STIs cannot transmit HIV (Vernazza et al. 2008, Bernard 2008). The current BHIVA guidelines on HIV and reproduction now support this view (Fakoya et al. 2008).
African aims summary
AFRICANS AIM 1: Africans reduce sexual HIV risk behaviours in any way available to them. This will require:
- Knowledge about HIV and how to prevent it.
- Motivation to reduce the risks of transmission.
- Knowledge of whether or not they have HIV and how to access HIV testing.
- Knowledge of HIV treatment and who is eligible to receive it in England without charge.
- Awareness of the potential for HIV sero-discordancy with sexual partners.
- Freedom from pressures to conform to behaviours that risk transmission.
- Skills to communicate openly with sexual partners about HIV risk-reduction and to inﬂuence partners’ behaviour.
- Freedom from sexual force.
- Control over the use of substances such as alcohol and drugs.
- Freedom from HIV-related stigma.
- Freedom from sexism and homophobia.
- Freedom from racism and xenophobia.
AFRICANS AIM 2: Africans decline unwanted sex or have non-penetrative sex. This will require:
- Appreciation and enjoyment of the beneﬁts of sexual pleasure when a choice is made to be sexually active.
- Conﬁdence and skills to refuse sexual contact when it is not desired.
- Acceptance of sexual contact other than intercourse as valid and pleasurable.
- Access to resources to expand their sexual repertoire.
- Conﬁdence and skills to introduce sexual contact other than intercourse with new or existing sexual partners.
AFRICANS AIM 3: Africans correctly use male and/or female condoms for intercourse. This will require:
- Knowledge of the availability of free and affordable male and/or female condoms and water-based lubricant.
- Access to as many male and/or female condoms (and appropriate lubricant) as they require.
- Awareness of and access to different types of condoms and water-based lubricants in order to maximise comfort and minimise failure.
- Skills to use condoms and lubricant correctly.
- Conﬁdence and skills to introduce male and/or female condoms and appropriate lubricant with new or existing sexual partners.
- Knowledge of the factors that contribute to condom failure.
- Awareness that condoms may fail even if they are used correctly.
AFRICANS AIM 4: African couples establish and maintain HIV concordancy. This will require:
- Accurate clinical knowledge of their own and their partner’s HIV status.
- Negotiation skills in order to ensure the use of male or female condoms until HIV statuses are determined and to ensure monogamy.
AFRICANS AIM 5: Africans with undiagnosed STIs get them diagnosed and treated. This will require:
- Knowledge of the existence of other STIs and of testing and treatment services.
- Appreciation of the costs and beneﬁts of testing for other STIs.
- Accessible testing and treatment services.
AFRICANS AIM 6: Africans who have unprotected intercourse practice withdrawal before ejaculation when partners are not conﬁdent they have the same HIV status. This will require:
- Knowing that during unprotected intercourse with an HIV-infected man that transmission is less likely to occur if he withdraws before ejaculation than if he does not.
- Knowing that HIV transmission can still occur even in the absence of ejaculation because HIV is present in pre-ejaculatory ﬂuid (pre-cum).
AFRICANS AIM 7: Africans without HIV who are sexually exposed to HIV take post-exposure prophylaxis (PEP). This will require:
- Awareness of the existence of PEP treatment and what its limitations are.
- Appreciation of the costs and beneﬁts of taking PEP.
- Swift access to PEP should they be exposed to HIV.
AFRICANS AIM 8: African people in sero-discordant relationships that want to conceive reduce HIV risks in doing so. This will require:
- Awareness that intercourse is not the only means of achieving conception.
- Accurate clinical knowledge of their own and their partner’s HIV status.
- Freedom from psychological and emotional pressure to bear children.
- Access to adoption services and recognition of adoption as a viable option.
- Knowledge of sperm-washing services and access to them (where the male partner has HIV and the female partner does not).
- Knowledge and skills required to undertake self insemination techniques (where the female partner has HIV and the male partner does not).
- Knowing that reduced viral load in the partner with HIV, and limiting unprotected intercourse to only take place during ovulation, will lessen but may not eliminate the risk of HIV transmission.
Page last updated: 18 February 2011