Having HIV may lead you to think that there’s no need to worry about protecting yourself during sex any more. You may also think that as long as you have sex with other men who are also HIV-positive then you can forget the condoms when you fuck or get fucked. This strategy of seeking other HIV-positive men to have unprotected sex with is known as serosorting, and we talk more about this in the section on your sexual partners.

However, there are still very good reasons for protecting yourself even though you’re already HIV-positive. If you have unprotected sex you could be putting yourself at risk of co-infection with another sexually transmitted infection (STI) and re-infection with a different strain of HIV. It’s a good idea to be aware of the risk of both co-infection and re-infection so that you can make an informed choice about whether to use condoms or not when you have sex.

Co-infection is having another infection as well as HIV. If you fuck without using condoms you could be at risk of getting hepatitis and other sexually transmitted infections (STIs), and we talk about these below. 

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Hepatitis is a general term referring to inflammation of the liver. There are six known Hepatitis types; A, B, C, D, E and G. The most important ones to be aware of are Hepatitis B and C and we go into more detail about these below. 
Hepatitis B (Hep B)
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Hepatitis B is a serious illness caused by a virus that attacks the liver. You can get Hep B in a similar way to HIV – by fucking without condoms or by sucking cock. Although sucking cock carries a low risk for passing on HIV, this is not the case for Hep B. Hep B is much more infectious than HIV. At some London HIV clinics up to 6% of gay men with HIV also have Hep B.

There is a vaccine available that can protect you against getting Hep B, and everyone who has HIV really should make sure they are vaccinated. The vaccine is available free from your HIV or GUM clinic, and is the best way to protect yourself, but it doesn’t work for everyone. The vaccine works better if your CD4 count is high and your viral load is low. Also, immunity after vaccination may not last for life, so you should have regular blood tests to check that your immunity is sustained, and you will probably need boosters every so often. Ask at your HIV or GUM clinic when you go for your jab.

About a third of people with HIV who get Hep B will not be able to get rid of it without treatment. Of this third, only 20-40% will respond to Hep B treatment. Those who don’t respond to treatment will go on to develop chronic (long-term) Hep B infection putting them at a high risk of developing liver disease and liver failure (which would be fatal without a liver transplant).

Alpha-interferon, a drug used to treat Hep B, can cause side effects such as high temperature, joint pain, weight loss, nausea & depression. Alpha-interferon can also cause low white blood cell and / or platelet count (known as thrombocytopenia).

Other drugs currently used to treat Hep B are 3TC, FTC and tenofovir (which are also anti-HIV drugs) and Adefovir, which can have side effects such as headache, stomach pain, nausea and diarrhoea.

The damage Hep B does to your liver could also mean that you have a greater risk of side effects from your anti-HIV drugs, especially those associated with liver side-effects such as AZT, ddI, ritonavir, indinavir and nevirapine. If these side effects become too severe, it could mean that you have to change to different anti-HIV drugs. This would reduce your choice of anti-HIV drugs.

If you are not vaccinated against Hep B, you can reduce the risk of getting it by fucking with condoms or not getting cum up your arse or in your mouth. 

Hepatitis C (Hep C)
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Hepatitis C (Hep C or HCV) is an infectious and potentially life-threatening illness caused by a virus that attacks the liver. Hep C infections amongst HIV-positive gay men have risen significantly over the last few years.

There is currently no vaccine available which can protect you against Hep C.

Approximately 250,000 to 600,000 people in the UK have Hepatitis C and only 55,000 have been diagnosed, according to HIV i-Base. That means up to 91% of people with Hepatitis C may be undiagnosed.

People co-infected with HIV and Hep C tend to progress to serious liver disease much more rapidly than those with Hep C alone. They also have an increased risk of developing cirrhosis and liver cancer. Liver disease is now a leading cause of illness and death among people co-infected with HIV and Hep C.

Hep C can be treatable, but early diagnosis is vital to give you the best chance of the treatment working. Hep C often shows no symptoms, which is why many people don’t know they are infected. The only way to be sure whether you have Hep C or not is to have a Hep C test, available at your clinic.

How Hep C is transmitted
Hep C is transmitted by infected blood and can survive for up to four days outside the body, even in dried blood. So even in tiny specs of blood on dildos, in pots of lube or on drug snorting straws, for example, Hep C can still be infectious for a long time.

There can be a high risk of transmitting Hep C where group sex is taking place. Hep C is often spread from one man to another (one arse to another arse) via a dildo or another man’s fist or cock, for example. This means that group fucking, fisting or using sex toys, even with condoms or gloves, could spread Hep C unless you use a new, clean condom for every fuck or every time you use a dildo, and a new, clean glove every time you fist.

Fucking without condoms may also carry a risk, especially if there is blood present in the man’s arse that could get onto your cock.

Studies show that Hep C can be transmitted in some or all of the following ways:

Sex: group fucking, fisting, sharing sex toys, sharing pots of lube, fucking without condoms
Drug use: sharing snorting straws/banknotes, sharing needles for injecting
Other routes: tattooing or piercing with unsterilised equipment, sharing items that could contain blood such as toothbrushes and razors
Hep C treatment
The standard treatment for Hep C is Pegylated Interferon (also known as peg-interferon) and Ribavirin. Treatment for Hep C can cause unpleasant side effects such as high temperature, joint pain, weight loss, nausea & depression. It can also reduce your HIV treatment options as Ribavirin should not be taken with anti-HIV drugs ddI, d4T, tenofovir or AZT.

Not all men who have HIV and Hep C will respond to Hep C treatment. Those that don’t will go on to develop chronic (long-term) Hep C infection putting them at a high risk of developing liver disease.

How to avoid Hep C

  • Using a new condom for every guy you fuck or get fucked by
  • Using a new glove for every guy you fist or get fisted by
  • Using a new condom on a dildo every time it gets used
  • Not sharing pots of lube
  • Not sharing drug snorting straws or banknotes or needles for injecting
  • Not sharing items such as toothbrushes or razors
  • Hep C testing
  • Since long term Hep C infection is harder to treat, early diagnosis is vital if you are to have the best chance of getting rid of Hep C. The only way to be sure whether you have Hep C or not is to have a Hep C test.

However, not all HIV clinics are routinely testing for Hep C yet, so make sure to ask your doctor for a Hep C test next time you go to your HIV clinic.

If you need more information or support about Hepatitis, speak to your doctor or health adviser at your clinic. Alternatively you can contact The British Liver Trust (www.britishlivertrust.org.uk, 01425 463080) or the UK Hepatitis C Resource Centre (www.hepccentre.org.uk, 020 7378 5495). 

Other sexually transmitted infections (STIs)
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Other sexually transmitted infections (STIs)
STIs such as syphilis, gonorrhoea, herpes, genital and anal warts, chlamydia or LGV (a type of chlamydia), can be more severe, progress faster and be harder to treat if you are HIV positive and your CD4 count is low. This is because having a low CD4 count means that your immune system is weaker than it otherwise would be, and is therefore less effective at fighting infections. Some STIs can also lead to more serious complications if left untreated.

For example, having a low CD4 count means that attacks of herpes can be more frequent, more severe and last longer, and LGV can progress much faster and cause extreme swelling and ulceration of the genitals.

The number of cases of syphilis seen in gay men has risen dramatically over the last few years. Syphilis can be harder to cure, more severe and progress more quickly if you have a low CD4 count. It is also highly contagious in the primary and secondary stages. More information about the different STIs can be found on our sex and sexual health site.

As having some STIs can make it easier for someone to get HIV, it is probable that having one of these STIs could make you more susceptible to re-infection, which we talk about later on this page. Some STIs can also increase your HIV viral load, making it more likely that you could pass on HIV to sexual partners.

Condoms can provide protection against some STIs, but not against all of them. However, most STIs are much easier to treat if they are diagnosed at an early stage.

Some STIs show no symptoms, so if you are sexually active then the best way to be sure you haven’t picked up an STI is to have regular free sexual health check-ups at your HIV or GUM clinic.

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Re-infection (also known as superinfection) is being infected with another strain of HIV in addition to the one you already have. We know that re-infection can happen, and we also know that sometimes when it happens it can have a negative impact on a person’s health. However, research so far suggests that re-infection with another strain of HIV is probably not very common, although no one can be certain of this. Research also suggests that re-infection is probably more likely to happen in the first three years after you got HIV, if you are not on HIV treatment, or if you are taking a treatment break.

Re-infection happens in exactly the same way as original (primary) HIV infection – mainly by fucking without condoms, but also by sucking cock, although oral sex carries a low risk of HIV transmission and therefore carries a low risk for re-infection.

If you are re-infected with a strain of HIV which is resistant to one or more anti-HIV drugs, your HIV treatment options could be reduced. This would mean that finding a combination of drugs that will be able to reduce your viral load to an undetectable level could be much harder.

If you are re-infected with a more aggressive strain of HIV this could cause a sudden rise in your viral load and a drop in your CD4 count, putting you at more risk of an HIV-related illness.

If you are concerned about re-infection, you can reduce the risk by using a condom when you fuck.