Ask the Experts
Experts at the HIV Center are available to answer questions from the general public about issues relating to HIV/AIDS. The Ask the Experts section is provided in conjunction with the website of the Columbia University Department of Psychiatry. To read about this service and guidelines for submission of questions, please click here.
Questions
(click your question below)
- I am faithful to my husband, but I think that he is cheating on me and I am worried about getting HIV or another STD from him. I would like to start using condoms with him, but don’t know how since I am on the birth control pill and we have never used condoms before.
- It seems to me that teenagers living in cities have plenty of access to solid information about HIV/AIDS and other issues of sexuality, but what about those living in suburban and rural areas? What particular concerns do they have, and how can they be reached?
- I have a busy medical practice that includes quite a number of people who have HIV or who are at risk of HIV. Yet none of them ever bring up the issue of sexual risk behavior and what they can do to stay safe. How can I raise the issue with them?
- I am HIV-negative and starting to date someone who is HIV-positive. I would like to pursue a relationship with him, but only if I can be 100% safe 100% of the time. Is this possible? If not, should I break things off?
- My brother recently told me that he is HIV positive. He found out in January and his doctors told him that he won't be put on medication now and that he should try to maintain a healthy immune system by exercising and eating dark greens. My brother, however, also suffers from depression, but he is medicated. Unfortunately I don't think his medication is working and on some days he can sleep as much as 18 hours in a day. Could his depression affect his immune system and speed up the progression of the virus?
- Last week, when I was drunk, I had my first, and very unexpected, sexual experience with a male friend. We did not use protection. Should I get tested for HIV? And where do I go from here? I am in love with my wife and cannot imagine telling her what happened or suggesting we use condoms when she is on the pill.
- Last month, I had sex with a woman. After about 10 minutes of intercourse, she took the condom off, performed oral sex for about a minute, and put the used condom on inside out. I think her vaginal fluids must have been on the condom and now I am scared that if her vaginal fluids contained HIV, I could have been infected. How likely is that?
- How widespread is the strategy of, "Let's get tested together before we have sex, for a variety of STDs"?
- Am I being a hypochondriac? A homeless man shook my hand a couple days ago because I gave him some money. Afterwards, I got scared because the day before, I got a superficial cut about a quarter of an inch long on my index finger. I didn’t see any wounds on the man or fluids on my hand, but I think the man was a drug user, perhaps because of his teeth and the burn scars on his hand. I got home 15 minutes later and washed my hands with peroxide and alcohol, worried that I might be at risk for HIV. If this man was HIV+, what are the chances that I am now HIV+?
- My first and only boyfriend had a problem with the condom and I am afraid I am HIV+ even though I have not had sex for 5 years and when I take HIV tests every year, they are always negative.
Is there any possibility I could be positive?- I have recently received oral sex from my girlfriend, who has been sleeping around about 2 to 3 times a week. All we did was oral sex without a condom. Am I at risk of getting HIV? Should I be tested?
- I am HIV positive and I infected my wife. Do we need to use condoms every time we want to make love? Can we still have a child without infecting him/her?
- A little over 3 months ago I was a victim of sexual assault. I was drugged unknowingly and can remember everything clearly except for 4 hours where the drug completely knocked me out....
Answers
- I am faithful to my husband, but I think that he is cheating on me and I am worried about getting HIV or another STD from him. I would like to start using condoms with him, but don’t know how since I am on the birth control pill and we have never used condoms before.
A response from Dr. Theresa Exner
One strategy you could try is to introduce the idea of condoms as an alternative to birth control pills. Many women don’t like to take the hormones in birth control pills for health or other reasons. And it would be possible to say that your health care provider recommended that you stop using birth control pills and start using condoms.
A good option for you could be the female condom, which has a lot of “selling points.” The man doesn’t have to put it on, and the woman can insert it ahead of time so that the sex act doesn’t have to be interrupted. It is made of polyurethane, which conducts body heat and conforms to the contours of the vagina. In fact, several studies have shown that many men believe that intercourse with the female condom feels very natural. And the female condom doesn’t have to be removed immediately after ejaculation, as the male condom does.
If this doesn’t work, there are other strategies you could try, such as reducing the number of times you have intercourse, or increasing other types of of sexual activity that are less risky than vaginal or anal intercourse. But this could be very challenging, and might not work in many relationships.
It seems that there is a larger issue in your relationship: you are having problems communicating with your husband about infidelity, safer sex, and possibly other important issues. These are subjects that it would be helpful to discuss with a professional counselor.
- It seems to me that teenagers living in cities have plenty of access to solid information about HIV/AIDS and other issues of sexuality, but what about those living in suburban and rural areas? What particular concerns do they have, and how can they be reached?
An response from Dr. Joyce Hunter:
It would be great if all youths had access to accurate, comprehensive information about all aspects of sexuality, including HIV, other STDs, contraception, and sexual orientation.
I wouldn’t be so sure that teenagers in cities necessarily have access to all the information and resources that they need. The quality, and even availability, of sex education varies widely. And many urban youths have a lot of other life stressors that also go unaddressed, such as poverty, racism, and other forms of discrimination.
Still, you may be right that many urban youths have more opportunities to access the services they need, such as youth drop-in centers, community-based organizations, and school clinics. Distances are so much smaller in cities that many teenagers can use public transportation to reach a wide range of resources outside of their own neighborhoods, where they are may have greater privacy. Youths in suburban or rural areas, especially if they are too young to drive or can’t afford a car, may face a great deal of social isolation. It can also be difficult for them to have the anonymity they may need to, for instance, acquire contraception or try to get support if they are questioning their sexual identity. And while some suburbs are affluent, it’s important to remember that poverty, and the stresses that come with it, also affect many suburban and, especially, rural areas.
Of course, the Internet has done a great deal to bring access to new resources and support to everyone, regardless of their geographic location. But in suburban and rural areas where there may be fewer services accessible to youths, it becomes more important for all of the services they encounter to provide quality sex education and social services to youth. Public schools, community agencies, health facilities, youth clubs and activities – all of these must recognize that just as sexuality is a part of everyone’s life so education and training in responsible sexuality should be part of their work as well.
- I have a busy medical practice that includes quite a number of people who have HIV or who are at risk of HIV. Yet none of them ever bring up the issue of sexual risk behavior and what they can do to stay safe. How can I raise the issue with them?
A response by Dr. Anke Ehrhardt:
Your position as a health care provider offers you a unique opportunity to talk about protected sexual behavior. Because this is such a sensitive subject, you cannot expect your patients to bring it up on their own. Instead, it is important for you to give them an opportunity to raise any concerns they may have, and then to take the time to have a discussion about risk behaviors.
One way to approach the issue is to say “Some of my patients wonder whether HIV may be a risk for them. Do you ever think about that?” By bringing up other people, you make it less about them individually than about a general issue faced by everyone. This same approach can also be used to discuss other sensitive subjects, such as contraception and sexually transmitted diseases. It is especially important to bring up issues related to sexuality with younger people. Many school systems are doing an inadequate job of teaching youths about sexuality, for example, by having “abstinence-only” curricula that are increasingly being shown to be ineffective. Instead, it is crucial to provide younger people with accurate, scientific information and to reflect openness to their concerns.
Discussing sexuality with a young person will not be “putting ideas in their heads.” Sex is “in their heads” already – they’re hearing about it ever day from their friends and peers as well as from a media-saturated society in which sexuality is everywhere. Based upon your expertise and comfort with discussing sexuality, you should be able to assess an individual’s risk and then also make appropriate referrals. Beforehand, you should familiarize yourself with a range of information sources and community-based organizations, and to share this information with your patients. More questions on this topic
- I am HIV-negative and starting to date someone who is HIV-positive. I would like to pursue a relationship with him, but only if I can be 100% safe 100% of the time. Is this possible? If not, should I break things off?
A response by Dr. Robert Remien:
Whenever an HIV-negative person is in a sexual relationship with someone who is HIV-infected, it is not possible to be 100% sure that HIV will never be transmitted. However, a lot is known about how this virus is transmitted and consistent and correct use of protective barriers can reduce the risk of transmission to a very minimal level. There are many resources available on the web and elsewhere that provide detailed information about safer-sex practices. I would strongly encourage you to take the time to educate yourself about the facts of HIV transmission and prevention.
As for becoming involved with this particular person, there are many reasons as to why one person may not want to pursue a relationship with another person. There are a lot of "risks" (physical and emotional) when we make ourselves vulnerable by truly opening ourselves to another person and daring to "fall in love." I do not believe that HIV status, in and of itself, needs to be a reason to not pursue a relationship. While being in a mixed-status relationship has its challenges, it is certainly viable. There are many people having happy, healthy, and satisfying long-term relationships even when they are of opposite HIV status.
To put some of this in another perspective, there is never 100% chance we will not get hit by a stray bullet or a "hit-and-run" driver, die in a plane crash, get sick from food poisoning, be injured by falling debris when walking down the street, be abandoned by a lover -- the list can go on and on. But we do not stop ourselves from leaving the house and engaging in life and relationships. With that said, you or anyone else certainly has the right to select a partner based on whatever characteristic may be important to the person -- whether that be HIV status or any other physical, health, or personality attribute.
- My brother recently told me that he is HIV positive. He found out in January and his doctors told him that he won't be put on medication now and that he should try to maintain a healthy immune system by exercising and eating dark greens. My brother, however, also suffers from depression, but he is medicated. Unfortunately I don't think his medication is working and on some days he can sleep as much as 18 hours in a day. Could his depression affect his immune system and speed up the progression of the virus?
A response by Dr. Milton Wainberg:
The question: Could his depression (treated but not very effectively) affect his immune system and speed up the progression of the virus? The answer:
Part 1. The short answer is that depression can have a negative impact and treatment has a positive impact. Studies before the HIV current medications became available were not very clear about the impact of depression on HIV but did show “association between depressive disorders, distress, and stressors and the number of HIV-related symptoms.” More recently, several studies have shown some associations between depression, stress and HIV illness progression. One study found that “faster progression to AIDS was associated with more stressful life events, more depressive symptoms, and less social support.” Another determined that “depressive symptoms among women with HIV are associated with HIV disease progression (women with chronic depressive symptoms were 2 times more likely to die than women with limited or no depressive symptoms). These results highlight the importance of adequate diagnosis and treatment of depression among both men and women with HIV as UNTREATED depression, besides affecting the quality of life of any person, may contribute with HIV illness progression.
Research at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute, by Dr. Judith Rabkin, has shown that antidepressants DO NOT interfere with the immune system, making it very safe to use them in people infected with HIV at any stage of their illness. Also, several non-medication treatment modalities have been helpful in treating depression in HIV-positive individuals, among them interpersonal psychotherapy.
Part 2. You also state in your question that you “don't think his medication is working and some days he can sleep as much as 18 hours in a day”. Either the medication for depression is not working, as you suggest, or it could also be that your brother may require a comprehensive assessment. For example, HIV-positive men suffer from low levels of testosterone – hypogonadism – which looks like depression. Other hormonal problems, such as low thyroid secretion (hypothyroidism) also look like can manifest like depression. So, it may be necessary for your brother to be assessed properly to define if he only has depression and how to address his symptoms.
- Last week, when I was drunk, I had my first, and very unexpected, sexual experience with a male friend. We did not use protection. Should I get tested for HIV? And where do I go from here? I am in love with my wife and cannot imagine telling her what happened or suggesting we use condoms when she is on the pill.
A response by Dr. Alex Carballo-Diéguez:
The HIV tests more frequently used detect the antibody to the virus, not the virus itself. Sometimes, antibodies need only two weeks to show up, but other times they take up to three moths. You can get tested for HIV now, but will need to follow up with a second test in three months and not have risky sex in between. The issue of whether to tell your wife or not is something you have to decide on your own. Telling her you had sex outside the relationship may ruin it; not telling her may expose her to a virus. It is a tough choice, and only you can decide. Besides that, you should examine your drinking habits. Obviously, when you get drunk you do things you later regret. You need to think how to avoid that. There are a wide variety of mental health resources available in community and clinical settings that can help with issues including communication within relationships, substance use, and sexual identity. Good luck!
- Last month, I had sex with a woman. After about 10 minutes of intercourse, she took the condom off, performed oral sex for about a minute, and put the used condom on inside out. I think her vaginal fluids must have been on the condom and now I am scared that if her vaginal fluids contained HIV, I could have been infected. How likely is that?
A response by Dr. Anke Ehrhardt:
Since HIV/AIDS is a serious illness, it can be natural to be concerned about the possibility of infection. However HIV is not an easily transmitted virus. HIV is not passed along by routine or household contact, and only rarely by only limited or fleeting sexual contact.
Condoms are a highly effective means of preventing HIV transmission, but only if they are used consistently and correctly. Certainly, the scenario you describe does not constitute correct use on several levels. Although HIV cannot remain intact for very long in the open air, it is possible that a very small amount of infectious bodily fluids could theoretically have been transmitted in the brief time you described. For transmission to occur, at least five conditions would have to have been met:
1) she would have to be HIV-positive;
2) her current viral load would have to be sufficient for her to be infectious;
3) some significant quantity of vaginal fluids would have to be adhering to the condom, and not wiped away during the removal and replacement process;
4) you would have to have had a site on the penis where HIV could directly enter your bloodstream; and
5) HIV would have had to successfully entered and infected you.The cumulative possibility that all five of these conditions were met in your situation is quite low, although not theoretically impossible. However, other sexually transmitted infections can be transmitted more easily, and thus you might consider making an appointment at an STI/HIV testing and counseling facility. You could begin by visiting the website of your local health department. You may also wish to include STI/HIV testing as a routine part of your health care check-ups.
To better acquaint yourself with misconceptions and realities concerning HIV transmission, you may wish to visit the HIV transmission section of the website of the Center for Disease Control and Prevention (CDC) (http://www.cdc.gov/hiv/resources/qa/transmission.htm), which offers answers to commonly asked questions. You could also check the HIV transmission Q&A board at the comprehensive website The Body (http://www.thebody.com/Forums/AIDS/SafeSex/index.html).
If you find that you are experiencing excessive, persistent, or unwarranted fears of HIV infection, please consult a qualified mental health care provider who can help you understand and address the underlying causes of your concerns.
- How widespread is the strategy of, "Let's get tested together before we have sex, for a variety of STDs"?
A response by Dr. Robert Remien:
Part of standard safer-sex counseling has been to advise individuals to either use condoms every time they have intercourse or to first rule out the presence of any HIV or other STI and then make a commitment to monogamy before foregoing condom use. This means that two people would have to test for HIV/STIs more than once over a period of six months (or more). If both people are HIV-negative and also free of other STIs, then that couple may choose to have unprotected sex with each other, provided they have been monogamous with each other over the period of testing and are committed to remaining monogamous.
To our knowledge, there are no data on how many people follow this strategy, which has sometimes been called "negotiated safety." However, overall numbers are probably not of as much concern as the specific situation of any particular couple. It can be challenging for couples to accomplish this and remain faithful to their monogamy commitment for the long term. Part of the agreement some couples make is to commit to communicate with each other, if and when the monogamy commitment is broken. Such communication can be difficult, however, particularly if it comes at a time that the relationship is also under a strain.
So, the bottom line is that one cannot get HIV or any STI from someone who doesn't have it. If two members of a couple are disease-free and remain so, then unprotected sex should be risk-free in terms of transmission of STIs. However, as mentioned above, this will only remain true if both people remain free of STIs and that requires ongoing trust that there are no outside sex partners or that all sex with other partners is 100% protected.
- Am I being a hypochondriac? A homeless man shook my hand a couple days ago because I gave him some money. Afterwards, I got scared because the day before, I got a superficial cut about a quarter of an inch long on my index finger. I didn’t see any wounds on the man or fluids on my hand, but I think the man was a drug user, perhaps because of his teeth and the burn scars on his hand. I got home 15 minutes later and washed my hands with peroxide and alcohol, worried that I might be at risk for HIV. If this man was HIV+, what are the chances that I am now HIV+?
A response by Dr. Anke Ehrhardt:
Since HIV/AIDS is a serious illness, it can be natural to be concerned about the possibility of infection. However, in general, HIV is not an easily transmitted virus. HIV is not passed along by non-sexual routine or household contact. Thus, your risk of infection in this scenario is non-existent; if HIV could be transmitted that easily, the entire world would be infected by now!
To better acquaint yourself with misconceptions and realities concerning HIV transmission, you may wish to visit the HIV transmission section of the website of the Center for Disease Control and Prevention (CDC) (http://www.cdc.gov/hiv/resources/qa/transmission.htm), which offers answers to commonly asked questions. You could also check the HIV transmission Q&A board at the comprehensive website The Body (http://www.thebody.com/Forums/AIDS/SafeSex/index.html).
If you find that you are experiencing excessive, persistent, or unwarranted fears of HIV infection, please consult a qualified mental health care provider who can help you understand and address the underlying causes of your concerns.
- My first and only boyfriend had a problem with the condom and I am afraid I am HIV+ even though I have not had sex for 5 years and when I take HIV tests every year, they are always negative. Is there any possibility I could be positive?
A response by Dr. Gregory Sullivan:
When someone has been infected with HIV, the immune system develops antibodies to the virus over the first few months after infection. This period is the "window period" during which it is possible for someone to have been infected but to show up negative on the HIV antibody test. Therefore repeat testing is recommended about six months after the potential exposure to HIV.
Since being "positive" by definition means that antibodies to HIV were present at the time of the antibody test, it is not possible to be become positive if repeated testing greater than six months after the potential exposure episode indicates no antibodies to HIV are present.
Sometimes anxiety can manifest as excessive concern about one's health, particularly when such concern is not allayed by medical evidence to the contrary. For example, the anxiety disorder known as obsessive-compulsive disorder can involve obsessive thoughts about contamination even though the individual recognizes the thoughts are excessive or unreasonable. When concerns as these take up much time or interfere with functioning, treatment of the anxiety is considered warranted.
- I have recently received oral sex from my girlfriend, who has been sleeping around about 2 to 3 times a week. All we did was oral sex without a condom. Am I at risk of getting HIV? Should I be tested?
A response by Dr. Anke Ehrhardt:
Since HIV/AIDS is a serious illness, it can be natural to be concerned about the possibility of infection. However, in general, HIV is not an easily transmitted virus. Although it is possible to transmit HIV to the partner who performs oral sex, it is nearly impossible for HIV transmission to occur to the receptive partner.
However, other sexually transmitted infections can be transmitted more easily, and thus you might consider making an appointment at an STI/HIV testing and counseling facility. (You can begin by visiting the website of your local health department.) You may also wish to include STI/HIV testing as a routine part of your health care check-ups.
To better acquaint yourself with misconceptions and realities concerning HIV transmission, you may wish to visit the HIV transmission section of the website of the Center for Disease Control and Prevention (CDC) (http://www.cdc.gov/hiv/resources/qa/transmission.htm), which offers answers to commonly asked questions. You could also check the HIV transmission Q&A board at the comprehensive website The Body (http://www.thebody.com/Forums/AIDS/SafeSex/index.html).
If you find that you are experiencing excessive, persistent, or unwarranted fears of HIV infection, please consult a qualified mental health care provider who can help you understand and address the underlying causes of your concerns.
12. I am HIV positive and I infected my wife. Do we need to use condoms every time we want to make love? Can we still have a child without infecting him/her?
A response by Dr. Robert Remien:
In theory, it is possible for one HIV-positive person to infect another HIV-positive person with another “strain” of the virus, including a strain that may already be resistant to a number of the antiretroviral drugs used to treat HIV. It is not well established how often such “reinfection” occurs. Some couples in which both people are HIV-positive do not believe it is very common, and thus choose not to use condoms. This is a decision that you and your wife will need to make (ideally in consultation with your physician) about how much risk you are comfortable with regarding HIV, as well as the possibility of transmission of other sexually transmitted infections. The way that a fetus or newborn is infected with HIV is through the biological mother. When an HIV+ woman becomes pregnant there is always some risk that the virus can be transmitted to the baby either during pregnancy, during delivery, or afterwards if breastfeeding occurs. However, there are many ways to reduce the likelihood of transmitting the virus, including antiretroviral treatment for the mother to lower her viral load (i.e., the amount of virus present in the body) as well as for the baby upon birth. Any decisions about getting pregnant and have babies should be made in consultation with a medical professional.
13. A little over 3 months ago I was a victim of sexual assault. I was drugged unknowingly and can remember everything clearly except for 4 hours where the drug completely knocked me out. Doctors and the rape crisis hotlines I have called have all said that due to being drugged, there is no way to actually know if I was raped or not. This is driving me crazy and a big part of the anxiety I am feeling is that I am scared that I could have contracted HIV. Three weeks after the incident I went and got tested, it was negative. I went again to have a rapid HIV test done a few days short of 9 weeks, again negative. I went last week for another test and am waiting to pick up the results on Friday. This was 13 and a half weeks after the incident. One test site said I'd know my HIV status for sure in 3 months, another said it could be up to a year before I'd know for sure. I'm getting mixed information from all different sources. I normally would be more patient, but my fiance is currently deployed. This has all been going on with him away (which has been extremely difficult). He gets back before I hit the 6 month mark. I need to know because this could potentially affect his health too. I wouldn't want to risk his health. At this point, I just need answers.
A response by Dr. Robert Remien:
If a person has had a single (possible) sexual exposure to HIV and continued to test HIV-negative for over two months, the chances are very low at this point that HIV infection occurred (though you should also be checked for other sexually transmitted infections.) However, it is true that there is a “window” period between initial HIV infection and the ability of blood tests to identify the HIV antibody (an antibody test is the standard test for HIV). During this early period of infection (called “acute HIV infection”) it is possible for doctors to check directly for the presence of the virus itself. If you are still concerned, you could consider such a test. However, to repeat, the antibody test has become increasingly sensitive, so that in most cases, this standard test will be able to tell if HIV infection has occurred within a couple of months after infection. It is also important for people who are victims of sexual assault – or who experience any incident of unprotected sex – to know that they can receive treatment to prevent HIV infection up to 72 hours after the incident (the sooner the better). This is called “post-exposure prophylaxis” (PEP) and has shown a high rate of success in preventing infection from becoming established. It is also important to know that it is during the first several weeks of HIV infection (known as the “acute” stage), that individuals are themselves the most likely to transmit HIV infection, so practicing safer sex during this period is crucial. Beyond the issue of HIV, you have had a very traumatizing experience and it is critical that you receive social and psychological support, including from your fiancé. An experience of sexual assault may change how you relate to your fiancé, to your sexuality, and indeed to your life overall. It is essential that you and your fiancé be able to discuss this event and the impact it is having on you; a professional counselor or physician should be able to help with this.
14. My new girlfriend just recently found out she is HIV positive. She is on medication and wants to have sex but does not want to use protection. She claims that she recently had a test run and it came back undetectable for HIV. What are the possible risks to me?
A response by Dr. Robert Remien:
Generally speaking, the lower someone’s “viral load” (i.e., the amount of virus present in their blood), the less likely they are to transmit the virus to another person. However, “undetectable” viral load only means that the amount of virus is below the ability of the test to detect; there is always still some virus present and viral replication is always occurring. Further, viral load levels can fluctuate due to many factors, such as the presence of another type of infection or a lapse in treatment. And while infection from a woman to a man through vaginal intercourse is not the most efficient mode of transmission, transmission risk can be higher due to other factors, such as if the man is uncircumcised or if the woman is menstruating. This is a decision that you and your girlfriend will need to make (ideally in consultation with your physician) about how much risk you are comfortable with regarding HIV, as well as other sexually transmitted infections. Trust and communication are also important in gauging any type of risk within a couple, particularly a new couple. Your phrasing that “she claims” to have had a test that came back undetectable suggests that you do not entirely trust her and are not comfortable with her around this issue. Speaking with a counselor, whether alone or with your girlfriend, may help you to communicate more effectively.
