Protection
Condoms and internal condoms, treatment as prevention, and pre-exposure prophylaxis provide reliable protection from sexual transmission of HIV. Transmission during drug use can be prevented through safer use practices and transmission to babies can be prevented by taking HIV medications and further measures. After potential contact with HIV, post-exposure prophylaxis started within 48 hours can significantly reduce the risk of infection.
Protection from sexual transmission of HIV
Reliable protection from sexual transmission of HIV is offered by condoms and internal condoms, effective antiretroviral therapy (treatment as prevention), and pre-exposure prophylaxis (PrEP).
Condoms and internal condoms („femidoms“)
and
Condoms and internal condoms during vaginal and anal intercourse provide protection from HIV and reduce the risk of other sexually transmitted infections.
Corrects use of condoms
When used consistently and correctly, (external/internal) condoms provide protection from HIV and reduce the risk of other sexually transmitted infections:
- Use condoms that bear the CE marking and are imprinted with DIN EN ISO 4074. Pay attention to the use-by date and any damage to the packaging.
- Internal condoms (“femidoms”) consist of an about 18-cm-long, thin, tearproof polyethylene or polyurethane sheath closed at one end with a ring at each end. The outer ring remains outside the vagina and covers the outer vaginal lips, the inner ring is inserted into the vagina and covers the mouth of the cervix and the cervix. Internal condoms can also be used during anal intercourse. They enable the receiving partner to initiate the use of a barrier method. In addition, they offer an alternative when the erection cannot be maintained while putting on a condom, since they can already be inserted long before the intercourse.
- Do not use any sharp objects (knife, scissors) or your teeth to tear open the packaging. Be careful with long fingernails!
- Do not put on the condom until the penis is erect. If necessary, pull back the foreskin and place the condom on the head of the penis (glans) with the ring facing outwards. Pinch the reservoir tip with one hand to remove any air pockets, then fully unroll the condom with the other hand.
- Never put two condoms on top of each other – they will rub against each other and can easily tear or slip off.
- Always use a sufficient amount of fat-free lubricant during anal intercourse and in the case of vaginal dryness. Fat-based products such as Vaseline, massage oil, or body lotion are not suitable – they can weaken condoms.
- Put on the condom before applying the lubricant. Never apply lubricant onto the penis before putting on an external condom, because the condom may otherwise slip off or tear.
- Check with your hand from time to time whether the condom is still in place.
- After sex, pull out the penis from the vagina or rectum while still erect, holding on to the condom at the rubber ring.
Treatment as prevention
HIV medications suppress HIV replication in the body. The number of HIV copies in the blood, semen as well as in the liquid film on the mucous membranes of the vagina, penis, and rectum is then very small. Major scientific studies demonstrate that HIV cannot be sexually transmitted by a person living with HIV on stable and effective HIV therapy¹. Treatment as prevention requires taking medications as prescribed and undergoing regular medical check-ups. Treatment as prevention also means that people with HIV on stable and effective ART can become parents without fear of transmitting HIV to their partners and children. Vaginal delivery and breastfeeding are possible, too. Temporary increases in viral load in the blood to values ranging between 50 and 1000 copies/ml were quite common in the studies, but did not lead to transmission. By contrast, if the viral load in the blood increases permanently during the therapy, for example because the medications are not taken as prescribed or are no longer effective, the viral load in the genital and rectal secretions also increases, and so does the risk of transmission.
1 HIV therapy is considered effective if the viral load in the blood is below the so-called detection limit for at least six months. Today, the HIV detection limit usually ranges between 20 and 40 copies/ml, whereas it was at 200 copies/ml in most scientific studies attesting to the effectiveness of treatment as prevention.
Pr-exposure-prophylaxis (PrEP)
In pre-exposure prophylaxis (PrEP, prevention before potential contact with HIV), HIV-negative people are taking HIV medications to protect themselves from HIV infection. PrEP can be taken daily or as an event-driven regimen. When taken as prescribed, it provides reliable protection from HIV (but not from other sexually transmitted infections).
PrEP with an HIV medication that combines the active ingredients emtricitabine and tenofovir has been shown to be highly effective in particular in gay men at high risk for HIV. In the cells of the vaginal mucosa, tenofovir does not accumulate as well as in the rectum. It therefore takes longer for sufficient HIV protection to build up here and strict patient compliance is required to maintain the protection – event-driven PrEP is not recommended for receptive vaginal intercourse.
Reliable protection from HIV is also provided by a long-acting injectable PrEP with the antiretroviral cabotegravir.
To date, only limited data is available on the effectiveness of PrEP in drug users. However, it can be indicated in individual cases where sterile injection equipment is not available (especially in prison).
Before starting PrEP, medical examinations and an HIV test are required to reliably rule out an HIV infection, because if an HIV infection is already present, the active ingredients of PrEP medications are not sufficient for treatment and the virus can become resistant to these important medications. For this reason, HIV tests also need to be performed four weeks after starting PrEP and then every three months. In the event of an infection despite PrEP (for example, because the PrEP medications were not taken as prescribed), PrEP has to be discontinued and replaced by full HIV therapy.
PrEP includes regular medical check-ups; in addition, regular screenings for sexually transmitted infections are recommended.
Safer Use
“Safer use” practices make drug use safer – for example, they reduce the risk of HIV transmission, but also the risk of overdose or dangerous interactions.
The key rule to ensure protection from HIV as well as hepatitis and other infections when injecting drugs: Only use your own syringe, needle, and equipment for each instance of drug use. Many drug counselling centers offer sterile injection equipment and sets with sterile spoons, single-use filters, and sterile water. In some cities, such equipment is also available from vending machines. In addition, alternative forms of drug use such as snorting or foil smoking reduce the risk of infection; corresponding equipment (such as uncoated foils or snorting tubes) is also provided by many drug counselling centres.
If sterile injection equipment is not available (e.g. in prison), used injection equipment should be disinfected as much as possible. HIV PrEP may also be indicated.
Prevention of transmission to babies
In Germany, all pregnant persons must be offered an HIV test; if this does not happen, they should address this topic themselves. The performance of the test (but not the result) is documented in the maternity record.
Transmission of HIV to the baby can be prevented by antiretroviral therapy of pregnant persons with HIV and by taking further measures, if necessary (e.g. scheduling a Caesarean section before going into labour and treating the newborn baby with preventive ART for up to four weeks).
Under specialised medical and interdisciplinary supervision, pregnant persons on effective ART can also give birth vaginally and breastfeed their babies. The advantages and possible disadvantages should be discussed with the medical specialist and the decisions should be made together.
Post-exposure-prophylaxis (PEP)
After contact with (“exposure to”) an amount of HIV that is sufficient for infection – for example after a needlestick injury with a needle contaminated with HIV-positive blood, unprotected sex with an untreated person with HIV or when sharing syringes and needles for drug use – post-exposure prophylaxis (“prevention after contact with HIV”) can usually prevent HIV from settling in the body and the onset of an infection. PEP should ideally be started within two hours, if possible within 24 hours, but no later than 48 hours after the 29 risk exposure. Contact details of hospitals offering PEP can be found at www.kompass.hiv/en, category: PEP point.
Circumcision
According to studies, circumcision of the foreskin reduces the risk of HIV infection during penetrative vaginal intercourse by up to 60 percent, especially because the surface area of the penile mucosa is reduced and the part of the foreskin that is rich in HIV target cells is removed. Whether or not circumcision also reduces the risk during anal intercourse has not been scientifically clarified. It should be considered that many men who have sex with men (MSM) practice both penetrative and receptive anal intercourse.
Caution: Highly error-prone strategies
Selecting sexual partners with the same HIV status
The idea behind this strategy: people with HIV are already infected and HIV-negative people cannot transmit HIV. To this end, however, the current HIV status must be known. This is often not the case, though, for example because a current HIV test result is not available – about 9,000 people in Germany are infected with HIV without being aware of their infection.
Selecting the sexual role in anal intercourse by serostatus
In this strategy, the HIV-positive partner takes the receptive (“passive”) role and the HIV-negative partner takes the penetrative (“active”) role. Although the risk during penetrative anal intercourse is indeed lower than during receptive anal intercourse, it is still high. Furthermore, there is no obligation in Germany to inform sex partners about an HIV infection.
Coitus interruptus („pull-out method“)
The attempt to pull out the penis from the body before ejaculating often fails. Moreover, if the mucous membranes contain large amounts of HIV, HIV transmission is also possible without ejaculation (in both directions), namely due to the friction between the mucous membranes of the penis and the rectal or vaginal mucosa.