what are the concerns?

what are the concerns?

Public health messages have traditionally urged disclosure to all sexual and drug using partners. In reality, disclosure is complex and difficult. Some HIV+ persons may fear that disclosure will bring partner or familial rejection, limit sexual opportunities, reduce access to drugs of addiction or increase risk for physical and sexual violence. Because of this, some HIV+ persons choose not to disclose. Programs need to accept that not disclosing is a valid option.

Many HIV service agencies and testing and counseling sites routinely offer self disclosure and dual disclosure, working with HIV+ clients by preparing and supporting them to disclose to partners on their own.

Although provider disclosure services have been used for many years with other STDs, there is a wide variety in rates of acceptance of provider disclosure in HIV: in North Carolina, 87% of newly diagnosed HIV+ persons accepted provider disclosure,8 in Florida 63.1%,9 Los Angeles, CA 60%,10 New York State 32.9%,11 Seattle, WA 32%12 and among anonymous testers in San Francisco, CA 3.1%.13 In Los Angeles, the most common reasons for refusal were: already notified partner (23.4%), not being ready to disclose (15.3%), being abstinent (15%) and having an anonymous partner (11%).10

Disclosing HIV status to partners can be scary, but also can be empowering. In one study, HIV+ injection drug users who disclosed their status found increased social support and intimacy with partners, reaffirmation of their sense of self and the chance to share experiences and feelings with sexual partners.14 Another study of HIV+ persons and their partners who received disclosure assistance found that emotional abuse and physical violence decreased significantly after notification.15

what’s being done?

Florida utilizes trained DISs to deliver disclosure assistance for all reported new HIV infections. In 2004, 63.1% of all newly infected HIV+ persons accepted provider disclosure, identifying 4,460 sex or needle-sharing partners. Among those, 21.8% had previously tested HIV+. Of the 2,518 persons notified, 84.2% agreed to counseling and testing and 11.5% were HIV+.9

The Massachusetts Department of Public Health piloted a client-centered model of disclosure assistance that is integrated into the client’s routine prevention, care and support services. The program required significant changes to the standard model of DIS provider disclosure, building close relationships between service providers and DIS to better support clients’ disclosure needs while protecting confidentiality.16

California instituted a voluntary disclosure assistance program that includes counseling and preparing HIV+ persons for self disclosure; anonymous third party provider notification; counseling, testing and referrals for notified partners; and training and technical assistance to providers in public and private medical sites. About one-third of patients opted for provider disclosure and 85% referred partners. Of the partners located, 56% tested for HIV and half had never tested before. Overall, 18% of partners tested HIV+.4

what needs to be done?

New HIV testing technologies can be useful with disclosure assistance services. Improved rapid testing is a potential invaluable tool for offering HIV tests in the field to notified partners. Nucleic acid amplification testing (NAAT) can determine acute infections, that is, new HIV infections that do not show up during the window period of other HIV tests. Combining these testing strategies with disclosure assistance can help identify newly infected persons and provide immediate counseling, support and referrals to medical or social services as needed.17

Disclosure assistance services, and particularly provider disclosure, may need extensive changes from the traditional DIS model in order to work well and be accepted within HIV services. Health departments could forge closer ties between their STD and HIV programs and with outside service agencies. HIV staff also can be trained to be DIS providers to broaden access to and comfort with disclosure services.

Disclosure assistance services should be made available not only upon HIV diagnosis, but on an ongoing basis as HIV+ persons’ circumstances and needs change. It is not the role of providers to decide if a client will need or want disclosure assistance, but to offer clients support and choices, whether or not a client chooses to disclose.

Where can I get condoms?

Where can I get condoms?

Family planning and sexual health clinics provide condoms free of charge. Condoms are available to buy from supermarkets, convenience stores and petrol/gas stations. Vending machines selling condoms are found in toilets at many locations. You can also order then online from different manufacturers and distributors.

There are no age limits for buying condoms. Buying a condom no matter how old you are shows that you are taking responsibility for your actions.

How can I check a condom is safe to use?

In the UK, condoms that have been properly tested and approved carry the British Standard Kite Mark or the EEC Standard Mark (CE). In the USA, condoms should be FDA approved, and elsewhere in the world, they should be ISO approved. Some countries have their own approval marks. To find out more see our page about condom effectiveness.

Condoms have an expiration (Exp) or manufacture (MFG) date on the box or individual packet - you should not use the condom if this date has passed. It's important to check this when you use a condom. You should also make sure the packet and the condom appear to be in good condition.

Condoms can deteriorate if not stored properly as they are affected by both heat and light. So it's best not to use a condom that has been stored in your back pocket, your wallet, or the glove compartment of your car. If a condom feels sticky or very dry you shouldn't use it as the packaging has probably been damaged.

So when and how do you use a condom?

You need to use a new condom every time you have sexual intercourse. Never use the same condom twice.

• 
• 
• 

Only put on a condom once there is a partial or full erection.

• Open the condom packet at one corner being careful not to tear the condom with your fingernails, your teeth, or through being too rough. Make sure the packet and condom appear to be in good condition, and check that the expiry date has not passed.
• Place the rolled condom over the tip of the hard penis, whilst pinching the tip of the condom enough to leave a half inch space for semen to collect. If the penis is not circumcised, pull back the foreskin before rolling on the condom.
• Roll the condom all the way down to the base of the penis, and smooth out any air bubbles. (Air bubbles can cause a condom to break.)

A video animation showing how to put on a condom.

If you want to use some extra lubrication, put it on the outside of the condom. Always use a water-based lubricant (such as KY Jelly or Liquid Silk) with latex condoms, as an oil-based lubricant will cause the latex to break.

The man wearing the condom doesn't always have to be the one putting it on - it can be quite a nice thing for his partner to do.

If you decide to have anal intercourse after vaginal intercourse, or vaginal intercourse after anal intercourse, you should consider changing the condom.

When you have ejaculated or finished having sex, withdraw the penis before it softens. Make sure you hold the condom against the base of the penis while you withdraw, so that the semen doesn't spill.

What do you do if the condom won't unroll?

The condom should unroll smoothly and easily from the rim on the outside. If you have to struggle or if it takes more than a few seconds, it probably means you are trying to put the condom on upside down. To take off the condom, don't try to roll it back up. Hold it near the rim and slide it off. Then start again with a new condom.

Appendix 3 – Questions for Key Informants

Appendix 3 – Questions for Key Informants
Opening
• What do you see as the relationship between HIV prevention and sex education in schools?
Development of sex, relationships and HIV education
• How has sex education in schools evolved or developed within your country/region of expertise? What have
been the major infl uences?
• Prompt: Family planning, HIV and AIDS education, religion
• How is sex education regarded by religious leaders and other key stakeholders?
• What examples exist of collaborations with, for example Parent-Teacher Associations, faith-based organizations
and other key stakeholders on the development of sex education in schools?
Any key documents you recommend in this regard?
Content of sex, relationships and HIV education
• Developmentally appropriate
• At what age/level does or should sex education in schools begin?
• How do approaches to sex education differ in primary versus secondary school?
• How do you think they should differ?
• In many countries, children/young people (especially girls) will not go on to secondary education. So, in terms of
sex, relationships and HIV education, what knowledge (attitudes, skills and behaviours) should they possess by
the time they leave school?
• What specifi c examples can you share of developmentally appropriate sex, relationships and HIV education?
Curriculum
• Is sex education included in the national school curriculum?
• Under what subject(s) is sex education taught?
• What are the main components of the sex education curriculum?
• What are the assumptions about human sexual relationships, young people and gender relationships?
• How can sex education explicitly address gender issues?
• What is taught about HIV?
• Is sex education taught in single sex or mixed classes?
• Is sex education taught in mixed age group classes?
• What is taught – if anything – about condoms?
• What is taught – if anything – about contraception?
Teacher support
• What training and support do teachers receive (if any) to prepare them to teach sex education?
• What are the main challenges for training teachers? And what are the most promising approaches?
• Who are the outside resource people that could assist with teacher training? How does one ensure quality?
Policies
• What policies are in place to support sex, relationships and HIV education in schools?
• To what extent is sex education linked to sexual and reproductive health (SRH) services?
Any key documents you recommend in this regard?
Coverage, Quality and Intensity
• What would you estimate is the coverage of sex education in schools in your country/region of expertise?
• Prompt: quality (e.g. gender-specifi city), intensity/exposure.
• What are the main challenges/successes to implementation of sex, relationships and HIV education in schools?
• Can you share any evidence to support this?
Any key documents you recommend in this regard?

infections and vaccinations in HIV

ph

Type-specific testing for HSV-2 infection can be considered if herpes infection status is unknown. A first dose of hepatitis A and hepatitis B vaccine should be administered at this first visit for previously unvaccinated persons for whom vaccine is recommended (see Hepatitis A and Hepatitis B). In subsequent visits, when the results of laboratory tests are available, antiretroviral therapy can be offered based on existing guidance (129). Recommendations for the prophylaxis of opportunistic infections and vaccinations in HIV-infected adults and adolescents are available (130,131).

Providers should be alert to the possibility of new or recurrent STDs and should treat such conditions aggressively. Diagnosis of an STD in an HIV-infected person indicates on-going or recurrent high-risk behavior and should prompt referral for counseling. Because many STDs are asymptomatic, routine screening for curable STDs (e.g., syphilis, gonorrhea, and chlamydia) should be performed at least annually for all sexually active, HIV-positive persons. Women should be screened annually for cervical cancer precursor lesions by cervical Pap tests. More frequent STD screening might be appropriate depending on individual risk behaviors, the local epidemiology of STDs, and whether incident STDs are detected by screening or by the presence of symptoms.

Recently identified HIV infection might not have been recently acquired; persons newly diagnosed with HIV might be at any stage of infection. Therefore, health-care providers should be alert for symptoms or signs that suggest advanced HIV infection (e.g., fever, weight loss, diarrhea, cough, shortness of breath, and oral candidiasis). The presence of any of these symptoms should prompt urgent referral to an infectious diseases provider. Similarly, providers should be alert for signs of psychological distress and be prepared to refer patients accordingly (see Counseling for Patients with HIV Infection and Referral to Support Services).