1. Safe Sex and HIV A Clinical Perspective
Ruth Hennessy
Psychology Unit Manager/
Clinical Psychologist
The Albion Street Centre, Sydney NSW

2. Outline Activity PLWHA and transmission
Impacts on disclosure and safe sex
Professional considerations
Treatment
Case

3. Sit down if you have ever…
Bungee jumped
Got a speeding ticket
Run a red light
Used recreational drugs/ drunk too much alcohol
Gone abseiling
Spent money you didn’t really have

4. Sit down if you have ever…
Encouraged a friend to drink more alcohol/ try drugs
Woken up next to someone and had no idea who they are!
Talked on the phone during an electrical storm
Had sex without protection having assumed a sexual partner is STI free & HIV negative

5. Hhmm… What do you think the level of risk was?
How did others rate the level of risk?
Did the potential positive consequences outweigh the negative ones?
What would be motivations & barriers to change?

6. PLWHA and transmission

7. knowing their HIV status has been overall beneficial
Majority of PLWHA are adamant that they would never want to infect anyone else (regardless of the law)
and
knowing their HIV status has been overall beneficial

8. Intentional Transmission
Very rare
Likely to have sociopathic, borderline and/or narcissistic personality traits
Motivations for change:
Egocentric- for own benefit
To avoid negative consequences:
loss/rejection
STIs
public outing/humiliation, incarceration

9. Intentional HIV Acquisition
Very rarely identified
Personality traits
Beliefs re increasing intimacy or keeping a relationship or belonging to a community
Impact of coercion, bullying from peers/partner

10. Sero-Discordant Relationships
Unprotected sex = a relationship
Sero-disco and unprotected sex:
Strategic positioning
UI viewed as sign of commitment/love
HIV:
status differences viewed as barrier to intimacy
not viewed as a negative consequence
resolves ongoing fears of transmission
mutual support

11. HIV transmission and sexual behaviour
Strategic positioning (top/bottom)
Withdrawal method
Undetectable viral load
Sero sorting
“I only go to poz parties or venues”
Beliefs attached to behaviour
No/Low risk perception

12. What impacts on PLWHA around disclosure/safe sex

13. Stigma Shame and discrimination
Criminalisation of HIV – ‘demonising’ of PLWHA
Fear of recrimination/litigation
Privacy issues around disclosure

14. Responsibility Beliefs
It takes two to tango…
“I have been responsible in knowing my status – now I carry this burden with me…I am not taking on anyone else’s too…”
Law says otherwise

15. Skill deficits Sexual negotiation Communication
“If he doesn’t talk about the issue or doesn’t bring it up, I don’t”
“I don’t like to mention it in case he might reject me”

16. Mood State “I didn’t want to think about it” “I didn’t care”
“I just wanted to escape from everything”

17. Trust
“He would have told me/used a condom if there was a problem…”

18. Condom Difficulties
Dislike of condoms; concern about diminished pleasure
“It’s like having a shower in your raincoat”
Erectile loss
“If I use a condom I will lose my erection”
Unavailability/Inconvenience of condoms
“The condom broke and we only had one”

19. Lack of Control Passion, excitement, impulsivity, substance use
“It was a passionate moment”
“I was off my head”
“I didn't know he had taken it off”

20. Impact of Mental Health
Mood Disorders (depression)
Anxiety Disorders (social anxiety)
Sexual Disorders (erectile dysfunction)
Substance Disorders (drug use)
Personality Disorders (poor empathy, self concept or communication skills, impulsive behaviours, substance use)

21. Other Issues Own view & experience of HIV Own view & experience of sex
“I deserve to have sex as I like”
“I am a sex pig”
Sexuality issues
Multiple sex partners
Anonymity of sex
Use of sexual stimulants (eg. Viagra)

22. Who do we see?

23. Who identifies the behaviour as a problem?
Referral from:
self
other health services eg. GP, treating doctors
partners
Health Department/Advisory Board
Aim to highlight benefits of change to self

24. Engaging people in discussions around HIV and risk
Normalise the process: part of standard assessment , similar to Domestic Violence, Child Protection
“The following questions cover areas that we always ask about as they are pertinent to your health and HIV”

25. HIV/STI disclosure
Highlight your and their obligations (incl. Public Health)
Limits to confidentiality
Risk of harm to self
Risk of harm to others

26. HIV/STI disclosure
“The law requires people to disclose their STI/HIV status/practise protected sex. Sometimes people have trouble disclosing their HIV status and/ or practising safe sex. This is something I have experience in and would like to work on if this is an issue for you. How do you approach disclosure and protected sex?”

27. Professional Obligations
Duty of care
Minister of Health can breach confidentiality
Board or senior advisory committee
Supervisor and Managers
Case notes and documentation

28. General Treatment Strategies

29. Treatment Rapport building Importance of engagement
Acknowledge and validate client’s willingness to raise/address issue
Assessment of motivations

30. Strategies Help identify personal obstacles to disclosure/condom use
Ask if there are any possible benefits to disclosure/condom use
Acknowledge and validate strong feelings

31. Correct Knowledge Gaps
Discuss the limitations of statistics
“What is your understanding of HIV transmission and viral load? …”

32. Cognitive Strategies
Teach to challenge obstacles to disclosure/condom use and generate more helpful and realistic beliefs
eg. Rejection fears
“Have you ever known anyone to accept a positive sexual partner?”

33. Skills Training Assertiveness and social skills training
(role plays, modelling)
Planning and problem solving
Peer support
Erection difficulties
eg. patient practises masturbation without and with condoms,
partner stimulates without and with condom

34. Encouraging Empathy Discuss:
Partners’ motivations for placing themselves at risk
Conflict between unsafe sex and concern for partners’ health
Non risk intimate practices eg. mutual masturbation, kissing

35. Specific Treatments Brief Interventions Motivational Interviewing CBT
Dialectic Behavioural Therapy

36. Motivational Interviewing
Identify the motivators (and barriers) to assist in resolving ambivalence (making change)
Monitor the degree of readiness to change to avoid resistance
Affirm self-direction

37. Case & Panel

38. Randy
Randy is a 38 year old gay man. He has been HIV positive for the last 15 years.
His GP referred him because he recently said he was contemplating stopping his HIV medications.
He also says he has been having a lot of unprotected sex with different partners in a sex club. This sex has mostly been associated with crystal meth use. Randy has used recreational drugs on and off for many years.

39. Randy
Randy used to work part-time for a friend but they had a falling out and he now has no friends, no job and little money.
About his sexual behaviour he says
‘I don’t have to worry about HIV so why should I care about not using a condom?’.
About his drug use he says
‘It’s the only time I feel good’
About stopping his medications he says
‘I am over them’.
He complains of everyone ‘attacking’ him.

40. GROUP ACTIVITY 1. What might this person be FEELING?
2. What might be key MENTAL HEALTH CONCERNS?
3. What REFERRAL OPTIONS and STRATEGIES can you suggest?
4. How does your ORGANISATION / PROJECT ROLE assist people like Randy?