Safe Sex and HIV A Clinical Perspective

1. Safe Sex and HIVA 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. 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 PLWHAaround 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. 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) Impact of Mental Health

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?