Human Immunodeficiency Virus (HIV) causes progressive damage to the immune system within the body. The immune system usually helps to fight off bacterial, fungal or viral infections and also some cancers. Acquired Immune Deficiency Syndrome (AIDS) is caused by HIV and occurs when the immune system is severely damaged, allowing infections and cancers to develop and become life threatening.
HIV can be transmitted through the exchange of blood, semen, anal mucus, vaginal fluids or breast milk, such as:
- Unprotected anal and vaginal
- Sharing needles and syringes when injecting
- Sharing piercing or cutting instruments that has been contaminated with another person’s blood
- Blood transfusion
- During pregnancy, at birth, or via breast milk
- In rare cases, it is spread through oral sex and needle-stick injuries
In order for transmission to occur HIV needs an entrance point like a cut, scratch, abrasion, open sore or bleeding gums, or to be injected directly into the bloodstream through a needle or syringe. The presence of other STIs, especially genital ulcers or sores, makes sexual transmission of HIV more likely.
In some Australian states, it’s against the law for sex workers living with HIV to work in the sex industry. Contact your local sex worker organisation to find out more about the rights and responsibilities of sex workers living with HIV.7
What is the risk of getting HIV from:
- Deep kissing: Safe. HIV is not in sufficient quantities in saliva for it to be transmitted.
- Oral sex: Very low risk. When giving oral sex, use condoms and dams, especially if the area around and inside the mouth contains any recent dental surgery, bleeding or inflamed gums, oral piercings and/or cuts. Don’t brush or floss teeth beforehand.
- Hand relief: Safe. Make sure the penis and ejaculate is directed away from the eyes if no condom is used. Eye sockets are lined with mucous membranes and small blood vessels which the virus can enter. In addition, make sure any cuts or abrasions which will allow the virus a passage to enter the body are covered.
Signs and Symptoms
Many people don’t get any initial symptoms at all. Others might experience flu-like symptoms (headache, fever, swollen glands and lymph nodes, tiredness, nausea, vomiting, diarrhoea achy muscles and joints) when they first contract HIV, which disappear on their own after a couple of weeks and the person feels fine again. Other identifying symptoms include rash, weight loss and mouth ulcers. There are no visible signs of HIV to look for when checking clients, either.
Testing for HIV
The decision to test is voluntary and should be made with informed consent. People taking a HIV test can request for information and counselling before and after the blood test and the results are confidential. There are a number of different tests used to detect HIV and a combination of these tests can be used together to detect the virus. The current combination HIV fourth generation test detects early markers of HIV infection as well as immune response to the virus. This means that blood test can detect HIV as early as 2-3 weeks from exposure and will be conclusive (either positive or negative test result) at 6 weeks.
Rapid HIV testing is performed using a device that tests for the presence of HIV antibodies or the virus itself (depending on the device), and provides results in about 20 minutes. Rapid HIV testing is currently available in numerous locations in Australia. Rapid testing is not suitable for early detection of HIV as the window period between seroconversion and detection is longer than laboratory blood testing. Seroconversion refers to the period of time HIV antibodies develop and become detectable in the blood. People who suspect that they have recently been exposed to HIV should access PEP.
A reactive result (also called a preliminary positive result) from a rapid test needs to be confirmed with a laboratory test, as rapid tests produce a small number of false positives (a false positive refers to the test producing a positive result even though HIV is not present).
Rapid tests are available in sexual health clinics, some GPs and community-based testing services such as mobile HIV testing vans.
Home sampling refers to taking a mouth swab or a finger prick, mailing it to a laboratory, and the results are delivered by phone, text or online. HIV home sampling is different to self-testing (also referred to as HIVST) in that home sampling requires the user to send off the sample that they have extracted outside of a clinical setting to a laboratory to be tested for HIV.
Home sampling may be available through trial projects in some state and territory HIV/AIDS organisations.
HIV self-testing is a HIV testing tool that allows a person to perform a HIV test at home using a rapid testing device or kit. Some self-tests use a swab along the gum line, and some use a finger prick to draw a small amount of blood. HIV self-tests are particularly beneficial for people who prefer to test in private, alone or with people they trust, rather than in a health clinic. However, a reactive (sometimes incorrectly referred to as a positive) result needs to be confirmed with a laboratory HIV test that is conducted by a trained testing provider. Additionally, self-tests are not recommended for people taking antiretroviral drugs such as Pre-exposure Prophylaxis (PrEP) or Post-exposure Prophylaxis (PEP), as there is a greater chance of getting a false non-reactive (false negative result).
In November 2018, the Therapeutic Goods Administration (TGA) approved Australia’s first HIV self-test kits, the Atomo self-test kits, to be available for purchase in Australia. As the Atomo kits are the only self-test kits approved by the TGA, it is the only kit that is recognised to meet Australian standards of safety and accuracy. These tests provide users a reactive or non-reactive result within 15 minutes of performing the test.
The Atomo self-test kits are anticipated to be available in online stores and distributed through organisations, such as HIV/AIDS organisations and sexual health clinics, in late March 2019. The Atomo kits are anticipated to cost no more than $25, including postage and handling. If you are buying the Atomo kits from an online store, you will be required to watch an instructional video on how to properly use the self-test before you complete your purchase. If you are accessing the Atomo kits through an organisation such as a HIV/AIDS or a Sexual Health Organisation, the peer educator or health worker is required to inform you on how to perform the test and interpret your results.
The Atomo kits come with:
- self-testing tools which include a cartridge and a bottle of test fluid which is added into the cartridge with the blood sample;
- a set of instructions to guide the user to extract the sample, perform the test and interpret the results;
- a disposal bag; and
- a ‘Care Card.’ The ‘Care Card’ will have a list of referrals for the user to contact if there are any questions or concerns about the self-tests.
The type of testing tool used to screen for HIV in the Atomo self-test kits are rapid tests. There are no known studies that investigates the number of false reactives and negatives produced in low prevalence populations by the rapid tests provided in the Atomo self-test kits. However, all rapid tests have a possibility of producing a false reactive result. The ratio of false reactive results will always be more likely in low prevalence populations, like the sex worker population in Australia, as opposed to high prevalence populations. Generally, all rapid tests and self-testing kits are recommended for high prevalence populations as it is more likely that this group will receive a ‘true’ self-testing result. The Scarlet Alliance Rapid Testing Position Paper highlighted that the Alere rapid tests produced a high number of false reactives when used in low prevalence populations, like the sex worker community in Australia.
As highlighted above, a reactive self-test result must always be followed up with confirmatory laboratory testing. Additionally, the Atomo self-tests have a window period of 3 months. This means that HIV will not be detected by the self-tests if exposure to HIV happened in the last 3 months. If you think you have been recently exposed to HIV, a laboratory test will be more effective in detecting the virus. If you think you have been exposed to HIV in the last 72 hours, you should consider using Post-exposure Prophylaxis (PEP). If you are unsure about the results of your self-test or whether you performed the test correctly, contact your community health service for a laboratory test.
HIV treatments, also called antiretroviral drugs, have significantly advanced since they were first introduced and there are many drug treatments to control HIV and reduce the risk of progression to AIDS. However, HIV treatment is often complicated and there are many factors to consider such when to start treatment, reducing resistance, side-effects, monitoring and changing treatments and interactions with other medications. As a result, when starting treatment, it is important to consult a doctor with expertise in HIV management.
Drug treatments (such as combination therapy) also reduce the risk of transmission of HIV from mother to baby during pregnancy. Whilst there is currently no vaccine or cure for HIV these medications enable a better quality of life for people living with HIV.
The proper use of condoms and lube during sex (anal or vaginal) will greatly reduce the risk of HIV transmission. In addition, the use of sterile injecting equipment and biomedical strategies such as TasP, PEP and PrEP will significantly reduce the risk of HIV transmission.
Safer sexual activities include masturbation, touching, voyeurism, kissing, cuddling, body-to-body rubbing and erotic massage.
Treatment as Prevention (TasP)
TasP refers to the use of antiretroviral drugs by people living with HIV to reduce the amount of HIV present in their bodily fluids (such as blood and genital fluids) to undetectable levels, which eliminates the risk of HIV transmission. There is strong evidence of the effectiveness of antiretroviral therapy (ART) as a means of HIV prevention. When ART results in viral suppression, defined as less than 200 copies/ml or undetectable levels, it prevents sexual HIV transmission. People who take ART daily as prescribed and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner. This means for HIV undetectable equals untransmittable (U=U).
Three different research studies with serodiscordant couples (where one person is HIV positive, and the other person is HIV negative) using TasP reported no HIV transmission. TasP can also prevent transmission of HIV between serodiscordant couples when conceiving.
Pre Exposure Prophylaxis (PrEP)
PrEP is the use of antiretroviral drugs by HIV negative people to greatly reduce the risk of contracting HIV upon exposure. PrEP is taken on an ongoing basis and is currently available through trial projects in some states and territories, or a script from a doctor or via personal importation. PrEP has recently been listed on the PBS reducing the cost to approx. $40 per month for PBS co-payments. If you are considering PrEP, you should discuss this with a doctor experienced in HIV or sexual health to help decide if PrEP is right for you.
Post Exposure Prophylaxis (PEP)
PEP is for HIV negative people who have potentially been exposed to HIV. PEP is a short course of HIV medication, that if taken within 72 hours of exposure to HIV, can significantly reduce the chance of getting HIV.
Potentially being exposed to HIV in a sex work setting is not grounds alone for being prescribed PEP. The doctor or nurse will make an assessment of whether you should be prescribed PEP based on:
- what type of HIV exposure you experienced (i.e. receptive or insertive vaginal, anal or oral sex, injecting or other) and its risk of transmission.
- the HIV status of the person/s involved. If you do not know the HIV status of the person you think may have exposed you to HIV, the prescribing doctor will use HIV prevalence data to assist them in determining your need for PEP.
- whether you currently have HIV. PEP is not effective or prescribed for people who already have HIV.
For example, the ASHM PEP for HIV: Australian National Guidelines generally do not recommend PEP for people who have had unprotected vaginal receptive intercourse with a person whose HIV status is unknown to them. You may not be prescribed PEP if a condom breaks while having vaginal receptive intercourse with a client whose HIV status is unknown to you. However, if the client is a man who has sex with other men (MSM) or from a high prevalence country, the health professional will investigate further whether you need PEP.
If a condom breaks while having receptive anal intercourse with a client whose HIV status is unknown to you and the client is a MSM or from a high prevalence country, the ASHM Guidelines generally recommends the prescription of PEP. However, there may be a broader range of circumstances that a healthcare professional may prescribe PEP for unprotected receptive anal intercourse with a person whose HIV status is unknown to you.
While there are guidelines for PEP prescription, healthcare professionals assess whether an individual is eligible for a prescription on a case by case basis. For this reason, it is highly recommended that you speak to a health care professional to assess whether you should be prescribed PEP if you think you have been exposed to HIV.
You must start taking PEP before 72 hours have passed since you were possibly exposed to HIV for it to be effective. If it has been over 72 hours since the potential exposure, it is still recommended that you seek medical attention to figure out what your options are.
When you are starting PEP, the health care professional will usually take a blood sample to test for HIV. This test is to see whether you had HIV before you started your PEP treatment. While you are taking PEP, you will be required to have a follow up test for HIV and other STIs, and 3 months after your treatment, you will need another HIV test to make sure that the PEP treatment was effective.
When you start PEP treatment, you must take the medication every day for 28 days. If you miss a dose, do not double dose to catch up. Take the medication as soon as you can and contact your prescribing doctor or a healthcare professional that specialises in HIV to discuss whether taking your dose late will impact the effectiveness of the treatment and what your options are.
Some people do not experience any side effects when taking PEP while others do. The side-effects of PEP are usually considered to be mild to moderate and can include nausea, diarrhoea, headaches, fatigue and vomiting. Usually the side-effects fade after about a week of taking PEP and they will completely go away after you finish your PEP treatment.
If you are experiencing side-effects or have any other concerns while taking PEP, speak to your prescribing doctor. Your prescribing doctor may be able to alter the PEP medications you are taking to minimise the side-effects. You may also be able to get a doctor’s certificate if you need some time off work.
You can get PEP from the emergency department of most public hospitals, sexual health centres, and prescribing doctors and clinics. Most states have a 24 hour PEP Hotline or information line or you can find out where you can get PEP in your state or territory via https://www.getpep.info/get-pep-now/. There are some hospitals and sexual health centres that dispense PEP free of charge. Otherwise, there may be a co-payment to getting your prescription filled. If you are not Medicare eligible, there may be additional costs involved.
Other drugs, such as vitamins, prescription drugs, and recreational drugs, can interact with PEP, changing the way PEP works and impacting the severity of PEP’s side-effects. If you are taking other drugs or plan to, it is recommended you discuss this with your prescribing doctor to minimise the impact this may have on your PEP treatment. PEP should not replace safer sex practices.