The only certain way to avoid contracting HIV sexually is either to avoid all varieties of interpersonal sexual contact that place one at risk for infection or to be involved in a monogamous, mutually faithful relationship with one noninfected partner. If nei­ther of these conditions is applicable, a wise person will act in a way that significantly reduces his or her risk of becoming infected with HIV.

Safer-sex practices that reduce the risk of contracting HIV/AIDS and other STIs are described in some detail in the last section of this chapter. Most of these preventive methods are directly applicable to HIV/AIDS. However, it is important to note that any strategies that reduce your risk of developing the other STIs previously discussed will also reduce your risk of HIV infection because of the known association between HIV/AIDS and other STIs.

Beyond the obvious safer-sex strategies of consistently and correctly using latex con­doms and avoiding sex with multiple partners or with individuals at high risk for HIV, the following list provides suggestions particularly relevant to avoiding HIV infection. Note that several of these suggestions are less significant for two healthy people in a monogamous relationship who apply common sense in evaluating what is most likely to be risky for them.

1. If you use injected drugs, do not share needles or syringes.

2. Injection drug users may wish to check with local health departments to see if a syringe-exchange program (SEP) exists. These programs, which provide clean syringes or needles in exchange for used syringes or needles, have been shown to reduce the spread of HIV and other blood-borne infections among high-risk injection drug users (H. Cooper et al., 2011; Drach et al., 2011). In 2009, 189 SEPs were known to be operating in 36 states (Centers for Disease Control, 2010g). The U. S. federal government did not support SEPs until the onset of Obama’s presidency (De Cock et al., 2011).

3. Avoid oral, vaginal, or anal contact with semen.

Sexually Transmitted Infections

4. Avoid anal intercourse, because this is one of the riskiest of all sexual behaviors associated with HIV transmission (Ibanez et al., 2010; Jenness et al., 2011).

5. Do not engage in insertion of fingers or fists ("fisting") into the anus as an active or receptive partner. Fingernails can easily cause tears in the rectal tissues, thereby creating a route for HIV to penetrate the blood.

6. Avoid oral contact with the anus (a practice commonly referred to as rimming).

7. Avoid oral contact with vaginal fluids.

8. Do not allow a partner’s urine to enter your mouth, anus, vagina, eyes, or open cuts or sores.

9. Avoid sexual intercourse during menstruation. HIV-infected women are at increased risk for transmitting their infection through intercourse while menstruating.

10. Do not share razor blades, toothbrushes, or other implements that could become contaminated with blood.

11. In view of the remote possibility that HIV may be transmitted by means of prolonged open-mouth wet kissing, it might be wise to avoid this activity. There is no risk of HIV transmission through closed-mouth kissing.

12. Avoid sexual contact with sex workers (male or female). Research indicates that sex workers have unusually high rates of HIV infection (Lamptey et al., 2006). •

All these methods for preventing HIV infection focus on preventing exposure to the virus. Several years ago the U. S. Department of Health and Human Services issued guidelines for using antiretroviral drugs to prevent HIV infection after unanticipated sexual or injection-drug-use exposure. These guidelines indicate that a 28-day course of HAART commenced as soon as possible after exposure can significantly reduce the risk of infection (Centers for Disease Control, 2005). A number of health departments, clinics, and individual physicians in the United States are now providing postexposure prophylaxis (PEP) via HAART after unanticipated exposure to HIV. PEP has also been utilized as an HIV infection prevention strategy with South African children who have been raped (Collings et al., 2008). Some health professionals believe that preexpo­sure prophylaxis (PrEP) via a daily pill may also be a viable option for preventing HIV infection. This possibility is discussed in the following paragraphs.

Is it possible that uninfected people could take a pill once daily to prevent HIV infection? Recent research suggests that PrEP with a once-daily ingestion of Truvada (a combination of two antiretroviral drugs) may accomplish this goal. In a study that included 2,494 gay men drawn from six countries, researchers found that men taking Truvada were 44% less likely to become infected with HIV than men taking a placebo. In addition, in men who took the pill every day, as indicated by blood tests, Truvada was more than 90% effective in preventing HIV infection (D. Smith et al., 2011). Some health professionals suggest that PrEP may prove especially advantageous for unin­fected people whose primary partner is infected, for people who feel unable to insist on condom use, and for commercial sex workers who often experience unprotected expo­sure to HIV. Concern has also been expressed that people utilizing PrEP may become less concerned about HIV infections and thus less vigilant about protecting themselves via safer sexual behaviors (Hayden, 2011).

A recent study in Africa found that PrEP via Truvada did not help prevent HIV infection in women (Stephenson, 2011). However, other recent research that studied about 5,000 heterosexual couples in Kenya and Uganda demonstrated that a daily dose of antiretrovirals did significantly reduce transmission of HIV for both men and women (Maugh, 2011). We await further research to clarify the effectiveness of PrEP.

At present, the best hope for curtailing the spread of HIV/AIDS is through edu­cation and behavior change. Because neither an effective vaccine nor a drug-based

cure seems likely to be available soon, the best strategy for significantly curtailing this pandemic is preventing exposure through education about effective prevention and risk-reduction strategies. A wide range of published studies of a variety of preven­tion strategies, directed at a broad range of target populations, has provided promising findings, indicating that intensive educational and behavioral interventions are often effective in reducing risky behaviors that increase vulnerability to HIV infection. The Obama administration recently increased HIV/AIDS prevention by establishing a national HIV/AIDS strategy that targets prevention efforts to those individuals most likely to be infected (Melby, 2012).

Many HIV/AIDS experts have stated that more emphasis needs to be placed on behavioral interventions that have been shown to help prevent the spread of HIV/ AIDS (Altman, 2008b). These prevention strategies include increasing awareness of risk behaviors for HIV infection and promoting safer sex through condom use, hav­ing fewer sexual partners, delaying sexual debut, decreasing use of injection drugs, pro­viding access to needle-exchange programs, and promoting male circumcision. Clearly, behavior-based HIV prevention interventions help slow the spread of HIV infections (Altman, 2008b; Jaffe, 2008; B. Johnson et al., 2011). In the absence of a cure or an effective vaccine, these efforts provide the best weapons in the worldwide war being waged against this devastating illness. An enduring frustration for the authors of this text and a multitude of researchers and health practitioners worldwide is the likelihood that "we will not know how the story of AIDS will finally end because the epidemic will outlast us" (De Cock et al., 2011, p. 1047).