Clinical Manual for Management of the HIV-Infected ... - myCME.com

as hepatitis C or another sexually transmitted disease)
and the (apparently low) risk of becoming reinfected
with another strain of HIV. It should be noted that
condoms are less effective in reducing the transmission
of organisms such as human papilloma virus (HPV)
and herpes simplex virus (HSV), which may result from
viral shedding from skin. In the event of allergy to latex
or other difficulty with latex condoms, polyurethane
male or female condoms may be substituted. “Natural
skin” or “lambskin” condoms are not recommended for
HIV prevention.
Of course, condoms must be used correctly to be highly
effective in preventing HIV transmission. Be sure that
the patient knows exactly how to use a condom. Table 1
provides instructions for condom use.
Table 1. Instructions for Use of Standard Condoms
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Use a new latex or polyurethane condom with each act of sex (oral,
anal, or vaginal). Make sure that the condom is undamaged, and
that its expiration date has not passed.
Carefully handle the condom to avoid damage from fingernails,
teeth, etc.
Being sure that the condom roll faces out, unroll the condom onto
the erect penis before any genital contact with partner.
Ensure that the tip of the condom is pinched when applying it to the
top of the penis, to eliminate air in the tip that could cause breakage
during ejaculation.
Use only water-based lubricants with latex condoms. Oil-based
lubricants (such as mineral oil, cooking oil, massage oil, body lotion,
and petroleum jelly) can weaken latex or cause it to break, although
they are fine with the use of polyurethane condoms. Adequate
lubrication during intercourse helps reduce the risk of condom
breakage.
Advise patients to avoid using nonoxynol-9 (N-9)
spermicides. Recent data suggest that N-9 may increase
risk of HIV transmission during vaginal intercourse and
can damage the rectal lining. N-9 should never be used
for anal intercourse.
For patients who complain about lack of sensitivity with
condom use, the following techniques may help:
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Apply a drop of lubricant inside the condom (not
more, because it increases the risk that the condom
will come off ).
Use polyurethane condoms instead of latex because
they conduct heat and may feel more natural.
Use insertive (female) condoms, which are not as
restrictive to the penis.
Section 2—Health Maintenance and Disease Prevention | 2–25
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Use specially designed condoms that do not restrict
the top of the penis (eg, Inspiral, Xtra Pleasure).
For those patients who are unable or unwilling to use
condoms, the following suggestions may help reduce
HIV transmission risk:
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Use plenty of lubricant to reduce friction and
microtrauma, which create portals of entry for the
virus.
Avoid spermicides that damage the vaginal or
anorectal linings.
Avoid douching products.
Avoid recreational drugs, especially
methamphetamine, which impair the ability to
maintain “safer” sex behaviors.
Avoid the use of drugs such as nitrates (poppers)
that enhance blood flow to the genitals.
For HIV-infected women, consider avoiding hormonal
birth control methods because of a possible increase in
the risk of HIV viral shedding.
Insertive (Female) Condom Use
The insertive “female” condom (Reality) may be used
for vaginal or anal intercourse. It is a thin polyurethane
pouch with a flexible ring at the opening, and another
unattached flexible ring that sits inside the pouch to
keep it in position in the vagina (for use in the anus,
the inner ring must be removed and discarded). The
female condom may be an option for women whose
male partners will not use male condoms or for couples
who do not like standard condoms. Female condoms
are more expensive than male condoms, but may be
procured at a lower cost at some health departments
or Planned Parenthood clinics. They generally are less
well known to patients and may be unacceptable to
some women whose culture or religion prohibits or
discourages touching one’s own genitals. Note that the
female condom cannot be used at the same time as a
male condom.
Be sure the patient knows how to use the insertive
condom before she or he needs it; after teaching,
encourage practice when alone at home and unhurried.
Women who have used the diaphragm, cervical cap, or
contraceptive sponge may find it easy to use the female
condom. Illustrated directions are included in each box