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There is no vaccine for HIV and the only way to prevent infection is to avoid activities and behaviors that are known to transmit the virus. Sharing drug-injection needles is extremely risky, even between people who show no signs of having AIDS, because HIV infection is often asymptomatic for the first 5 to 10 years. In some areas of the United States, reused contaminated needles are the primary cause for HIV transmission.

According to the Centers for Disease Control, not only can injections needle be contaminated, but drug solutions can be contaminated during preparation by

• using blood-contaminated syringes to prepare the drugs;
• reusing and sharing water;
• reusing bottle caps, spoons, and other "cookers" for dissolving and heating the drugs; and
• reusing cotton balls or other "cottons" to filter out particles that can block the needle.

For this reason, needle exchange programs and adequate cleaning techniques are the most effective ways to reduce the risk for needle transmission of HIV and other blood borne diseases for people who are unable to stop using injectable drugs.

Needle Exchange Programs
Obtaining sterile needles from a pharmacy requires a prescription. Needle exchange programs allow drug users to exchange used needles for sterile ones, no questions asked. This is the best way to ensure the use of clean needles and the proper disposal of used ones. Many researchers and AIDS activists believe that easy access to clean needles reduces the rate of HIV transmission. Other people believe that needle exchange programs encourage illicit drug use and increase the spread of HIV.

Research has shown that needle exchange programs reduce the spread of HIV without increasing the use of illegal injection drugs among participants or increasing the number of injection-drug users. Many national and regional organizations recommend needle exchange programs based on the weight of this evidence. These organizations include the United States Centers for Disease Control and Prevention (CDC), American Medical Association (AMA), National Institutes of Health (NIH), United States Preventative Services Task Force, National Institute of Drug Abuse, and most state and local departments of health.

In addition, needle exchange programs often provide life-saving services to high risk drug users, who may be otherwise hard to reach. Services may include free latex condoms, HIV counseling and testing, tuberculin skin testing, and primary health care including care for HIV, hepatitis C, and other illnesses associated with injection drug use.

In the United States, over 50% of all new AIDS diagnoses among African Americans and Latinos are related to injection drug use. African Americans and Latinos who inject drugs are nearly 5 times more likely to develop AIDS than Caucasians who inject drugs. Some experts believe that this discrepancy is due to the fact that Caucasians generally have easier access to sterile needles.

The North American Syringe Exchange Network provides information about regional needle exchange programs.

Cleaning and Reusing Needles
It is widely recommended that people who inject drugs use a new, sterile syringe and needle for each injection. For those who cannot obtain new sterile injection equipment, sterilization with undiluted bleach is recommended. Bleach is commonly used to disinfect drug injection equipment, but only careful cleaning techniques effectively kill HIV. The following guidelines can minimize the risk for disease transmission when a new needle is unavailable:

• Rinse syringe and plunge with clean, cold water several times.
• Fill to the top with fresh, undiluted bleach and leave for 30 seconds; plunge it out and repeat at least 3 times.
• Fill to the top with clean, cold water; squirt it out and repeat at least 3 times.
• Shake the equipment while cleaning and rinsing it.

Many people think that because hot water kills germs, it is best for killing blood borne pathogens. But hot water may cause blood left in the needle or works to clot, making it harder to remove. Equipment should always be rinsed after use, even if cleaning with bleach is delayed. It is necessary to use full-strength, undiluted bleach, which must remain in the syringe for 30 seconds. Also, the syringe should be shaken to loosen any remaining blood before the bleach is pushed out. Some evidence suggests that the bleach must remain in the syringe for 2 minutes to kill hepatitis B, and it is not known whether bleach kills hepatitis C in the syringe.

Detachable needles and custom equipment should be disassembled for cleaning. Spoons and other cookers also should be cleaned in this manner. Cotton ball filters and other "cotton" should never be shared, because they cannot be cleaned thoroughly.

Some studies have shown that tiny amounts of blood remain in bleach-cleaned syringes, even after vigorous washing and rinsing. In fact, some researchers believe that sharing bleach-cleaned, blood-contaminated syringes may increase the rate of HIV transmission if traces of bleach are left in the syringe. The oxidant effects of bleach and the local inflammation that occurs when a needle with traces of bleach enters the skin may enhance transmission. Equipment should always be rinsed thoroughly after cleaning with bleach.

Minimizing Risk
People who inject drugs can minimize the risk for contracting or transmitting HIV in the following ways:

• Seek drug treatment and stop injecting drugs. Consult the Yellow Pages of the phone book under "Drug Abuse" for local treatment or support centers. They provide information about needle exchange programs, counseling services, and support groups. Contact the Center for Substance Abuse Treatment at 1.800.662.4357.
• Obtain syringes from reputable sources; syringes are sometimes repackaged and sold as new.
• Always avoid used or shared needles and syringes.
• Use clean, fresh water, cookers, and filters.

Safer Sex
According to the National Institutes of Health (NIH), practicing safe sex involves the following:

• Use barrier protection for both vaginal and anal intercourse
• Withdraw the penis prior to climax and ejaculate outside the partner
• Avoid all low- and high-risk sexual activity, even with protection

Some sexual behaviors have never been connected to transmission of HIV. Dry kissing (kissing that does not involve the tongues or contact with mucous membranes inside the mouth) and touching are not routes of transmission. These are considered no-risk behaviors.

High-risk Sexual Behaviors
High-risk sexual behavior is statistically correlated with HIV infection. The three statistically significant high-risk sexual behaviors known to transmit the virus from one partner to another include the following:

• Penile-anus sex (penis in contact with the anus)
• Penile-vaginal sex (penis in contact with the vagina)
• Brachio-anal sex (finger(s) or hand in contact with the anus)
• Unprotected sex (sex without a condom or other barrier)

Most HIV infections are transmitted through penile-anal and penile-vaginal contact. The risk for transmission is dramatically reduced with the use of condoms. However, in rare cases, HIV has been transmitted via penile-anal and penile-vaginal sex, even when condoms were used.

Factors that increase risk for transmission include the following:

• Enema or rectal douching before anal intercourse
• Anal or vaginal irritation or infection, including the following:
• Chlamydia
• Condyloma
• Gonorrhea
• Herpes
• Syphilis
• Trichomonas
• Sexual activity that may damage the mucosal lining of the vagina or rectum
• Tampon use (Tampons can cause vaginal dryness and cellular abnormalities. Sanitary napkins are recommended.)
• Vaginal dryness (A water-based lubricant is recommended.)

Safer Sex for Patients with HIV Who Have CD4+ Counts Less Than 200
Patients with compromised immune systems are at increased risk for contracting opportunistic infections. Intestinal infections are especially debilitating for patients who have HIV, and it is essential to practice safe sex to lower the risk for transmitting HIV and other infectious viruses and bacteria.

People with low CD4+ counts should avoid any contact with oral and rectal fluids by practicing the following safer sex behavior:

• Limit the number of partners with whom they are "deep kissing."
• Use dental dams or plastic wrap as a barrier during cunnilingus (vaginal-oral sex) and anilingus (anal-oral sex).

The NIH warns that studies have not been done to prove that dental dams, plastic wrap, or latex condoms that have been cut open can effectively prevent transmission of HIV or other STDs.

STDs and HIV
Studies have shown that people who have other sexually transmitted diseases (STDs) carry an increased risk for HIV infection. Treating or preventing STDs may also help prevent HIV infection. Studies are being done to evaluate the impact of aggressive STD prevention programs on HIV transmission.

Condoms

Latex Condoms for Men
Latex condoms are an effective barrier against the transmission of HIV and most other STDs. Condoms made of biological products such as lambskin are not effective, because HIV can pass through the pores.

One compelling study examined HIV transmission rates in heterosexual couples with one infected partner. Of the 123 couples who regularly used condoms, none of the uninfected partners became infected, compared to 12 new infections in the 122 couples who did not use condoms.

Condoms should be purchased from a source that can guarantee product reliability and freshness. Heat, pressure, and age can break down latex. Condoms should not be used more than 5 years after the manufacture date. If the condom looks deteriorated or discolored, or feels sticky or brittle, it should be discarded. If the packaging is torn or damaged, the condoms should not be used.

Condoms are easily torn if they are handled roughly or with sharp fingernails, so care should be taken while putting them on and taking them off. Petroleum or oil-based lubricants (e.g., Vaseline, baby oil) can break down latex and should not be used. Water-based lubricants (e.g., KY Jelly) should be used and are usually labeled "For use with latex condoms or diaphragms."

Polyurethane Condoms for Men
Newer condoms made of synthetic materials, such as polyurethane, are now available for people who are allergic to latex. Ask your doctor, pharmacist, or other health care provider which materials have been proven effective to prevent transmission of HIV and other STDs.

How to Use a Condom
Incorrect use accounts for more rips and breaks in condoms than any other factor. If not used correctly, a condom can slip off or down the penis during intercourse. To use a condom correctly, do the following:

• Use a new condom for each sexual act (vaginal, anal, or oral intercourse).
• Do not put the condom on too late and do not take it off too early—leave it on from start to finish.
• Put the condom on as soon as erection occurs and before there is contact between the penis and the partner's vagina, anus, or mouth.
• Put the condom on by holding it at the tip and unrolling it onto the erect penis. Leave a small amount of space at the tip and make sure there is no air trapped there.
• Use water-based lubrication to prevent the condom from breaking. Do not use oil-based lubricants—they degrade latex.
• Withdraw immediately after ejaculation and hold the condom firmly to the base of the penis so it does not slip off.

Polyurethane Condoms for Women
HIV infections are increasing more rapidly among women, according to the NIH. Women contract the virus primarily through unprotected sex with an infected male partner.

Latex condoms provide adequate protection when used correctly and consistently, but they require the consent and cooperation of the male partner. Many men will not use condoms, and in many situations and cultures, women are not empowered to negotiate condom use or to say "No." How can women protect themselves if their male partner will not use latex condoms? Women may use the polyurethane condom for women.

Polyurethane condoms for women fit inside the vagina and cover some of the vulva, the area outside the vagina. They can be used with a water-based or oil-based lubricant. The NIH warns that there is not conclusive evidence that these condoms effectively prevent HIV transmission. Polyurethane condoms for women are expensive and some argue that, like men's condoms, they should be distributed free.

Nonoxynol-9 (N-9) is an ingredient found in contraceptive foams and jellies. Early in the AIDS epidemic, many activists advocated the use of N-9 with condoms, because N-9 is a viricide (substance that destroys viruses) that would decrease HIV transmission. However, recent studies show that the use of N-9 with a condom does not improve protection and may damage the mucosal lining of the vagina, increasing the risk for infection. Women who use N-9 without a condom have a 50% higher rate of infection.

Microbicides
Researchers are developing microbicides, which are substances that destroy viruses and bacteria, to be applied inside the vagina before having sex. Efforts are being made to produce a fast-acting, unnoticeable, inexpensive, safe product that will destroy HIV. Women who are interested in using microbicides should ask their doctor or other health care provider about clinical trials and other information.

To protect yourself and your partner:

• Stay informed and make smart choices.
• Do not let drinking or drugs interfere with your decisions.
• Do not let the fear or embarrassment of talking about sex keep you from protecting yourself.
• Remember that people are not always honest about their past sexual experiences, nor do most people who are infected with HIV look any less healthy than uninfected people. If in doubt, be cautious.
• Talk about HIV before having sex. Do not wait until passion keeps you from protecting yourself or your partner.
• Abstinence—not having sex—is the surest way not to contract HIV and other STDs.
• If you have sex, limit the number of sexual partners.
• The safest sex is between two partners who are not infected with HIV, who have never used injectable drugs, and who have never had another sex partner.
• Always use a latex condom or other form of barrier protection during sex. Though not foolproof, condoms are highly effective at preventing transmission of HIV and other STDs.
• Know how to use a condom correctly and how to store condoms so that they do not degrade.
• Explore sexual activities that do not involve intercourse.

If you have questions or concerns about either you or your partner, talk to an HIV counselor. In the United States, call the CDC National HIV/AIDS hotline:

• 1.800.342.2437 (English)
• 1.800.344.7432 (Spanish)
• 1.800.243.7889 (TDD)

Low-risk Sexual Behaviors
Sexual behaviors that are not a proven route of HIV transmission are considered low risk. However, any close contact of bodily fluids poses some risk. HIV can be transmitted through low-risk sexual behaviors, although the chances are slight.

Since HIV is transmitted via contact of bodily fluids with mucous membranes or the bloodstream, any of the following behaviors could possibly transmit the virus.

• Oral-oral contact, or kissing—If one or both partners have oral bleeding or oral disease, there is direct contact with the bloodstream that greatly increases the risk for transmission. Dry kissing carries no risk.
• Penile-oral sex, or fellatio—Ejaculate can contain a greater amount of virus than saliva. If there is any oral or penile bleeding or disease, there is direct contact with the bloodstream that greatly increases the risk for transmission.
• Vaginal-oral sex, or cunnilingus—Vaginal secretions can contain the virus. If there is oral or vaginal bleeding (including menstruation), there is direct contact with the bloodstream that greatly increases the risk for transmission.
• Vaginal-vaginal sex, or tribadism—Vaginal secretions can contain the virus. If there is vaginal bleeding (including menstruation), there is direct contact with the bloodstream that greatly increases the risk for transmission.
• Anal-oral sex, or anilingus—Anal secretions and feces can contain the virus. Any rectal or oral bleeding or disease greatly increases the risk for transmission.
• Urino-oral contact, or oral contact with urine—Some ejaculate may remain in a man's urethra after ejaculation. Any urinary or oral bleeding or disease greatly increases the risk for transmission.
• Brachio-vaginal sex, or fingers or a fist inserted into the vagina—Partners should wear latex gloves and use a water-based lubricant. If there is any bleeding or disease in the hands or vagina, brachio-vaginal contact should be avoided.
• Brachio-rectal sex, or fingers or a fist inserted into the rectum—Partners should wear latex gloves and use a water-based lubricant. If there is any bleeding or disease in the hands or rectum, brachio-anal contact should be avoided.
• Sex toys—Sex toys that have not been cleaned properly should not be re-used. Toys not made of latex should not be used because they may harbor traces of infected bodily fluids.

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