Sexual Harm Reduction And Hiv
All sexually active people make choices to balance their desire for sexual pleasure and intimacy with their desire to stay healthy and protect the health of their sexual partner. A sacrifice must be made in favor of one or the other. There is nothing "wrong" or "bad" about prioritizing the natural experience of sexual pleasure over your rational knowledge about sexual health risks. Whatever you decide to do (or not do) to reduce your risk of getting or giving HIV, take time to make a thoughtful decision that you know you can live with during and after sex. Not making a conscious decision, or not fully committing to that decision, may result in impulsive choices in the heat of the moment, choices that you may regret later.
In the United States, many of us learn that common sexual activities (oral, vaginal, and anal sex) carry an identical risk of HIV infection. Unfortunately, that misconception has been promoted by recent HIV-prevention materials issued by our own federal government, as well as by abstinence-based “sex education” programs in our public schools. Good evidence-based HIV prevention advice has been distorted or ignored, and detailed safer sex guidelines have somehow become harder to locate in recent years. Federal tax dollars have been used to publish and distribute intentionally misleading materials including the false claim that “abstinence before marriage” is the only effective HIV-prevention method because condoms offer poor protection against HIV infection and unwanted pregnancy. Nonsense!
One familiar alternative to the conservative “faith-based” philosophy of HIV prevention has been promoted by the more liberal “let’s face reality because people do have sex” educators: “Use a condom all the time, every time.” How many people do you know who consistently use condoms for every sexual activity with every sexual partner over an entire lifetime? Human sexuality and relationships are far too complex for such a simplistic solution. What if you both tested negative and you are in a monogamous gay relationship? What if your partner refuses to use condoms for oral, but uses them every time you have vaginal sex? What if he wants to ejaculate, but only on your chest? What if you are always the top? What if you are a lesbian? What if both of you are already HIV+? What if you want to get pregnant?
Clearly, one slogan does not fit all.
There are several factors that play a role in estimating the probability of getting or giving HIV during sex. Most of these factors cannot be measured accurately - especially while you are having sex! They are:
1) the quantity of infected fluid (how much);
2) the strength and concentration of the virus present in that fluid (how infectious);
3) which orifice (mouth, anus/rectum, vagina) the infectious fluid enters (ease of entry);
4) trauma or injury to the penetrated orifice (ease of entry);
5) the size of an open cut or wound (ease of entry);
6) how long a cut or wound has had to heal (time);
7) co-infection with another STI (Sexually Transmitted Infection, STD, “venereal disease”);
8) how often, how many, and which strains of HIV the sex partner has been exposed to in the past (history);
9) any natural biological resistance to infection (history);
10) whether the receptive female partner is menstruating (how infectious);
11) whether you are the insertive (male) or receptive male or female) partner (top or bottom); and
12) whether an insertive partner ejaculates semen inside an orifice.
So why get so detailed? Why not just tell people that if they don’t use a condom every time they have sex, they may become HIV+ (HIV-positive)? Why educate people as to the various risks of different kinds of sexual activity when it takes just one mistake to get or give HIV? Won’t naïve readers misinterpret this information and conclude that it is not so important to use condoms? Isn’t so much information dangerous, especially for young minds?
It has been my experience as an HIV test counselor and prevention educator that most boys and men will not wear a condom or use a barrier during oral sex to protect themselves or their sex partner from HIV or other STIs. At least 90% of my straight and gay male clients would not have oral sex performed on them if it comes with the condition that they must wear a condom.
A significant percentage of these men and their sex partners have told me that since they don’t use condoms or any barrier for oral sex, they don’t need to use a condom for vaginal or anal sex. Unfortunately, their reasoning is wrong, but it makes sense if they are basing it on the inadequate information provided by those federally-funded HIV-prevention programs I mentioned earlier. Armed with that misinformation, some people assume that if any HIV was present in saliva, vaginal fluids, or semen, it has already been transmitted to them through oral sex. Of course, this is a bad assumption based on incomplete information. It is much easier to transmit HIV through anal or vaginal sex than it is to transmit the virus through oral sex of any kind. And HIV cannot be transmitted through saliva, period.
If you or your male partner will not wear a condom for oral sex, you still need the protection of a condom for vaginal and anal sex. If you or your male partner will not wear a condom for oral and vaginal sex, you still need the protection of a condom if you have anal sex. For maximum protection of yourself and your sex partner against HIV transmission and other STIs (not to mention unwanted pregnancy) yes, a condom should be used for oral, vaginal, and anal sex. In addition, a barrier (a sheet of plastic wrap, split condoms, or dental dams) placed between one partner’s mouth and the other person’s anus or vagina during oral sex can prevent not only the possible transmission of HIV, but the probable transmission of other STIs as well.
Please pay close attention to this next point. Many people do not become HIV+ during their first unprotected sexual encounters with an HIV+ person. It can take only one exposure to become infected, or to infect someone else. It also can take three, ten, one hundred or more sexual exposures to the virus before transmission actually occurs. When it comes to HIV prevention, there is never a good time to stop using condoms based on the assumption that transmission of the virus must have already occurred. No matter how many times the condom breaks or slips off, no matter how many times you have had unprotected sex of any kind, continued condom use after unprotected sex may prevent a future infection.Not all “bodily fluids” of an HIV+ person are infectious.
Urine, sweat, saliva, and tears are not infectious fluids in HIV+ people and these fluids do not need to be avoided or limited during sexual activity. There is not enough concentration of the virus in any of these fluids to transmit HIV.
Infectious fluids that come into contact with unbroken skin will not result in HIV transmission. Semen, blood, and vaginal fluids on unbroken skin are safe. So it is safe to ejaculate anywhere on a partner’s body where there are no open sores or exposed mucous membranes (pink parts). Any HIV transmission through “skin contact” requires an open cut or wound that hasn’t had a chance to begin healing. The larger and deeper the opening in the skin, the newer the wound, and the greater the quantity of infected fluid that comes into direct contact with that wound, the higher one’s chances are of becoming HIV+ through that exposure.
The rectum, vagina, and mouth each provide different environments for HIV. I just listed them in order of vulnerability to HIV infection, with the rectum being the most vulnerable. Although it is not possible to precisely measure the relative risks of HIV transmission during various sexual activities, research tell us that unprotected anal sex with ejaculation by an HIV+ male inside his partner’s rectum puts his partner (male or female) at the highest possible risk of HIV infection through sexual activity. (I am assuming that sharing needles for intravenous drug injection is not part of your sexual repertoire.)
Unprotected vaginal sex with the ejaculation of semen inside the vagina also puts the receptive female partner at high risk of infection, though not so high a risk as anal sex with internal ejaculation (semen ejaculated into the rectum). Anal, vaginal, and oral sex with internal ejaculation is always riskier than anal, vaginal, and oral sex without internal ejaculation. However, not ejaculating semen inside any orifice only reduces the risk of HIV transmission for the receptive partner; it does not prevent HIV infection and it is not an effective substitute for using a latex or polyurethane male or female condom. Even while wearing a condom, some HIV+ men who know their status choose to ejaculate outside the vagina or rectum to reduce the risk of HIV transmission should the condom accidentally break or slip off.
BTDTWoman
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cont...
Some men are confused about the role of ejaculation in HV transmission. A man who ejaculates inside or outside his partner’s body does not put himself at any greater risk of HIV infection. He cannot infect himself with his own semen.
Performing oral sex (cunnilingus) on an HIV+ female while she is menstruating, and performing oral sex (fellatio) on an HIV+ male who ejaculates inside his partner's mouth, are both riskier than performing oral sex on the vulva of an HIV+ woman who is not menstruating.
Of all the infectious body fluids, blood has the highest concentration of virus in HIV+ individuals. Semen carries the next highest concentration, and external vaginal fluids have a somewhat lower concentration than blood or semen. However, some internal vaginal fluids (cervical secretions) sometimes have as much virus in them as semen does. Repeatedly bumping up against the cervix (vaginal intercourse) of an HIV+ female with the unprotected tip of your penis repeatedly exposes the mucous membranes of your urethral opening (peehole) to highly infectious fluid.
A man who penetrates his HIV+ male or female partner is always at a lower relative risk of becoming infected with HIV than an uninfected person being penetrated by an HIV+ man will be. Simply put, a top is at less risk than a bottom. A penetrating man also is at less risk than a penetrated female partner. Still, there is a significant risk of infection for the penetrating man (top), since virus in his HIV+ partner’s blood or vaginal fluids can enter his bloodstream through the mucous membranes of his urethral opening or any open sores on his penis.
Uncircumcised (and newly circumcised) males are at higher risk of infection during penetration because the “pinkish area” immediately below the head of his penis is more vulnerable than the rest of his shaft. Unbroken skin, such as the healed skin beneath the head of the penis on a circumcised man, provides greater protection against HIV. Tops (and bottoms) with recent genital piercings are at higher risk for becoming HIV+. Having an STI (other than HIV) also increases the chance of becoming infected with HIV for tops (and bottoms).
If a female sex partner is menstruating, or if anal sex causes internal bleeding inside his (male or female) receptive partner's rectum, the penetrating male is at a higher risk of being infected by his HIV+ partner than if there were no blood present. Vaginal sex without menstrual blood, and anal or vaginal sex with limited trauma and tearing of the vagina, rectum, or anus are safer for the penetrating man than if there were a large quantity of blood present. More trauma (caused by “rough sex,” rape, very deep and forceful thrusting, penetration of an unlubricated dry orifice, penetration of undeveloped or small orifices, an extended period of thrusting, etc.) means more tears and deeper tears, and therefore more internal bleeding. Of course, blood inside an orifice is not visible until it appears on the penis between thrusts, or leaks outside the orifice.
Even gentle anal penetration produces some tearing of the delicate lining of the rectum, and these tears make the receptive partner highly vulnerable to HIV infection. A tear provides HIV with direct access to the bloodstream, and if an HIV+ male ejaculates an average amount of semen with a high concentration of HIV directly onto that tear, there is a relatively high risk of transmission. It is also possible, but less likely, for transmission of the virus to occur through the receptive partner’s exposure to preseminal fluid (precum), especially if the penetrating male produces higher-than-average quantities of preseminal fluid.
A vagina has 40 layers of protective epithelial cells lining its walls; a rectum has only one layer. Research shows that HIV transmission is more likely to occur at the cervix than through viral penetration of the vaginal walls during non-traumatic vaginal sex. A young teen has an even higher risk for HIV and STI infection, because her maturing cervix is more receptive to infection than a mature adult cervix. Some researchers have suggested that the use of a diaphragm may reduce, though not eliminate, a female’s risk of infection with HIV and some STIs. Women whose male partners are violent and refuse to use male or female condoms may use the hard to detect diaphragm as a harm reduction method that is better than no barrier at all.
As of this writing, microbicides such as nonoxynol-9 are no longer recommended for the purpose of HIV prevention. The development of a safe and effective microbicide is now a priority on the international HIV-prevention agenda.
The subject of sex toys often arises during HIV prevention training sessions. While there is a relatively low risk of HIV transmission through shared sex toys, some overzealous HIV-prevention educators seem to forget that a dildo cannot actually ejaculate infectious fluid. Penetrating sex toys do not pose as high a risk of HIV transmission as a human penis. If you withdraw a dildo from an orifice filled with HIV+ blood or HIV+ semen, and then immediately insert said dildo into another orifice of a person without HIV, transmission could occur through fresh fluids left on the dildo. For this reason, you can cover insertive sex toys with one or more condoms, and remove only the top layer when switching orifices. Of course, this does not apply to a human penis.
The most common questions I get about HIV and kissing involve the possibility of unseen blood in the partner’s mouth. But there must be more than a small drop of blood diluted in saliva in order for HIV transmission to occur while kissing. The oral cavity (mouth) is a very hostile environment for HIV, because saliva has digestive enzymes that quickly weaken or destroy the fragile virus. The vagina and rectum make friendlier hosts.
The possibility of oral transmission rises somewhat when the performing partner (the one going down on the HIV+ partner) has recently brushed or flossed her teeth, just had dental work, suffers from gum disease or cavities, or has sores inside her mouth. Nevertheless, kissing is widely considered one of the safest sexual activities in terms of HIV infection. Many experts say that ordinary kissing is safe.
It has been well established that saliva in itself absolutely cannot transmit HIV because of the extremely low concentration of virus present in any quantity of saliva. (The rapid oral HIV test looks for HIV antibodies, not the virus itself.) Therefore, the chance of HIV transmission through oral sex performed by an HIV+ person on an uninfected person’s genitals is also extremely low. In other words, having an HIV+ person "go down on you" is almost risk-free in terms of acquiring HIV, although risky for other STIs. Only if significant quantities of HIV+ blood or HIV+ semen were present in your partner's mouth as s/he performed oral sex on you could that risk increase.
This low-to-nonexistent risk of HIV transmission through oral sex that is performed on you includes analingus (rimming), which is considered safe in terms of HIV transmission for both parties - unless there is visible blood present. However, it is well known that analingus performed even on the cleanest anus and perineum can still transmit bacteria, parasites, Hepatitis A, and other STIs.
Before wrapping up, I want to address some of the surprisingly persistent common misconceptions about the sexual transmission of HIV. Here are the facts related to those myths:
1) HIV cannot be created by sexual activity itself; one person must already be infected with HIV in order for HIV to move from the fluids of the infected person into the bloodstream of the uninfected person.
2) A newly infected person has an unusually high viral load, which means that HIV+ people are most infectious to others during the early months after acquiring the virus.
3) There is some debate over whether an HIV+ person with an undetectable viral load can transmit the virus during sex, but most experts say that a person who has been told s/he has an undetectable viral load is still able to transmit the virus.
4) Breast milk is not infectious to adults with healthy immune systems.
5) Animals cannot transmit HIV to or from humans.
6)Lesbians can be HIV+. Virgins can be HIV+. Straight white middle-class people can be HIV+. Asians can be HIV+. Priests can be HIV+. Your mother can be HIV+. Your sex partner can be HIV+.
Condoms are far more reliable than trust.
Except in cases of sexual coercion or assault, you are the person ultimately responsible for whether or not you are willing to expose yourself or others to HIV infection.
In this 25th year of the HIV pandemic, smart well-educated clients tell me that they chose not to use a condom because their sex partner: a) was athletic, b) is a doctor or nurse, c) tested negative this week, d) is an old friend or ex-spouse, e) isn’t the promiscuous type, f) uses condoms with every sex partner except him, g) would never dream of cheating on her, h) is not gay, i) loves him too much to ever put him at risk, m) made the honor roll, and n) is always the bottom.
None of the above ever stopped this virus from entering someone’s bloodstream. Condoms do.
BTDTWoman