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.


Posted: 29 Sep 20:46