How is HIV Transmitted? : Specific Sexual Practices: What are the Risks?

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How is HIV Transmitted?
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Specific Sexual Practices: What are the Risks?

Studies have repeatedly demonstrated that certain sexual practices are associated with a higher risk of HIV transmission than others.

Vaginal Intercourse

Unprotected vaginal intercourse is the most common mode of HIV infection worldwide. At least five European and American studies have consistently demonstrated that male-to-female HIV transmission during vaginal intercourse is significantly more likely than female-to-male HIV transmission. In other words, HIV-positive men are much more likely to transmit the virus to HIV-negative women through vaginal intercourse than HIV-positive women are to HIV-negative men.

There are a few reasons for this. First, there are more men than women in the United States infected with HIV, meaning that it's much more likely for a female to have sex with an HIV-positive male than for a male to have sex with an HIV-positive female. Second, women have a much larger surface area of mucosal tissue—the lining of the vagina and cervix that can chafe easily and are rich in immune system cells that can be infected by HIV—than men do on their penises (though uncircumcised men do have mucosal tissue on their foreskins).

There have been a number of studies showing that men who are uncircumcised have a higher risk of becoming infected with HIV or transmitting the virus if they are already HIV positive. However, it is important to stress that men who are circumcised can still be infected (or transmit the virus) if condoms are not used for vaginal sex.

Men or women who have sexually transmitted infections (STIs) that cause sores on the anus, penis or vagina, such as genital herpes or syphilis, are more likely to spread the virus if they are HIV positive or to become infected with the virus if they are HIV negative.

To reduce the risk:
Correctly and consistently use latex or polyurethane condoms every time you have vaginal intercourse with a partner who is positive or whose HIV status you do not know.
Use a water-based or silicone-based lubricant with latex condoms. Lube keeps condoms gliding smoothly, reducing the risk of rips and tears. Lubrication also helps protect the vaginal wall from rips and tears, which can increase the risk of transmission.
 
Don't douche before engaging in vaginal intercourse. This can destroy the healthy bacteria in the mucosal lining of the vagina and can eliminate the vagina's natural lubrication.
 
Don't engage in unprotected vaginal intercourse during menstruation.

Anal Intercourse

Being the receptive partner—the "bottom"—during unprotected anal intercourse is linked to a high risk of HIV infection. The reason for this is that HIV-infected semen can come into contact with fragile and porous tissue in the anus that can be damaged easily during anal intercourse. And the risk of HIV transmission isn't necessarily reduced if the "top" pulls out before ejaculation—studies have demonstrated that pre-ejaculate (pre-cum) can contain high amounts of HIV and can result in transmission during anal intercourse.

It's important to note that both MSM and heterosexuals have anal intercourse. Many heterosexuals report that it is a pleasurable form of intimacy that eliminates the risk of pregnancy. However, it is still associated with a high risk of HIV infection, if condoms are not used and the insertive partner's HIV status is either positive or not known.

We know that men can be infected with HIV through vaginal intercourse—an activity in which they are the insertive partner. Based on this knowledge, it is also believed that the insertive partner during unprotected anal intercourse can also be infected with HIV. Studies, using mathematical estimates, suggest that unprotected insertive anal sex is roughly four to 14 times less risky than unprotected receptive anal sex. However, experts still believe that the risk for transmission is noteworthy.

To reduce the risk:
Correctly and consistently use latex or polyurethane condoms every time you have vaginal intercourse with a partner who is positive or whose HIV status you do not know.
Use a water-based or silicone-based lubricant with latex condoms. Lube keeps condoms gliding smoothly, reducing the risk of rips and tears. Lubrication also helps protect the vaginal wall from rips and tears, which can increase the risk of transmission.
 
Don't douche before engaging in anal intercourse. This can destroy the healthy bacteria in the mucosal lining of the anus and can eliminate the anus's natural lubrication.
 

Penile-Oral Sex

Of the different sex acts, the one that often causes the greatest amount of confusion in terms of risk—and raises the greatest number of questions—is penile-oral sex. The fact is, most experts agree that fellatio, sometimes referred to as "blow jobs," is not an efficient route of HIV transmission. However, this does not mean that it cannot happen.

Because unprotected fellatio can mean that body fluids from one person can (and do) come into contact with the mucosal tissues or open cuts, sores, or breaks in the skin of another person, there is a "theoretical risk" of HIV transmission. "Theoretical risk" means that passing an infection from one person to another is considered possible, even though there haven't been any (or only a few) documented cases. This term can be used to differentiate from documented risks. Having unprotected receptive anal or vaginal intercourse with an HIV-positive partner is a documented risk, as they have been shown in numerous studies to be an independent risk factor for HIV infection. Having unprotected oral sex is a theoretical risk, as it is considered possible, but has never been shown to be an independent risk factor for HIV infection.

There have been a number of studies that have closely followed MSM and heterosexual couples, in which one partner was HIV positive and the other partner was HIV negative. In all of the studies, couples that used condoms consistently and correctly during every experience of vaginal or anal sex—but didn't use condoms during oral sex—did not see HIV spread from the HIV positive partner to the HIV negative partner.

There have been three case reports and a few studies suggesting that some people have been infected with HIV as a result of unprotected oral sex. However, these case reports and studies all involved MSM—men who were the receptive partners (the person doing the "sucking") during unprotected oral sex with another HIV-positive man. There haven't been any case reports or studies documenting HIV infection among female receptive partners during unprotected oral sex. Even more importantly, there hasn't been a single documented case of HIV transmission to an insertive partner (the person being "sucked") during unprotected oral sex, either among MSM or heterosexuals.

Is insertive oral sex a possible route of HIV transmission? Yes. But is it a documented risk? Absolutely not.

To reduce the risk:
Don't get cum in your mouth. Also consider using an unlubricated (possibly flavored) condom every time you have oral sex with a partner who is positive or whose HIV status you do not know.
Avoid brushing or flossing your teeth immediately before oral sex. This reduces the risk of cuts, tears or abrasions in the mouth that can serve as an entry way for HIV.

Oral-Vaginal Sex

Like the study of fellatio, evaluating the risk of unprotected oral-vaginal sex (cunnilingus) is difficult, given that most people surveyed in studies did not avoid other types of unsafe sexual activity. However, there have been case reports highlighting one case of female-to-female transmission of HIV via cunnilingus and another case of female-to-male transmission of HIV via cunnilingus. Both of these cases involved transmission from receptive partner (the one receiving oral sex) to the insertive partner (the one performing oral sex). There haven't been any documented cases of HIV transmission from the insertive partner to the receptive partner.

To reduce the risk:
Use a latex barrier—such as a natural rubber latex sheet, a dental dam or a cut-open condom that makes a square—between your mouth and the vagina. A latex barrier reduces the risk of blood or vaginal fluids entering your mouth. Plastic food wrap also can be used as a barrier.

Oral-Anal Sex

Oral-anal sex is often referred to as analingus. Analingus, or "rimming," is not considered to be an independent risk factor for HIV. However, it has been shown to be a route of transmission for hepatitis A and B, as well as parasitic infections like giardiasis and amebiasis.

To reduce the risk:
Use a latex barrier—such as a natural rubber latex sheet, a dental dam or a cut-open condom that makes a square—between your mouth and the anus. A latex barrier reduces the risk of blood or anal fluids entering your mouth. Plastic food wrap also can be used as a barrier.

Digital-Anal or Digital-Vaginal Sex

Digital-anal or digital-vaginal sex is the clinical term for "fingering" either the anus or the female genitals (including the vagina). While it is theoretically possible that someone who has an open cut or fresh abrasion on his or her finger or hand can be infected with HIV if coming into contact with blood in the anus or vagina or vaginal secretions, there has never been a documented case of HIV transmission via fingering.


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Last Revised: August 17, 2012

This content is written by the POZ and AIDSmeds editorial team. For more information, please visit our "About Us" page.

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