What is the difference in the risk of transmission of HIV during homosexual and heterosexual sex?
In fact, there is none. Most new infections worldwide occur as a result of heterosexual sex. In many countries, men who have sex with men and sex workers are disproportionately represented. HIV can be transmitted via blood, semen and vaginal secretions. It isn’t the gender identity or sexual orientation of the people that determines the risk but the activity and the circumstances under which it takes place. The reason why sexual activity is a risk for HIV transmission is because it allows for the exchange of body fluids such as blood, semen and vaginal secretions. Some sexual activities are associated with a higher risk of HIV transmission than others. Unprotected anal or vaginal intercourse with a partner who is either positive, or does not know his or her HIV status, accounts for the vast majority of sexually-transmitted HIV cases worldwide.
Unprotected Anal Intercourse
The average HIV transmission rate during anal sex is estimated to be 18 times higher than the rate during vaginal intercourse. However, being the receptive partner (bottom) during unprotected anal intercourse is linked to a high risk of HIV infection whether you're a man or a woman. The reason for this is that HIV-infected semen, including pre-ejaculate (pre-cum) can come into contact with mucosal tissues in the anus, which are easily damaged during anal intercourse.
The insertive partner, (top) also at risk for contracting HIV during unprotected anal intercourse. HIV is present in anal mucosal tissues. It can enter the tops penis via small cuts that may occur during intercourse or through the urethra. If the mucosal tissues tear and bleeding occurs then HIV in the blood can also enter via this route.
To reduce the risk
Correctly and consistently use latex or polyurethane condoms every time you have anal intercourse with a partner who’s positive or whose HIV status you don’t know. This includes changing to a fresh condom if the activity has been going longer than 20 minutes. Always use a water-based or silicone-based lubricant with latex condoms as it keeps condoms gliding smoothly thus reducing the risk of rips and tears. Note that silicon based lubricants can leave a stain on the sheets. Don't douche less than one hour before engaging in anal intercourse as it can destroy the healthy bacteria and eliminate natural lubrication.
Unprotected Vaginal Intercourse
Unprotected vaginal intercourse is the most common mode of HIV infection worldwide. 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. Some of the reasons for this vary from country to country and culture to culture. However, one thing remains constant. Women have a relatively large surface area of mucosal tissue. The mucosal tissue lining the vagina and cervix can chafe easily during vaginal intercourse and have a high concentration of CD4 and T-cells which are targeted by HIV. For men, HIV must enter through a cut or abrasion on the penis, or through the lining of the urethra inside the penis. HIV can enter in this way.
To reduce the risk
Correctly and consistently use latex or polyurethane condoms every time you have vaginal intercourse with a partner who’s positive or whose HIV status you don’t know. This includes changing to a fresh condom if the activity has been going longer than 20 minutes. Always use a water-based or silicone-based lubricant with latex condoms as it keeps condoms gliding smoothly thus reducing the risk of rips and tears in the vaginal wall. Note that silicon based lubricants can leave a stain on the sheets. Don't douche less than one hour before engaging in vaginal intercourse as it can destroy the healthy bacteria and eliminate natural lubrication. Don't engage in unprotected vaginal intercourse during menstruation.
Oral-Penile sex
Oral-Penile sex, fellatio, (blow jobs), are not high risk when it comes to HIV transmission. However, it has happened. Because unprotected fellatio can mean that body fluids, especially semen (cum), 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 risk of HIV transmission.
To reduce the risk
Don’t get cum in your mouth. If you do, get rid of it as soon as possible. That is, swallow or spit immediately. Also consider using an unlubricated (possibly flavored) condom every time you have oral sex with a partner who’s positive or whose HIV status you don’t 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
Oral-Vaginal sex (cunnilingus) is not high risk when it comes to HIV transmission. Nevertheless, HIV is in vaginal secretions and menstrual blood and there are some documented cases involving transmission from the partner receiving cunnilingus to the one performing it. The presence of cuts and sores increases the risk of HIV transmission.
To reduce the risk
Avoid brushing or flossing your teeth immediately before cunnilingus. This reduces the risk of cuts, tears or abrasions in the mouth that can serve as an entry way for HIV. Also, avoid this activity while the receptive partner is menstruating. Also, consider covering the vagina with a natural rubber latex sheet, dental damn or cut open condom that makes a square.
Oral-Anal Sex
Oral-Anal sex, analingus, (rimming) is not considered a risk factor for HIV transmission unless there are open sores present on the anus of the receptive partner or in the mouth of the insertive one.
To reduce the risk
Avoid brushing or flossing your teeth immediately before rimming. This reduces the risk of cuts, tears or abrasions in the mouth that can serve as an entry way for HIV. Also, avoid this activity if there are open sores present on the anus. Also, consider covering the anus with a natural rubber latex sheet, dental damn or cut open condom that makes a square.
Oral stimulation of the female breast
This is not considered a risk factor unless the woman receiving the stimulation is a nursing Mother. HIV is found in breast milk and can be transmitted to a sexual partner as well as to a child being breast fed by a HIV+ woman.
To reduce the risk
Avoid getting breast milk in your mouth from a partner who is HIV+ or whose status is unknown. If you do, get rid of it as soon as possible. That is, swallow or spit immediately.
Digital-Anal/Digital-Vaginal Sex
Digital-Anal/Digital-Vaginal sex, (fingering or, if the whole hand is involved, fisting), is not considered a high risk factor in HIV transmission. However, the risk increases if there are cuts on digits of the insertive partner and/or the receptive one is menstruating or suffers a tear in the lining of the anus.
To reduce the risk
The insertive partner should cover his/her fingers with individual finger cots or the whole hand with a latex glove if fisting. Change to a fresh finger cot of glove if the activity has been going longer than 20 minutes. Also, always use a water-based or silicone-based lubricant with latex finger cots and gloves as it facilitates ease of movement thus reducing the risk of rips and tears.
Sex Toys
This often involves the insertion of vibrators and dildos into the vagina and/or anus and is not considered a risk factor in HIV transmission unless the toys are shared.
To reduce the risk
Correctly and consistently use latex or polyurethane condoms every time you use sex toys with a partner who’s positive or whose HIV status you don’t know. If you share the toy, change to a fresh condom. Also, change to a fresh condom if the activity has been going longer than 20 minutes. Always use a water-based or silicone-based lubricant with latex condoms as it keeps condoms gliding smoothly thus reducing the risk of rips and tears. Note that silicon based lubricants can leave a stain on the sheets. Don't douche less than one hour before inserting sex toys in the vagina or anus as it can destroy the healthy bacteria and eliminate natural lubrication.
S&M and other sex games
S&M acts involving the infliction or reception of pain or humiliation. Other games can include piercing and/or shaving. These are not considered as risk factors unless body fluids, especially blood, become involved.
To reduce the risk
Consensual S&M (rough sex), is considered safe if there is no blood involved. Set limits that don’t involve blood and stick to them. Don’t share razors if shaving. If you are piercing each other, use fresh needle each time or clean the needle with bleach. Disinfect the body areas to be pierced with alcohol and wear latex gloves.
Finally, men or women who have ulcerative sexually transmitted infections (STIs), 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. The vast majority of new HIV infections occur because the infected partner in the serodiscordant couple didn’t know his/her HIV status.
I hope readers have found this blog entry helpful.
Get tested, stay healthy and, if you’re on ARV, compliant with your ARV regimen.
Malcolm Brown.
"WE ARE ALL IN THIS TOGETHER.
NO PLHIV is alone with his or her struggle with HIV!"
-Pozziepinoy-
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