HIV Sexual Transmission Under HAART

In January 2008, the Swiss AIDS Commission issued a controversial report on the transmission of HIV in heterosexual mixed status couples. The report stated that HIV is not likely to be passed on when the positive partner fully adhered to a potent HIV regimen, had undetectable viral load for at least six months, and did not have any other sexually transmitted infection (STI) during that time, even despite sex without condoms.
What ensued after its publication has been tumultuous community discourse and opinion pieces worldwide. Some have denounced the Swiss government as being irresponsible. Others responded with "no comment". Few others, like Project Inform, invited this as a way to discuss issues faced by people living with and affected by HIV.
At the 2008 International AIDS Conference in Mexico City, a Sunday afternoon session, HIV Transmission under ART, provided a forum to discuss this report. Seven panelists attempted to clarify the persistent questions that have lingered ever since. Project Inform attended this session of about 300, which expands our earlier coverage of this topic.

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The outcry over the Swiss report stems from the perception that they were saying that people who take effective HIV drugs can stop having safer sex or abandon their condom use without infecting their partners. The panelists were clear: this is not their message. Some have criticized other aspects of the report, arguing it failed to address other important issues, such men who have sex with men.
The possible implications for others living with HIV are about as diverse as the outcry has been. Project Inform believes the report and the conversations it has spurred can help inform these discussions for a wide range of people living with HIV. The main issues brought up by the Swiss Report are broadly outlined below.

Provide Accurate Information

The report provides a good deal of applicable data, much buried beneath the vocal backlash. Physicians, community health professionals, and others who interact with HIV-positive people and their partners can and must provide information clearly and accurately. The basic model of fully informed decision-making that has defined Project Inform's approach to HIV treatment decisions is just as applicable to this situation.

Use This as a Tool

We should encourage sophisticated discussions of the issues facing mixed status couples. After nearly three decades of the epidemic, a great deal is known about how HIV is and is not passed. Each partner, along with their doctors, can be encouraged to discuss these issues. These data, when discussed alongside a person's needs for true sexual intimacy, can lead to fuller and more honest discussions between sexual partners.
There's a great degree of disagreement over the effect this report might have on sexual practices and condom use. Lacking any real world data, people are left mostly to conjecture. One of the panelists shared findings from an anonymous survey he helped administer to people with HIV. He stated the report was widely well received by people with HIV, and did not have a marked influence on sexual practices. Interestingly, many did report feeling more able to honestly discuss their sexual practices with their doctors after the report.
Some of the panelists feared the Swiss report would lead to less condom use. One audience member asserted his belief that the report said that condom use was not needed when people were on suppressive HAART. Others felt that the report was likely to increase adherence to both treatment and safer sex practices.

Get Regular Health Care

One undeniable take-home message from the Swiss report is the critical importance of having accurate medical information to make informed decisions. Vast inequalities in access to things like viral load tests and STI screening must be accounted for in settings worldwide.
Some panelists felt that these differences render the report largely meaningless to most people with HIV. Project Inform sees it differently. It is much like the early data on combination therapy: information that might have only applied to small numbers of people at that time can have profound implications for far more people down the line. As seasoned AIDS activist Heidi Nass puts it, 'progress in progress.'

Push This Discussion to Test for HIV

The report underscores the need to reach those who are undiagnosed or untested. These discussions can only work when people know their HIV status. Most estimates in the US find that around 1 in 4 people with HIV do not know they have HIV. Project Inform encourages testing as a way to take control of one's life.

Explore New Ways to Prevent HIV

The report highlights the role that effective treatment plays in preventing new infections. Project Inform recently revised its mission statement to include biomedical prevention methods to help reduce new infections. This includes interventions such as Pre-Exposure Prophylaxis (PrEP), vaginal and rectal microbicides, and male circumcision, among others. These alternate prevention methods should be considered as being additive and synergistic to behavior interventions such as condom use. Therefore, no one method should preclude the others. The more choices one has, the better. The better the data are, the more confidence people can have in their choices.
One of the stories leading in to this meeting was the CDC's announcement that the number of new HIV infections in the US was 40% higher than previously estimated. This disturbing statistic highlights the crucial need for new prevention methods. The Swiss statement has the potential to help, as it underscores the connection between effective treatment and prevention.

Understand the Limitations of the Report

In some parts of the world, it's a privilege to have access to the spectrum of health care that's necessary to fully inform these decisions. For most people, this just isn't possible. Some health care systems are overburdened and cannot accommodate the discussions. For many, viral load or STI tests are just not available. For others, medical infrastructures barely exist. Though the world has reacted to this report, it may very well not apply to most of the planet.
Another obvious weakness of the report is that the authors only had data from studies of heterosexual sex to guide them. In the US, the CDC estimates that just over half of new HIV infections are among men who have sex with men, reinforcing the importance of studying the impact of treatment on prevention among this group.

Adapt the Limitations of the Report

Too often critics of the Swiss report have used its limitations to dismiss the report entirely. This is both scientifically and ethically unsound. No study, or review of studies, is above critique. Science works best when studies and reports are examined honestly, taking into account both their strengths and weaknesses.
Some have said it's premature to talk about these kinds of data until such time that there are more mature and definitive results. One panelist reminded the audience of the experience of male circumcision where 17 years elapsed between the emergence of supportive circumstantial evidence of its role in reducing HIV infection rates, and the definitive results from prospective, randomized studies.
Although the medical resources may not be available to most who face these issues, it is still possible to encourage conversations with couples on issues that they can do something about. This includes encouraging each partner to disclose his/her status, to discuss their fears, or to even start engaging in safer sex, among many others.

Practice Safer Sex

The Swiss report does not suggest individuals abandon using condoms or other safer sex practices. In fact, it spotlights the necessity for a couple's continued diligence in this area. One panelist argued that condom use without treatment provides similar levels of protection as treatment without condoms. It is common and fairly uncontroversial to recommend that people with HIV use condoms regardless of whether they're on treatment. The report argues that the best possible prevention comes from combining treatment and condoms. Accurate information on transmission risk should drive these decisions.

Understand This Report in Its Context

At various points throughout this epidemic, many medical, social and behavioral issues have emerged. We have grappled with the risk of casual transmission and the risk of oral sex -- each without the benefit of definitive research. In these cases, observations and an understanding of the mechanics of HIV transmission helped mold recommendations that have stood the test of time.
What now is taking place is a study called HPTN 052 is currently enrolling and is designed to answer the risks of transmission under HAART. The results likely won't be available until 2016, at which point we may look back and wonder what the commotion was all about. We also might ask ourselves, as many have in light of the male circumcision saga, how many new infections could have been prevented in the meantime?

Raise New Research Questions

Much new data need to be uncovered to more fully answer the concerns raised by the community. How do STIs play a role in transmission and at what level? Do different strains of HIV affect its transmission? Do different classes of HIV drugs affect the levels of HIV in genital tract secretions differently? How do viral load blips affect the likelihood of transmission? How much do we know about HIV transmission through oral, vaginal or anal sex? Pursuing these and other questions are critical to help better inform those faced with these decisions.

The Asymmetry of Risk

One interesting point raised by a panelist was the asymmetry of risk. If you say something is dangerous, and it turns out not to be so, there's usually little consequence. However, if you claim something is not risky and it turns out to cause harm, the repercussions can be catastrophic. This can lead groups to be overly conservative in protecting their own interests. Looked at in this light, the Swiss statement is remarkable.
Also worth pointing out is how little attention has been paid to issues of pleasure, intimacy and stigma facing people with HIV throughout these public debates. While researchers might not place much emphasis on these issues, they're of great importance to people living with HIV. They have profound implications for their day-to-day lives, not to mention their emotional and sexual well being. A full discussion of treatment and prevention must take these issues into account, or risk being of little use to people living with HIV.
Project Inform encourages sophisticated conversations among mixed status couples and others. As we have stated in our March 2008 response to the Swiss Report, we encourage all sexually active individuals to learn their status by regularly testing for HIV; we encourage treating HIV as early as individuals are ready to start and the medical information suggests; we encourage adhering to HIV treatment while practicing safer sex; and we encourage the honest conversations between partners and their providers on the medical and behavioral issues of transmission.

What Are HIV-Positive Persons' HIV Prevention Needs?

Why Prevention for HIV-Positive Persons?

Every new HIV infection involves an HIV-positive person. The Centers for Disease Control and Prevention (CDC) estimate that there are 600,000-900,000 people living with HIV in the U.S. Yet very few prevention interventions have been directed to HIV-positive women and men. People who are HIV positive deserve to have interventions to help them stay safe and play an active role in stopping the epidemic.
In the past few years, advances in the treatment and care of HIV-positive persons have helped many people enjoy increased health and longer life. For many, this allows for a renewed interest in sexual and for some, drug using activity. More sexually active and drug using HIV-positive persons means the possibility of more new infections.

Why Haven't We Done More of This?

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In the past, prevention efforts had not been directed toward HIV-positive persons for fear of "pointing the finger" or blaming HIV-positive persons for the epidemic. Although AIDS has become less stigmatized in the U.S., in some communities there is still serious stigma experienced by HIV-positive persons. AIDS activists and HIV-positive persons have also feared laws criminalizing sexual risk behaviors and further prosecution of injection drug users (IDUs).

Prevention efforts for HIV-positive persons have focused on protecting one's own health from the possibility of reinfection with untreatable strains of HIV. Few efforts have addressed altruis -- the responsibility of HIV-positive persons to not transmit the virus to others and the opportunity for HIV-positive persons to actively contribute to ending the epidemic. Prevention efforts need to address both issues: taking responsibility for one's own health and the health of one's partners, children, other family members and community.

Why Would Someone Infect Another?

Most HIV-positive persons are concerned about not infecting others and have made efforts to prevent transmission. Yet there has not been much support for HIV-positive persons to gain the necessary skills and tools to adopt new, safer behaviors. Couples where one partner is HIV positive and the other is HIV negative often wrestle with issues such as how to maintain sexual satisfaction and trust. For some couples, the risk of losing commitment and intimacy in a relationship is more threatening than the risk of transmitting HIV.
A precondition of reducing your risk is knowing you're HIV positive and getting help. There are an estimated 200,000-250,000 Americans unaware that they are infected with HIV. It is imperative to help HIV-positive persons get tested before they unknowingly infect others. Finding out HIV status can also allow early access to life-prolonging treatment and services.

Disclosure

Incorrect assumptions and denial of responsibility between partners can lead to risky behavior. Many HIV negative persons are unaware of their partners' status or risk behaviors and may make assumptions that they are not at risk for HIV because they are married, in a relationship, their partner looks healthy, or simply because their partner did not ask to use a condom. HIV-positive persons may make the same assumptions that their partner is also HIV positive because the partner didn't ask about serostatus or suggest using condoms. Likewise, there may be a difference of opinion on who's responsible for keeping safe, the HIV positive person, the HIV negative person, or both.
Disclosure can be a way of beginning a discussion about safer sex or drug use. Yet disclosure of one's serostatus is difficult for many HIV-positive persons, especially women, who may fear stigma, rejection or violence from their partners.
Practicing safer sex with all partners and always using clean needles is one way of preventing transmission without having to disclose status. However, in many communities where this is not the norm, simply using a condom can disclose HIV-positive status, even without saying it.
HIV is a disease that is often mistakenly associated with careless sexual behavior. However, many HIV-positive persons become infected within a loving relationship. In one study of HIV-positive men and women, 41% reported becoming infected by a spouse, significant other, or long-standing friend. Research has shown that people are often more comfortable disclosing and practicing safer sex with partners outside of their main relationship.

What Are Barriers to Prevention?

Often, the same factors that led someone to become infected are also barriers to preventing transmission. Many HIV-positive persons face complex issues that can affect their ability to engage in safer sex or drug-using behaviors. Depression, substance use and abuse, history of violence and abuse and sexual compulsivity are all issues that may need to be addressed. Many of these issues cannot be addressed in a prevention program and may require referral to longer-term counseling or other social services.
Legal, political, and environmental factors can be barriers to HIV prevention among HIV-positive persons. For example, the lack of access to sterile syringes and needle exchange programs, as well as laws prohibiting possession of syringes, hamper the ability of IDUs to engage in safe behaviors. Fear of arrest for carrying drug paraphernalia has been associated with sharing syringes and other injection supplies.

What's Being Done?

In 1998, the CDC funded five Health Departments to create demonstration projects providing primary HIV prevention for HIV-positive individuals. California, Los Angeles, San Francisco, Maryland, and Wisconsin have begun a variety of programs that address a wide audience including: HIV-positive women, men of color who have sex with men, IDUs, youth, female sex and needle sharing partners of IDUs, and incarcerated men and women.
Interventions include: HIV, STD and TB counseling, testing and treatment; referral and linkage to care; prevention case management; HIV-positive peer "buddies"; outreach via social networks; mass media and internet marketing; partner counseling and referral services; skills building; and community level forums and social events.

Campaign

AIDS Action Committee in Boston, MA, created an ad campaign that targets HIV-positive gay men with messages aimed at opening discussion about transmission and promoting responsibility. Posters with messages such as "Ask. Tell." "Let's stop new infections now." and "If you're positive, think about transmission." were placed over urinals in gay bars and sex clubs. A survey of men leaving the bathrooms found that 70% could recall two or more of the messages.

Couples

Couples counseling for sero-discordant couples (where one partner is HIV positive, the other HIV negative) has proven highly effective at reducing new HIV infections. One program for heterosexual women and men provided couples counseling in combination with social support. As a result, condom use increased and no new HIV infections were reported among the couples. Couples counseling can help ease communication and provide support for both the HIV-positive and HIV-negative partner in straight and gay/lesbian relationships.

What Needs to Be Done?

HIV-positive persons are a unique population in that they require both care and prevention, which requires better coordination between these two worlds.

• Health care providers need to be trained to deliver HIV prevention, as seroconversion can provide a strong motivation to change risky behaviors.
• HIV prevention programs need to address HIV-positive persons and include STD, hepatitis and TB screening and treatment as well as referrals to drug treatment, family planning and mental health services.
• HIV-positive persons' partners, children and families must be included with support and education.
• We need more effective HIV testing and counseling strategies.

Don't Know

There is currently an unacceptably high number of persons who do not know they are HIV positive unknowingly infecting others. The social network approach (encouraging HIV-positive persons to provide information and outreach to peers who might be positive) is one way to create a more efficient and targeted approach to HIV testing and counseling for those at greatest risk.
There are many things we don't know about the relationship between new anti-HIV drugs and HIV transmission. How much do they affect a person's infectiousness and how does that affect transmission? Is reinfection or super-infection a valid concern? These questions need to be researched, and the answers disseminated widely so that HIV-positive persons can make informed decisions about preventing transmission of the virus.
If you have tested HIV positive, reach out and get some help. If you don't know your HIV status, take the test -- it's free and confidential.
If you need a prevention for positives program to help you reduce your chances of transmitting virus to others, please call the Women Alive Coalition at 323.965.1564. Ask for Gina!

Reducing the Risk of Getting HIV From Sexual Activities

Safe(er) Sex

When thinking about "safe" sex, it is important to realize that risk from various sexual practices often falls along a continuum, rather than having a clear safe vs. not safe boundary. Throughout this discussion, we will refer to "safer" sex, with the thought that by placing more or fewer "boundaries" around a particular sexual act, it can be made more safe or less safe.
Any sexual practice can be made safe or unsafe. For instance, mutual masturbation can become unsafe if people touch their own genitals after getting a partner's infected semen, blood or vaginal fluids on their hands. We hope to help you develop criteria to use to decide whether previous experiences you've had were safe or not, and how to stay safe in the future.
It is helpful to think about safer sex using a wide definition of sex. Many people think about sex fairly narrowly. For instance, thinking that sex only starts when penetration takes place may limit people's ability to protect themselves and to enhance their sexual lives through safer sex. We consider sex to include any practices that a person finds erotic and sexually exciting.
Remember, telephone hotline staffers are available to talk with you about any of these issues. Within California, call the San Francisco AIDS Foundation's California AIDS Hotline toll free at 800/367-AIDS. Outside California, call your state's AIDS Hotline or the CDC-Info line, toll free at 800-232-4636. To find the number for your state's hotline go to http://www.aidshotline.org/ and click on Other Hotlines.

Why Practice Safer Sex?

Most people are inclined to think that people who practice safer sex are only those who are concerned about getting HIV from their partners because they don't know their sexual partner(s)' HIV status or they know if their sexual partner(s) is/are HIV-positive.
In fact, there are other reasons why some people decide to practice safer sex. Some examples:

• HIV-negative people who always practice safer sex so they don't lose the habit of protection. Also, if a person agrees, with ease, to practice safer sex, this is an indicator that the person has practiced safer sex with previous partners.
• HIV-negative people in a sexual relationship who want to avoid dealing with issues of trust between them. By practicing safer sex, there is no need to discuss whether they are being monogamous.
• HIV-negative people who agree to practice safer sex with each other for three months before they are tested again for antibodies to ensure they are both uninfected. After this time, they may decide to engage in unprotected sex with each other, though HIV infection could occur if either partner is having unsafe sex outside of the relationship.
• HIV-negative and HIV-positive people who want to avoid getting sexually transmitted diseases other than HIV.
• HIV-positive people who want to avoid getting reinfected with HIV. It is possible for someone with a drug-resistant strain of HIV to give it to another HIV-infected person, which could potentially limit their treatment options.

Of course, sexual partners who are HIV-negative, and wait three to six months after their last risky activities before taking an HIV-antibody test, and trust that neither one of them is or will engage in sexual or needle sharing activities that could put them at risk, may practice sex without protection. Obviously, trust and communication are essential.

Safer Sex And Pregnancy

For couples who are uncertain of their HIV status, it is highly recommended that you both get tested for HIV prior to attempting to have a baby.

Safer Sex Guidelines

Any sexual practice that does not let someone else's semen, blood, or vaginal fluids get into someone else's body is generally considered "safer" sex. The parts of the body where HIV could enter the bloodstream are the anus and rectum, the vagina, the penis, the mouth, and the eyes. These body parts must be protected from contact with HIV-infected fluids. HIV cannot go through the skin unless there are open sores or bleeding cuts.
We hope to give you the tools with which you can make your own decisions about where you want to fit in on the continuum from safer sex to riskier sex. Each time you engage in a sexual activity, you choose (whether consciously or unconsciously) the level of risk you are comfortable with for that moment.
Safer sex often involves use of latex condoms, latex dental dams, plastic wrap, latex gloves and finger cots as barriers between the infectious fluids and mucous membranes or open cuts.

Why Latex?

Latex has been proven effective in preventing the transmission of HIV. Latex is a very resilient and strong material that does not allow HIV to pass through it. When used properly, latex products offer the best possible barrier against HIV and other sexually transmitted diseases.

Lubricant

Use of lubricants can make sexual penetration more comfortable and may also help reduce the risk of condom breakage during sex. With latex condoms, however, be sure to use a water-based lubricant. Do not use baby oil or other oil-based lubricants. These may cause the condom to be ineffective.
In addition, there has been controversy over lubricants that contain nonoxynol-9, a spermicide that is added to some products. Recent studies by the CDC, the World Health Organization, and the Population Council of New York have each demonstrated that hundreds of epithelial cells, which provide a protective membrane in the anus, were stripped away by products containing N-9.
Originally, N-9 was thought to help prevent HIV, because it killed the virus in a test tube, but now it's been documented that N-9 washes away the protective cells and might actually increase the risk of infection.
Due to public pressure, all lubricant manufacturers agreed to stop making lube with nonoxynol-9. There are, however, manufacturers that continue to make condoms laced with N-9. Condoms containing N-9 should not be used for anal sex; however, if a condom containing N-9 is the only method available, using this condom is significantly safer than using no condom at all.

Condoms and Other Safer Sex Devices

"Male" condoms	A condom is a sleeve, closed at one end, which fits over the penis. There are three types of condoms: latex, polyurethane and lambskin. The lambskin condoms may allow passage of HIV, and therefore are not recommended. Latex or polyurethane condoms are recommended because they do consistently prevent passage of HIV.
"Female" condoms	An approved alternative to the regular condom, the 'female' condom, is a disposable vaginal pouch made out of polyurethane. It is soft and thin and has a latex ring at each end. The ring at the closed end goes into the vagina and over the cervix (the opening of the uterus). The other end stays outside the vagina and covers the labia (vaginal lips). The polyurethane covers the cervix and the vaginal canal. The vaginal condom is currently marketed under the name "Reality." This condom is sometimes used by either men or women for anal sex, although it has not been designed for or tested for this usage.
Latex Dental Dams	Dental dams are squares made out of latex that dentists use to isolate the tooth on which they are working. AIDS educators have advocated their use for oral sex, either mouth-vagina or mouth-anus. Because they were not originally designed for sex, they tend to be thicker than condoms.
"Dammit"	This device consists of a couple of leather straps with snaps that can be adjusted around the legs to hold a dental dam in place, like a garter belt. This harness has several purposes: (1) one's hands are left free to hold or stimulate the partner and, (2) there is no risk of flipping the dental dam over and using the wrong (exposed to fluids) side for as long as the "dammit" is being used.
Plastic Wrap	Plastic wrap is a common product in people's kitchens. It has been shown to prevent passage of HIV and it is recommended as a barrier for oral sex, either mouth-vagina or mouth-anus. Although dental dams can also be used for these activities, plastic wrap has the advantage of being transparent, thinner, cheaper, and easier to get.
Latex Gloves	Latex gloves are easy to find in drugstores and medical supply stores. They may be used to cover the hand when inserting the fingers or fist in the vagina or rectum. They may also be used by people who have open cuts in the hands or chronic skin problems such as eczema. Some people simply enjoy the feel of latex on their skin.
Finger Cots	Finger cots are made out of latex and cover only one finger. They can be found in medical supply stores.

Types of Condoms

There are a wide variety of condoms on the market. They can be lubricated or non-lubricated. They come in different colors, shapes, sizes, textures and thickness. There are condoms that are flavored and those that glow in the dark. There is practically no limit to the selection.
Some men complain that condoms make them lose sensitivity in the penis during sex. We encourage these men to try out different brands and types of condoms and select the ones with which they are more comfortable (they can masturbate with them to get used to them and feel more comfortable during sex with their partners). Some people find that although they may lose their sensitivity at first, after using condoms for a while they can regain it. And, of course, they feel more relaxed about sex since they know they are protected.
There are no rules about what condom to use. Some men feel better with a thicker condom while others prefer a thinner one. Some people get excited about colors and flavors while others find these features boring or irrelevant. [Please see the subject of lubricants above and the concern over use of condoms that contain Nonoxynol-9 (N-9)].
Some men claim that their penis is too big for a condom. We encourage them to try different brands (which fit different people in different ways; there are no "better" brands). There are also brands of condoms designed explicitly for men who have a large penis. Interestingly, few if any men say that their penises are too small for a condom.

Using "Male" Condoms

• Pick up the condom by grabbing the "nose" (the reservoir tip) between your thumb and forefinger (to ensure that no air bubble gets trapped in the tip, which may cause breakage during intercourse).
• With both hands place the condom on the head of a fully erect penis (remember, you are holding the "nose" in one hand; you roll the condom down onto the penis with the other hand).
• Unroll the condom completely, all the way down to the base of the penis. Having used both hands and held onto the reservoir tip, you have just ensured that no air is trapped inside the condom. Not only does this prevent air bubbles popping the condom during the friction of intercourse, but it also creates a vacuum, which helps to keep the condom in place.
• Use plenty of water-based lubricant (some people use a single drop inside the tip to keep the air out).
• When pulling out, the man or his partner should hold the condom between the fingers so that it does not slip off and spill any semen inside the body.

Preventing Condom Breakage

The main reason for condom breakage is user failure. Although condoms are very resilient, they may become weaker when affected by several factors:

Heat	Condoms should never be left in places where they will be exposed to heat, such as glove compartments, under direct sunlight or in pockets of tight jeans.
Old age	Condoms should be fresh when used. We recommend not keeping condoms longer than a year. If there is any uncertainty about how old a condom is, it should be thrown out. Most condoms will have expiration dates on the package.
Insufficient lubrication	It is important to use a lubricant (such as saliva or a commercial lubricant like KY jelly or another product) to reduce friction on the outside of the condom during sexual intercourse. When in doubt, more lubrication should be added.
Use of oil-based lubricant	Oil-based lubricants affect the latex and make it break. Lubricants that should never be used include: Vaseline, baby oil, Crisco, hand lotion, massage oil, face cream, etc. Just look on the label for ingredients: water should be the first ingredient.
Air bubbles	The main reason condoms break during sex is because air bubbles get trapped inside them, which make them break due to the motions of intercourse. The air must be pinched out of the condom's tip before putting it on.

Using Condoms During Oral Sex

If you wish to perform safer oral sex on a man, you have the option of using non-lubricated condoms and also polyurethane condoms. Lubricated condoms do not taste good to most people and if there is nonoxynol-9 on the condom, it may cause numbness of the lips lasting several hours. (See "Lubricant" above for more information on nonoxynol-9 and some concerns regarding it). Some people don't like the white powder that covers non-lubricated condoms. That white powder is cornstarch and can be easily wiped off with a wet washcloth.

Condom Availability

Condoms are, in general, very easy to find. Most drug and grocery stores carry them. However, in some places people have to ask the clerk for them, which can be embarrassing.
Condoms are usually inexpensive. Some stores have an arrangement of selling them at cost (that is, they charge only what the manufacturer charges them) to make them even more accessible. Some health departments and STD clinics, and nonprofit HIV/AIDS service organizations have condoms available for free.
We encourage you to keep a good supply of condoms available at home or at any place where you are likely to have sex. Having condoms readily available increases the probability of their being used.

Using Dental Dams and Plastic Wrap for Oral Sex

The dam or plastic wrap can be placed between the mouth and the vagina or anus during oral sex to reduce risk of sexually transmitted diseases. It is very important that you use a different dam or piece of plastic wrap every time that you perform oral sex. It is not a good idea to set the barrier aside and use it again because it's too easy to flip it over and forget what side touched the vagina or anus.
Dental dams are not as readily available as plastic wrap. They can be bought from medical supply stores, and from some sex shops and drugstores. They can also be ordered by phone.

Using Dildoes and Other Sex Toys

Part of practicing safe sex is being creative. Sex toys can add to the pleasure and creativity of sex. However, some precautions are necessary when they are being used by more than one person.
It is best to have one's own personal sex toys and never share them. However, dildoes and other toys may be washed with soap and water and then used by another person. Condoms may be placed on dildoes and vibrators to avoid needing to wash them before a second person uses them. It is important to change the condom every time that the toy passes from one person to another.

Risk from Specific Sexual Practices

Anal Intercourse

Anal intercourse without a condom is the riskiest activity for HIV transmission. The receptive partner (or "bottom") is at risk because the anal area provides easy access to the bloodstream for HIV carried in semen. The insertive partner (or "top") is also at risk because the membranes inside the urethra can provide an entry for HIV, possibly present in blood inside the anus, into the bloodstream.
Using a condom from start to finish greatly reduces the risk. However, the risk is not zero because the condom could break. It is important that you understand that condoms are only effective against HIV if they are used properly and do not break.

Vaginal Intercourse

Unprotected vaginal intercourse is also considered quite risky. In a heterosexual encounter, HIV passes more easily from male to female than vice versa. Therefore, the woman is at more risk. No matter what the gender of the partners, latex can reduce the risk of HIV transmission and other sexually transmitted diseases.

Oral Sex

Oral sex (mouth-penis, mouth-vagina) has very minimal risk for transmitting HIV as the mouth is an inhospitable environment for HIV, for several reasons. Saliva contains enzymes that break down the virus; also, the mucous membranes in the mouth are more protective than those in the anus/rectum or vagina and fluids generally don't remain in the mouth for long periods of time (they are swallowed or spit out).
There are, however, a few documented cases where it appears that HIV was transmitted orally. These cases are all attributed to ejaculation in the mouth (i.e., exposure to semen, not exposure to vaginal fluid or pre-seminal fluid).
If there is infected ejaculate, vaginal fluid, or blood present, the risk for infection is higher. How much does it increase the risk? We can't say for sure. Certainly, not to the level of risk from ejaculation inside an anus or vagina. And we can definitely say that there are only a few documented cases of HIV in which the only possible source of infection was through oral sex, so the risk is still very low. But it is incorrect to equate the risk of oral sex with ejaculation to the risk of oral sex without.
A person receiving oral sex is generally not at risk, because that person is coming into contact only with saliva. (There is a theoretical risk of transmission if the person performing oral sex had blood in her/his mouth.) Many people find using a condom unacceptable and are practicing oral sex on men without ejaculation. They are coming into contact with pre-cum (pre-ejaculate fluid). There is no conclusive evidence that pre-cum transmits HIV, but some studies suggest that HIV is present in this fluid. Although HIV may be present in pre-cum, it is in very small amounts, and the mouth is not an easy path for transmission. This means unprotected oral sex without ejaculation is a very low risk activity for HIV transmission.
Performing oral sex on a woman who is menstruating increases the risk because blood has more HIV than vaginal fluid. There is little data on how often HIV is transmitted via oral sex from an infected woman to an uninfected man.

Watersports / Urine in Sex or Sex-Play

Urine does not transmit HIV. Even if the urine contained small amounts of blood, the fragile virus would be battered by acid, heat, friction, enzymes, and dilution. And again, it's important to think about how this fluid is coming into contact with another person. To transmit HIV, there would have to be a source of bleeding, and then we're not talking about urine transmitting HIV, we're talking about blood.

Rimming (Oral-Anal Contact)

Feces may contain some blood, but it poses very minimal risk for HIV transmission. However, rimming is a risk for transmission of hepatitis, parasites, and many other sexually transmitted diseases. Safe rimming means using a dental dam or plastic wrap.

Fisting

Fisting refers to inserting the fingers or hand into the rectum or vagina. When people talk about fisting, they almost always mean anal fisting, but the precautions are the same for both. Fisting could be risky for the insertive partner (or "top") if there is broken skin that would allow blood from the rectum or vagina into the bloodstream. Using a latex glove reduces the risk.

Kissing

This activity is not known to pose any risk for HIV infection. Saliva does not transmit HIV. One should be aware of cuts or sores in the mouth and, if concerned, not floss or brush right before French kissing. "Dry" or "social" kissing (with the lips closed) poses no risk for transmitting HIV.

Mutual Masturbation

The skin is an effective barrier against all sorts of organisms, and will stop HIV. Any possibly infected fluid on the skin should be washed off. An intact scab is as effective as unbroken skin. Open cuts in the skin might allow passage of the virus, but the breaks need to be open and/or bleeding to pose a risk. If there is any question, latex gloves or finger cots should be used. It is not (if one wants to be as safe as possible) advisable to ejaculate on someone else's penis or labia, nor to touch the genitals with someone else's fresh semen or vaginal secretions on the hand.

Solo Masturbation

With solo masturbation there is no fear of infection. Anything done solo is okay as long as someone else's infectious fluids are not present.

Body Massage, Hugging, Rubbing

With only skin-to-skin contact, these activities are risk free. This includes body-to-body rubbing ("frottage").

SM Activities

These are safe, unless someone's blood, semen or vaginal fluid enters the bloodstream of another person. It can include bondage, tit or nipple play, spanking, discipline or any of a number of other activities, limited only by the imagination.

Fantasy, Voyeurism, Exhibitionism, Phone Sex

These can be elements of many safe activities. They can include costumes or uniforms, and can appeal to senses other than touch.

Drugs, Sex and HIV Transmission

Studies have found a connection between drug use and HIV transmission. Drugs such as crack, crystal meth, alcohol and others can increase sexual desire and/or impact a person's sexual behavior in ways that can lead to unsafe sex. Drug use can potentially impair a person's judgment and reduce inhibitions, potentially leading to more risky behavior. Unprotected sex may also occur when sexual favors are exchanged for money to buy drugs like crack or crystal meth.
Smoking crack or crystal meth may also be a co-factor in transmission of HIV because it can cause severe burns or cuts on the mouth and lips. These cuts or burns can serve as a transmission site for HIV or other blood-borne infections during oral sex or when sharing pipes used for smoking crack.

How Safe Is Oral Sex?

Have People been infected with HIV through oral sex?
· The San Francisco Department of Public Health has recorded at least three
cases of men who have become infected with HIV through oral sex. This isn't
very many, considering how many men have oral sex. Other cases have been
reported elsewhere.
· Unprotected oral sex is certainly much safer than unprotected anal or vaginal
sex. The lining of the mouth is much tougher and less permeable than the
lining of the vagina or anus. Saliva may neutralize the virus. It's easier to get
semen out of your mouth than a vagina or anus.
· Receptive oral sex - sucking dick, or going down on someone - is certainly
riskier than having someone suck or go down on you.
· HIV is in pre-cum, as well as in semen. But there's usually less pre-cum than
semen during any one sexual act. It's unlikely that pre-cum by itself can
transmit HIV, but it's possible.
· The length and intensity of the sexual act may affect transmission. If his dick is
pounding against the back of your throat, your tissues may become irritated,
becoming more permeable and increasing the likelihood of infection.
· The presence of other sexually transmitted diseases (STD's) can increase the
likelihood of transmission through providing easier ways for the virus to
enter the body. If you have had unprotected oral sex and you have a sore
throat or a dry cough, get tested for oral gonorrhea and strep. If you have
sores, discharge, or burning when you pee go to your doctor or STD clinic.
· Some people are more susceptible to infections than others. Some people
have better oral hygiene than others. Bleeding gums, sores in the mouth, and
abscessed teeth may increase the likelihood of transmission. HIV-positive
men and women may be more or less capable of infecting others, depending
on how long they've been infected themselves.


What can I do make oral sex safer?
• Avoid coming in someone's mouth. Or having them come in yours.
Remember, even with pre-cum there's still some risk. "Swallow or spit, don't
let it sit."
• You can also avoid sucking the tip of the penis, concentrating on the shaft
instead. Place non-lubed condom inside out like a little cap over the head of
the penis.
• Oral-vaginal sex (cunnilingus) with someone of unknown HIV status is also
relatively low risk. The risk of infection with STD's is higher if there is
menstrual blood or an unusual vaginal discharge. Make your partner a Saran
Wrap panty or use a latex dental dam with a harness for even safer oral sex.
• If you see something suspicious - a sore or a discharge on someone's penis or
a funny odor or or sores on the vulva, avoid going down on it.
• Know your STD status and don't put yourself or others at unnecessary risk.
Get checked for STDs including gonorrhea, herpes, and syphilis.
• Consider using condoms for oral sex. Try Kimono Micro Thins, Lifestyles
"Kiss of Mint," or Trustex condoms which have flavored lubricants (available
in many flavors). And don't knock it until you've tried it. Condoms without
spermicide taste a lot better.
• Avoid deep throating. It can irritate the tissue at the back of the throat, and
possibly provide a more efficient route for HIV to enter the body. Floss and
brush regularly - but not right before you have oral sex. If you want to freshen
up your breath before kissing your partner, try mouthwash. Schedule a dental
check-up too! Above all, make the choice that's right for you. If ten minutes -
or ten hours - after you've had sex, you're anxious