Estimating precise per-act risk is difficult because so few people practice oral sex to the exclusion of other, higher-risk sexual activities. Based on the scientific evidence discussed in this chapter, Table 2 classifies sexual practices by their level of risk for HIV transmission. Receptive oral-penile sex carries the risk of pharyngeal gonorrheal infection for both men and women, and insertive oral-penile sex, although carrying only extremely low, hypothetical risk of HIV infection to the insertive partner, carries a demonstrable risk of urethral gonorrheal infection. Nonoxynol-9 N-9 , a detergentlike molecule once thought to be a leading candidate in the search for vaginal microbicides against HIV, is no longer recommended. Permeability to Viruses Several laboratory experiments were conducted to test the ability of latex condoms to provide an effective physical barrier against HIV. Decisions About Partner Selection Sexual contact with many persons increases the probability of coming in contact with an HIV-infected partner. Women in some developing countries may be more infectious due to higher prevalence of sexually transmitted infections STIs and untreated HIV disease, although the authors state that evidence for the relative importance of these factors is unclear. Not everyone will open a discussion about safer sex with a health care provider. Decisions About Sexual Activity Because sexual contact is the major transmission route for HIV infection, eliminating sexual contact eliminates risk of transmission by this route.
Studies of latex condom performance during human use reported breakage and slippage rates varying from 1. It is important to keep in mind that safety and efficacy have not been demonstrated in anal use, and that female condoms are neither recommended nor approved for this purpose. In addition, no report has documented cases of HIV transmission by these fluids. Nonoxynol-9 N-9 , a detergentlike molecule once thought to be a leading candidate in the search for vaginal microbicides against HIV, is no longer recommended. In a large multicenter cohort study of MSM, the investigators devised a composite variable called "rectal trauma," composed of enema usage, receptive fisting, report of blood around the rectum, and evidence of scarring, fissure, or fistula on examination. In addition, laboratory evidence suggests that improper use of latex condoms eg, applying an oil-based lubricant can make condoms more susceptible to breakage. Although the FDA eventually determined that the polyurethane condom was safe for consumer use in , 96 six epidemiologic studies have since addressed this question. Given their much higher per-unit costs versus male condoms, this question is particularly relevant for women in resource-poor environments. Hence, saliva, tears, and urine are highly unlikely sources of HIV transmission. Oral-genital sex, both oral-penile and oral-vaginal, can transmit STIs other than HIV with varying degrees of efficiency. Thus, one risk-reducing strategy to consider is a reduction in the number of sexual partners, but this in no way reduces the risk of infection by sexual contact with even a single partner who is HIV positive. Although these are low probabilities, the authors suggest that oral-penile sex may play a larger role in the epidemic among MSM as more men adopt these behaviors as risk reduction measures. Others may be too embarrassed to open the discussion. Latex condoms are impermeable to HSV 79,80 and hepatitis B virus. Insertive oral-penile sex is an efficient route for the transmission of herpes simplex virus HSV. Condoms can fail to provide complete protection for a variety of reasons, including failure to use them consistently, failure to use them properly, condom breakage, and condom slippage. Proper use of barrier methods can reduce the risk of transmission associated with many of these practices. Decisions About Specific Sexual Practices Evidence shows that some sexual practices are associated with a greater risk of HIV transmission than others. No leakage of HIV across latex condoms was demonstrable. In addition, condom breakage or failure may occur. Condoms were tested by placing a solution containing HIV inside the condoms, and culture medium free of HIV outside the condoms. Transmission of HIV to the receptive partner probably occurs as a result of the deposition of HIV-infected semen on traumatized rectal mucosa. Only one study was able to do this 68 ; another examined monogamous serodiscordant couples whose only unprotected sexual activity was oral sex. In general, it was asserted that polyurethane condoms were more prone to breakage and slippage, and this delayed the approval by the U. Nonetheless, it is an important option to consider, as some persons may feel that at least limited periods of abstinence may be the best choice under certain circumstances. It is therefore important in high-prevalence settings to continue to encourage risk reduction behaviors that include both safer sex practices and HIV testing.
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