Risky Business

Whether they like it or not, people with HIV all too frequently find themselves having to educate others about how HIV is -- and is not -- spread. That's not really fair, but that's the reality of things. Several years ago on MTV's The Real World, HIV-positive cast member Pedro Zamora protested when his housemate Rachel asked him to reassure her that she was not at risk of exposure to HIV because they shared a bathroom. Pedro told her that it wasn't his job to reassure her. If she had doubts or fears, he said, she should educate herself. He was right, of course. But living with people inevitably involves compromises, and in the end Pedro did undertake the task of educating Rachel and the rest of his housemates.

Like Pedro, people with HIV often find themselves cast in the role of educator. This is particularly true in the case of HIV-positive individuals and their sexual partners. The minute someone reveals that he or she has HIV, that person's prospective sexual partner must confront the very real fear that sexual contact could lead to infection. This fear -- which may have been little more than an abstract concern up to that point -- is now a reality, and it must be addressed.

Fear that sexual relations with an HIV-positive person will result in infection of the HIV-negative partner are reasonable, legitimate, and entirely understandable. After all, the vast majority of all HIV infections were transmitted sexually. But the fact that someone has HIV should not be a barrier to sexual relations, so long as those activities are undertaken with a barrier -- in the form of a brand-new latex or polyurethane condom.

It is important to recognize that fears can exist on both sides of the relationship, and prospective sexual partners need to talk, openly and candidly, about those fears. The fact that HIV-negative partners fear potential infection is obvious. What may not be as obvious is that HIV-positive partners fear spreading the virus, and they may also fear catching diseases that will further strain their depleted immune systems. In situations where both partners are positive, there is the fear of exchanging different strains of HIV and of passing along other infections.

Overcoming all of these fears can only be accomplished through open communication. The fears need to be voiced, and the risks of various sexual activities need to be assessed, with the partners working together so that they can arrive at a level of security that each can be comfortable with. To do that, both need accurate information on the risk of HIV transmission that is associated with various sexual practices.

"People living with HIV must behave responsibly with each and every one of their sexual partners, each and every time they have sex -- even when a partner does not insist on safety. And all sexually active teenagers and adults must learn to treat each and every one of their sexual partners as a potential source of HIV infection -- even when that partner insists that he or she is HIV negative."

How safe are condoms?

The first subject that needs to be considered is how reliable condoms are in preventing the spread of HIV. Since it first became apparent that HIV could be transmitted during sex -- and that the consistent use of latex condoms prevented transmission -- the media have aired a number of alarmist reports about the failure rate of condoms. The truth is, however, that condoms are virtually 100% effective in blocking HIV transmission -- when they are used correctly.

Although condom failure rates are 3% to 12% when used to prevent pregnancy, these same numbers cannot be applied to the use of condoms in HIV prevention. The risk of HIV transmission due to condom failure is much lower than the risk of a woman becoming pregnant due to condom failure . This is because the chance that HIV will be transmitted during a single unprotected sexual act is much lower -- ranging from 1 chance in 500 for vaginal sex to 3 chances in 100 for anal sex -- than the risk that a single act of unprotected vaginal sex will lead to pregnancy.

In a study of straight couples in which one partner was HIV positive and one was not, none of the HIV-negative partners became infected among the 24 couples who consistently used condoms. But 6 of the 44 HIV-negative women in couples where condoms were used inconsistently became HIV-positive during the study. Another study of condom use among such couples found that none of the 124 negative partners in the couples that consistently used condoms became positive, compared to 12 infections among 121 partners who did not use condoms. This study involved thousands of sexual contacts, yet not a single infection occurred in the group that used condoms consistently.

The use of a spermacide can make sex with condoms even safer. Laboratory studies have shown that one spermacide, nonoxynol-9, effectively kills all of the HIV that is present in a condom. Even condoms that have not been treated with nonoxynol-9 do not permit the passage of HIV unless they break -- a failure that occurs less than 1% of the time with proper use (see the PULL OUT AND SAVE feature of this issue, "Where the Rubber Meets the Road").

Once prospective sexual partners have reassured themselves about the reliability of condoms, they will want to discuss the relative risk of HIV transmission that is associated with various sexual activities.

Risks of specific sexual behaviors

For the receptive partner -- that is, the one into whom the penis is inserted -- unprotected anal sex with ejaculation poses enormous risk of infection. Indeed, this form of unprotected sex is by far the most dangerous of all forms of sexual activity. Estimates of the risk of infection for each act of anal sex range from 1 in 200 to 3 out of 100. These may seem like long odds, but some 60% of the 1.5 million Americans who are HIV-positive got infected in this way.

Even without ejaculation, anal sex is considered highly risky, because HIV is present in the seminal fluid known as pre-cum, which is produced just prior to ejaculation. Anal sex is not as risky for the partner inserting his penis, but there are reported cases of HIV where this was the mode of infection, and so insertive anal intercourse without a condom should also be considered highly risky.

During unprotected vaginal sex, HIV can be transmitted from either partner to the other. Transmission from the woman to the man is less likely than from man to woman, but if the woman is having her period this may increase the risk that her partner will be infected. Estimates of the risk of infection through unprotected vaginal sex vary widely, ranging from 1 in 500 to 1 in 5,000,000.

Unprotected oral sex (giving or receiving head) can also result in the transmission of HIV. Here again, the risks are different for the person performing oral sex than they are for the one receiving it. A man or woman who performs oral sex on a man is generally at higher risk than the man who is receiving the oral sex, but cases of HIV transmission to the receptive partner have been recorded.

Performing oral sex (cunnilingus) on a woman has also been shown to spread HIV, but there have been no proven cases of a woman getting HIV from receiving oral sex. It is generally thought that transmission of HIV is at least ten times less likely to happen during oral sex than during vaginal or anal sex.

Open-mouthed kissing leads to contact with saliva. Although HIV has been found in saliva, the amount of virus present is known to be extremely low. There is no evidence of anyone being infected with HIV through kissing. Several studies have examined the possibility of HIV transmission through human bites. Estimates of the risk of infection from a bite range from 1 chance in 250 to 1 in 1,000. Several cases of transmission following a bite by an HIV-infected person have been reported, but in all but one of these cases other risk factors were present.

The insertion of fingers or the fist into the anus or vagina does not generally involve any exchange of body fluids, and therefore these activities are highly unlikely to lead to HIV infection. If the skin of the inserted finger or hand has cuts or abrasions, however, there is at least a theoretical risk of HIV transmission from one partner to the other.

A much more real risk is that if fingering or fisting is not done with care (and sufficient lubrication), it may cause cuts or tears in the lining of the vagina or rectum -- and these microscopic injuries may increase the risk of HIV transmission during later sex play. Even so, there are no recorded cases of HIV infection attributed to fingering or fisting.

"It is possible for people with HIV to have sexual relations that are stimulating and gratifying -- all while keeping the risk of transmission to a minimum. But people who are HIV-positive, and the sexual partners of these individuals, must recognize that virtually all forms of direct sexual contact carry some risk of infection, however remote. And in the end it is up to both partners to negotiate the degree of risk that they are willing to assume in order to attain the degree of stimulation and gratification they need."

Similarly, there is no evidence that the use of sex toys such as dildoes or butt-plugs poses a risk, unless the sex toy is shared by partners without first being properly disinfected. In that case, semen, blood, or vaginal juices from one partner may come into contact with the mouth, vagina, or anus of another, and HIV transmission is possible. Like fingers and hands, sex toys used roughly or without enough lubrication can damage the vaginal or anal linings, causing increased risk in later sex play. Sadomasochistic (S&M) play that involves piercing skin or that causes bleeding may also carry some risk, but to date no one has been infected through these activities.

Although there have been no reported cases of HIV infection through unprotected oral-anal contact (rimming), many microbes are transmitted by this route. The ingestion of these microbes can lead to any number of infections -- among them giardia, hepatitis, cryptosporidiosis, and amoebas -- that can be life-threatening in people with weakened immune systems. For this reason, it is wise for a person with HIV to use a barrier -- a dental dam, a condom split up the middle and spread open, even a double-layer of plastic wrap -- during contact with a sex partner's anus.

Mutual masturbation is considered a safe sexual activity. In theory, if semen, blood, or vaginal juices from an HIV-positive person came into contact with a cut, tear, or other break in the skin of an HIV-negative sex partner, transmission could occur. In practice, however, there have been no reported cases of HIV transmission attributed to mutual masturbation.

People living with HIV must behave responsibly with each and every one of their sexual partners, each and every time they have sex -- even when a partner does not insist on safety. And all sexually active people must learn to treat each and every one of their sexual partners as a potential source of HIV infection -- even when that partner insists that he or she is HIV negative. Both partners must clearly understand the risks of various activities, must respect one another's limits, and must clearly communicate these limits.

It is possible for people with HIV to have sexual relations that are stimulating and gratifying, emotionally saturated and erotically charged -- all while keeping the risk of transmission to a minimum. But people who are HIV-positive, and the sexual partners of these individuals, must recognize that there is a difference between minimal risk and no risk. Virtually all forms of direct sexual contact carry some risk of infection, however tiny, however remote. And in the end it is up to both partners to negotiate the degree of risk that they are willing to assume in order to attain the degree of stimulation and gratification they need.

The New Reality

Condoms for women: another way of preventing the transmission of HIV infection In 1975 a team of researchers surveyed 486 women at a private college, asking them -- as part of an a nonymous questionnaire -- how often the men they had sex with used condoms. Only 11% of those who answered said that their partners used condoms "always or almost always." Follow-up surveys, conducted at the same college in 1986 and 1989, found that the use of condoms "always or almost always" doubled with each survey: to 21% in 1986, and to 41% three years later. The most recent survey, conducted in 1995, revealed that condom use has doubled again: 87% of respondents reported that their male partners used condoms always or almost always. The participants in these serial surveys were all women, and they were being asked how often their male partners used condoms. But in the next edition of the survey women may be asked how often they use condoms -- because a condom for women is now available.

Made of strong but lightweight polyurethane, the device -- marketed by Wisconsin Pharmaceuticals as the Reality(R) Female Condom -- can be inserted into the vagina up to eight hours before sex (see the PULL OUT AND SAVE feature of this issue, "Where the Rubber Meets the Road"). This advantage, and the fact that this new condom gives women much more control over condom use during sex, may make the female condom an appealing alternative to the traditional male condom. The price difference -- female condoms cost roughly four times as much as male condoms -- may be offset by the protection against HIV and other sexually transmitted diseases that regular use will give. Used correctly, the female condom should fail no more than 5% of the time, according to the F.D.A. -- a rate consistent with that for male condoms. A study taken among women who have used the female condom found that 73% preferred it to the male condom. Half of those questioned reported that their partners also preferred the device.

Joshua Schechtel, M.D., is from the Center for AIDS Prevention Studies, San Francisco, CA.