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Reducing the Risk of Getting HIV From Sexual Activities

August 25, 2008

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 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.



  
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This article was provided by San Francisco AIDS Foundation. It is a part of the publication AIDS 101. Visit San Francisco AIDS Foundation's Web site to find out more about their activities, publications and services.
 
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