Safer Sex Knowlege Base
Safer Sex Project Table of ContentsDefinition of TermsThere is a theoretical risk of HIV infection from any behavior that study has failed to show resulted in HIV infection, but in which a body fluid which is known to contain HIV comes in contact with a partner's mucous membranes or blood stream. There is a known risk of infection wherever a behavior has been documented to result in HIV transmission by case series or prospective, epidemiological study. There is a low risk of infection when prospective, cohort-style studies have failed to demonstrate a statistically significant relationship between the behavior and infection, but case reports continue to suggest a correlation. There is a high risk of infection when prospective cohort-style study has established a relationship and the risk is deemed substantial by the Subcommittee.
AssumptionsThe primary purpose of a Safer Sex Program is to prevent the sexual transmission of HIV. The major focus of a Safer Sex teaching model must be the infected individual's responsibility to protect others. The corresponding focus for the uninfected must be the individual's responsibility for self-protection, but the client must also be assessed for whether they are at risk of harm (e.g. assault) should they attempt to protect themselves; and, if so, referred to a Social Services professional. A Safer Sex Program will be most useful to the educator and the client if it is simply and succinctly written and provides useful information and advice about the risk of specific sexual behaviors. The array of sexual behaviors reviewed for risk must be comprehensive and not limited as a product of the educator's morality, personal taste or sexual preference. Sexuality is a Quality of Life issue and is not expendable for anyone, including the HIV-infected. A Safer Sex Program must establish standards which the provider and client can use to develop a sexual practice style which provides the client with a personally acceptable sexual experience. Sexual behaviors can be classed as no risk, low risk, and high risk; and theoretical or known based on scientific literature and case studies. Behaviors characterized in the knowledge base as low risk or theoretical present a risk low enough that whether to engage in the behavior should be left to the informed client's individual choice. The relative risks of specific sexual behaviors based on whether the individual is the insertive or receptive partner cannot be addressed if the standards are to remain simple and succinct. The presumption is made therefore that where there is a theoretical or known risk of infection, the risk is always bi-directional.
The Safer Sex needs of the HIV-infected, especially those with CD4+ counts of
less than 200, are different from those of the general population and must be
specially addressed.
After review of the peer-reviewed literature, community-based organization educational materials, case reports and expert presentation and discussion, the Subcommittee acknowledges and concludes: The most important Safer Sex principles are:
The most important teaching principle is: Sexual expression and transmission of HIV in various populations differs substantially along trajectories of age, race, culture and gender[1].
Despite the effective barrier which latex condoms represent, penile|rectal and penile|vaginal transmissions do occur, albeit more rarely, among those persons who practice rectal and vaginal intercourse using barrier precautions9, most likely due to product failure[7].
Penile|rectal intercourse is not confined to male homosexuals but is practiced with substantial frequency by heterosexual couples[8],[9],[10].
Penile|rectal and penile|vaginal transmissions also occur more frequently in the setting of concurrent rectal or vaginal irritation, infection or disease[11],[12],[13],[14],[15]. Genital ulcerative diseases (GUD) such as trichomonas, chlamydia, syphilis, gonorrhea, herpes and condyloma are among the infections which predict a substantially increased risk of transmission. Localized irritation caused by chemical irritants (e.g. lubricants containing high concentrations of nonoxynol-9) may also increase the likelihood of infection should barriers fail[16].
Infection of intact epithelial mucosal cells has been demonstrated in vitro; these cells may serve as the primary site of infection[17].
Preparatory rectal douching or enema increases the likelihood of infection should barrier precautions fail8,[18],[19].
A higher rate of tampon use was noted among infected wives as compared with uninfected wives of HIV infected hemophiliacs[20]. Tampon use, especially "superabsorbant" tampon use, has been shown to result in dryness, desquamation and other cellular abnormalities which may increase the likelihood of infection[21]. In one study the older wives of infected men were more likely to become infected than younger women[22]; this finding may reflect aging-related changes in vaginal mucosa that result in greater tissue fragility.
Oral|oral transmission by deep kissing is theoretically possible7, 8, 9, 23. Oral secretions have been demonstrated to contain HIV[23]. Oral secretions have been demonstrated to inactivate HIV in vitro[24],[25].
Penile|oral transmission by fellatio is theoretically possible and the case for its occurrence is stronger than that for kissing since the amount of virus is markedly greater in ejaculate than in oral fluids[26],[27],[28]. Oral transmission from fellatio with ejaculate has been the subject of controversial case reports detailing suspected transmission in seven men33,[29],[30],[31],[32],[33]. The reliability of sexual behavior histories taken from clients under circumstances of assessment for route of HIV exposure has been questioned by some authors9,[34]. One important question is whether a newly infected client may find it so difficult to admit to non-barrier protected intercourse (a community censored behavior) when confronted by the health care worker that the client would mislead the interviewer as part of a pattern of coping with guilt and difficult feelings. All studies reviewed reported substantial cohorts of persons continuing to engage in penile|oral behaviors, and who deny engaging in vaginal or rectal intercourse, who remain persistently seronegative7, 8, 9, 23,[35]. There is a theoretical risk associated with non-barrier protected fellatio from virus in pre-ejaculate since pre-ejaculate contains lymphocytes17.
Vaginal|oral transmission by cunnilingus is theoretically possible. The presence of virus in vaginal fluids has been demonstrated[36],[37],[38].
Vaginal|vaginal transmission by tribadism is theoretically possible. The presence of virus in vaginal fluids has been demonstrated41, 42, 43. The ability of HIV to infect intact mucosal cells has been demonstrated in vitro22.
Anal|oral transmission during anilingus is theoretically possible since anal secretions and fecal matter may contain lymphocytes. Anal|oral transmission is the mode of infection for other pathogens associated with substantial morbidity.
Fecal|oral transmission during coprolagnia is theoretically possible since anal secretions and fecal matter may contain lymphocytes. Fecal|oral transmission is the mode of infection for other pathogens associated with substantial morbidity.
Urino|oral transmission during urolagnia, in particular immediately following ejaculation while ejaculate is still in the urethra, is theoretically possible. Virus has been recovered from urine[39].
Brachio|vaginal and brachio|rectal transmission during brachio-rectal and brachio-vaginal contact is theoretically possible and brachio-rectal contact was found to be a significant transmission mode by multivarate analysis in two studies24,[40].
Breast milk has been demonstrated to contain virus[41]. Breast milk has been demonstrated to infect infants[42].
HIV infection requires contact of bodily fluids with mucous membranes or blood stream[43],[44].
There is a theoretical risk of infection during piercing, tattooing and scarification if infected bodily fluids contact disrupted skin surfaces.
There is a theoretical risk of cross-infection from sexual appliances since they may harbor traces of infected bodily fluids.
Latex condoms are an effective barrier against HIV[45]. Heat, pressure and age degrade latex condoms and lead to product failure[46]. Condoms made from biologic products (e.g. lamb parenchyma) leak virus[47]. Latex condoms may rupture when roughly handled or handled with fingernails[48],[49]. The polyurethane women's condom is impermeable to HIV[50].
Petroleum- and mineral oil-based lubricants degrade latex and cause condom rupture[51]. The wording "water-based" has been confused by some consumers to mean "washes away easily with water" leading to inappropriate product choice and condom rupture12.
Nonoxynol-9 (N-9) is an effective viricidal when used in conjunction with a latex condom[52],[53],[54],[55], but may cause mucosal irritation17. The failure of N-9 to prevent HIV transmission when used without barrier precautions has been documented17. Clinical consensus suggests N-9 concentrations for inactivation of HIV need not exceed 5%. Clinical consensus favors discontinuing a N-9 lubricant should irritation occur. The consensus feeling is that the processes of local irritation will result in a greater risk of infection than that the risk of using a lubricant which does not contain N-9.
Reduction in inhibition control is associated with unsafe sexual behaviors[56].
To further decrease the possibility of infection the client should be advised to decrease their number of sexual partners. The Subcommittee offers two behavioral definitions of this advice; which to use might be based on a variety of individual factors including the client's willingness and ability to alter personal sexual behavior:
HIV-infected persons with less than 200 CD4+ lymphocytes are at substantially greater risk of infection with opportunistic organisms[57]. Clinical consensus in the group was that enteric infections are more difficult to treat and more debilitating in the HIV-infected individual regardless of CD4+ count.
A number of authorities have concluded that disclosure of HIV infection status to a new sexual partner should occur prior to sexual conduct[58],[59]. The Subcommittee endorses two strategies for providing potential partners of HIV- infected persons with information prior to potential risk: The HIV-infected individual should be advised to inform every potential partner of their infection prior to sexual contact.
The HIV-infected individual should be encouraged to participate in
community-based social programming for HIV-infected persons where all
attending are known to be infected.
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[57].Yarchoan, R. and others. CD4 count and risk for death in patients infected with HIV receiving antiretroviral therapy. AIM, 115:184-189. August 1991. [58].Goedert, J.J. What is safe sex? NEJM, 316(21):1339-1342. May 21, 1987. [59].Wofsy, C. B. Prevention of HIV transmission. Infectious Disease Clinics of NorthAmerica 3:307-319, June 1988. The plain text version of this document is available from the NIAID Gopher at gopher://gopher.niaid.nih.gov/00/aids/nursing/nurs-edu/Safer+Sex+Knowledge+Base+3-94 or by using your gopher client to go to gopher.niaid.nih.gov and selecting
6. AIDS Related Information/
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