Dr. Robert Grant "Person of the Year"

via Time, by Alice Park

Dr. Robert Grant has been a quietly powerful force in HIV research for years. In the early 2000s it was Grant, a professor of medicine at University of California, San Francisco, and Gladstone Institute of Virology and Immunology, who pushed to test the potential of antiviral drugs — normally used to treat people who already have HIV — as a way to protect healthy, uninfected people from acquiring the virus. His first study of the medications in gay men wasn't popular — why test the drugs in healthy people when millions of HIV-positive patients didn't even have access to the medications? — but proved successful, lowering new infection rates among men taking the antivirals prophylactically.

But it wasn't until 2011 that Grant's true influence on the battle against AIDS finally emerged. His initial research set the stage for further studies of the treatment-as-prevention strategy in other populations. This year a groundbreaking study found that treating the uninfected partner in heterosexual couples — in which one person had HIV and the other did not — dramatically reduced the risk of transmission. Another study found that giving antiviral drugs to heterosexual men and women also cut their risk of infection. The findings are crucial, since it is the heterosexual population that currently bear the heaviest burden of new HIV infections around the world. With hopes for a vaccine continually receding and safe-sex campaigns of limited value, Grant's idea (along with other emerging prevention strategies, like male circumcision) has the potential to halt the AIDS epidemic by stopping infections from occurring in the first place.
 
 
[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

PrEP Media Round-Up - It Works for Heterosexuals Too!

[UPDATED JULY 18]

The exciting news was announced last week that pre-exposure prophylaxis has been shown to work for heterosexual men and women as well as MSM. This is HUGE for HIV prevention.

Below is a selection of news items and press releases we have collected on the two studies that reported out last week. In the comments feel free to share your reactions to this news.

Washington Post: Two studies show that drugs used to treat AIDS can be used to prevent HIV infection, too

EurekAlert (Microbicide Trials Network): VOICE study will continue as it considers what action to take after results of 2 trials

CDC: CDC Trial and Another Major Study Find PrEP Can Reduce Risk of HIV Infection among Heterosexuals

iPrEX News: Two Major Studies Prove HIV Pre-Exposure Prophylaxis (PrEP) Works in Heterosexual Women and Men; Build on iPrEx Data Showing PrEP Reduces HIV Infections in Men Who Have Sex with Men

Wall Street Journal: AIDS Drugs Can Prevent Infection, Studies Show

AIDSMAP: Two major studies show that HIV drugs prevent infection

New Vision: Drugs prevent HIV infection up to 73%

Science Now: Anti-HIV Pills Show Powerful Effect Against AIDS

Reuters: 2-Once-daily AIDS pill can slash HIV infection risk

POZ: PrEP Reduces HIV Risk in Two Major Studies

PlusNews: HIV/AIDS: More proof that PrEP works

New Scientist: One cheap pill protects healthy people from HIV

The Daily Nation: Daily dose of drug ‘lowers risk of HIV infection’

Fit Perez: New Pill Could Prevent HIV

Project Inform: Project Inform urges government action following the positive results of two PrEP studies in heterosexual men and women

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Two studies show that drugs used to treat AIDS can be used to prevent HIV infection, too

[THIS IS HUGE!]

via Washington Post, by David Brown

Two new studies done in three African countries have shown for the first time that AIDS drugs taken daily can cut by more than half a person’s chance of becoming infected with HIV through heterosexual intercourse.

The results, announced early Wednesday, provide more evidence that the drugs responsible for saving the lives of millions of HIV-infected people over the last 15 years may also be the most useful tool for preventing new infections.

Read the rest.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

NEWS ROUNDUP: Early HIV Treatment Can Reduce Transmission Risk By 96%, Study Results Show

via Kaiser Family Foundation


Results from a multicountry clinical trial, sponsored by the National Institute for Allergy and Infectious Diseases (NIAID), show that HIV-positive people who take combination antiretroviral therapy (ART) can reduce the risk of transmitting the virus to their HIV-negative partners by 96 percent, U.S. researchers announced on Thursday "[i]n what is being hailed as a breakthrough in HIV prevention," the Los Angeles Times reports (Maugh, 5/13).

The randomized controlled trial, run by the HIV Prevention Trials Network and named HPTN 052, was meant to run another four years, but an interim analysis by an independent monitoring group prompted NIAID to halt the trial and release the results, ScienceInsider writes. The study, conducted since 2005 at 13 sites in nine countries, recruited 1,763 couples, 97 percent of whom were heterosexual, in which one partner was HIV-positive at enrollment. None of the HIV-positive partners had taken ART, and their CD4 cell counts, a measure of the immune system's health, were between 350 to 550. "Half the participants received immediate treatment, and the other half did not start [therapy] until their CD4 count dropped to 250 or they developed an AIDS-related symptom, according to ScienceInsider (Cohen, 5/12).

Analysis "identified 39 new cases of HIV among the previously uninfected partners. In 28 of these cases, genetic analysis confirmed that one partner had infected the other. Of these 28 infections, 27 – or 96 percent – occurred among couples in which the HIV-infected partner did not start antiretroviral therapy immediately," HealthDay/U.S. News reports (Reinberg, 5/12). The couples were all counseled on safe sex practices, given free condoms and provided treatment for sexually transmitted infections, BBC News adds (Gallagher, 5/12).

"This new finding convincingly demonstrates that treating the infected individual – and doing so sooner rather than later – can have a major impact on reducing HIV transmission," NIAID Director Anthony Fauci said in a statement (5/12).

The New York Times notes that though the trial was "relatively large," there are limitations to interpreting the results for other populations, like men who have sex with men, because nearly all "of the couples in the trial, who lived in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States and Zimbabwe, were heterosexual" (McNeil, 5/12).

Treating HIV-positive participants early also improved other health outcomes, the Los Angeles Times reports, noting that the results showed 17 cases of disseminated tuberculosis (TB) among those whose treatment was deferred compared with three cases among the treatment group (5/13). According to Bloomberg News, researchers will continue to monitor study participants to determine whether treatment benefits persist (Cortez/Bennett, 5/13).

Treatment As Prevention

"Until now, antiretroviral therapy was known to improve the health of people infected with human immunodeficiency virus, but this is the first study to show a solid impact on preventing transmission to an HIV-negative partner," Agence France-Presse reports (Sheridan, 5/12).

Though the preliminary results "are likely to end, or at least diminish, a bitter feud within the AIDS world over how much funding should go to treatment versus prevention," funding "will be a major obstacle," the Wall Street Journal writes. With more than five million HIV-positive people on treatment at the end of 2009, and another 10 million in need of the drugs based on international treatment guidelines, UNAIDS has estimated a treatment funding shortfall of more than $7.5 billion, the Wall Street Journal notes (Schoofs/McKay, 5/12).

Observational studies have shown a benefit to early HIV treatment, leading UNAIDS last year to adopt "as its goal" a "test and treat" policy that "encourages doctors to start people on treatment as soon as they test positive for HIV," the New York Times states. Still, "[f]or lack of money, clinics in Africa are turning away patients who are not just infected but close to death. And in some American states where money provided by the Ryan White Care Act has run out, poor uninsured people are on waiting lists," the newspaper adds (5/12).

UNAIDS Executive Director Michel Sidibe said, "This breakthrough is a serious game changer and will drive the prevention revolution forward. It makes HIV treatment a new priority prevention option," adding, "Now we need to make sure that couples have the option to choose treatment for prevention and have access to it," according to Reuters (Steenhuysen, 5/12). Sidibe said "he hopes the new results will compel pharmaceutical companies to lower the price of ARVs as the demand for the drugs expands," that "new partnerships will form to advocate for increased funding and that the findings will be prominently discussed next month at the United Nations High Level Meeting on AIDS in New York City," ScienceInsider reports (5/12).


[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Amount of HIV in Genital Fluid Linked to Transmission

Via Health News, by Randy Dotinga

In a development that could enhance HIV-prevention research, a new study of heterosexual couples confirms that the risk of transmitting HIV rises with the level of the virus in semen and cervical fluid.

The finding, that more virus translates to higher likelihood of transmission, hasn't been proven to this extent before, said study lead author Dr. Jared M. Baeten of the University of Washington in Seattle.

"This confirms what we had thought about the biology of HIV," he said, "and it gives us new information about genital levels of HIV being particularly important, even independent of blood levels."

For the study, researchers obtained samples of genital fluid from 2,521 heterosexual couples living in seven African countries. Most were married and living together. At the start of the two-year study, one partner in each couple was infected with HIV, the AIDS-causing virus, and none was taking anti-HIV drugs.

Over the course of the study, published April 6 in the journal Science Translational Medicine, 78 partners became infected within the relationship.

The researchers compared cervical and semen fluid samples from partners who transmitted the virus with samples from men and women who didn't transmit the virus and found that the risk of HIV transmission approximately doubled with each specified HIV increase in genital fluids.

This can help researchers better understand "the natural protections that the penis, the vagina and the rectum have that we want to make sure we preserve," he said. The study "is highlighting what we need to look at going forward," he added.

Read the rest

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Bringing Up The Rear

Via salon.com, by Tracy Clark-Flory

It's no secret that more Americans are having anal sex than ever before: A study published last year in the Journal of Sexual Medicine found that more than 45 percent of women in their late 20s had tried anal sex.

On the flip side, women rarely get the opportunity to be penetrators. Virginia Vitzthum exquisitely described the appeal of taking on the male role in a piece for Salon back in 1999 -- before we even called it "pegging"

"In a way I'd never understood those words before, he was mine. The knowledge I could really hurt this person by being less than careful made me feel responsible, protective. The vulnerability appalled me at the same time; it was vaguely disgusting that he would let someone do this to him. Mixed in with the disgust was possessiveness. The thought of anyone else penetrating him seemed revolting. These observations clicked into place in quick succession; I felt like a projector being loaded with slides of maleness, of male seeing."

But, taboos change, and so do the cultural meanings of particular sexual acts. Just as the gay community has long debated the politics of being a top or a bottom, the hetero world is slowly catching up -or, um, bringing up the rear. As Pulley puts it, "We only have so many orifices. You'd think we'd all be itching to take advantage of them all, right?"

Read the rest

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Is Africa ready for PrEP?

Via Incidence0.org, by Adebisi Ademola Alimi

One of the biggest breakthrough in HIV clinical research, since the outbreak of the epidemic 30 years ago, is the recent success in a clinical trial of a new HIV prevention approach based on the daily use of the antiretroviral drug Truvada by HIV negative person to prevent HIV transmission (Called PrEP, for Pre-Exposure Prophylaxis).

The results of the iPrEX trial raised hope but also many questions and concerns as showed by the ensuing debate about what the next step should be. Divergences culminated with the Aids Health Foundation (AHF) petitioning the FDA not to consider Gilead’s request for a licence to use Truvada for the prevention of HIV infection and a joint counter response by a number of HIV advocacy organisations.

But for me as an advocate and an African living in Europe, the most important thing on my mind is “Will Africa be able to access PrEP?” Providing ARV to HIV negative people in Africa needs to be considered in light of the challenge of accessing treatment in Africa, where more than 50% of HIV positive people in the world live (UNAIDS report).

Even if PrEP drugs become available, what are the mechanisms in place to ensure that it will not be tribalized in a continent where there are some indications that access to ARVs is based on political and ethnical loyalty and where there are evidences of bribery at the delivery point, misused of funds and a non-negligible ARVs black market leading to ARVs being dispensed to increasing numbers of patients at the periphery of the health system. One has to be skeptical about the PrEP implementation process in this context.

Read the full article

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

CROI 2011: Rectal Microbicides to Prevent HIV Infection in Heterosexual Populations in High-prevalence Settings

Poster from CROI 2011

Dobromir Dimitrov*1, M-C Boily2, S Abdool Karim3, and B Mâsse1,4
Fred Hutchinson Cancer Res Ctr, Seattle, WA, US; 2Imperial Coll London, UK; 3Univ of KwaZulu-Natal, Durban, South Africa; and 4Univ of Montreal, Canada


Background:
The role of anal intercourse in the overall heterosexual HIV epidemic remains unclear. However, it may be an important risk factor because the considerably higher risk of HIV infection during unprotected receptive anal intercourse compared to vaginal intercourse. Anal intercourse is widely practiced by heterosexuals in many countries; in Tanzania, 6% of sexually active school pupils reported anal intercourse at their first sexual experience. In Cape Town, 10 to 14% of the study participants reported engaging in anal intercourse over the last 3 months. Different mathematical modeling studies have assessed the potential impact of a vaginal microbicide in heterosexual populations and of a rectal microbicide for homosexuals. However, none have assessed the potential impact of a rectal microbicide in heterosexual population. Our study aims to compare the potential impact of rectal, vaginal, and bi-compartment (i.e. applied vaginally and protective during vaginal and anal intercourse) microbicides to prevent HIV acquisition and transmission in heterosexual populations.

Methods:
Risk equations were used to determine under which conditions a rectal microbicide could be as useful as a vaginal microbicide. A transmission dynamic model was used to assess the population-level impact of the different microbicides in a variety of intervention scenarios and high HIV prevalence settings and to predict the fractions of new HIV infections prevented over fixed time periods.

Results:
Without anal intercourse, a 50% efficacious vaginal microbicide used by 100% of females prevents about 10% and 25% of all new male and female HIV infections over 10 years if adherence is 30% and 75%, respectively. These 10-year infection preventions are reduced by 32% in populations with 10% frequency of receptive anal intercourse, assuming 4-fold increase in transmission risk per receptive anal intercourse (RRRAI). A rectal microbicide could be as effective as a vaginal microbicide in populations with anal intercourse rates ranging from 5% to 20% across a range on RRRAI, assuming similar efficacy and frequency of use of both products. A rectal microbicide has less impact than a vaginal microbicide in populations with <5% anal intercourse, unless it is used more often or is more efficacious than a vaginal microbicide. The 10-year infections prevented of bi-compartment microbicide is 2-fold larger than vaginal microbicide in populations with 10% anal intercourse if RRRAI = 10- and ~6-fold larger than rectal microbicide, in populations with 5% anal intercourse if RRRAI = 4.

Conclusions:
Both rectal microbicide and bi-compartmental microbicide are necessary prevention tools for heterosexual populations engaging, relatively frequently (~10% of sex acts), in anal intercourse.


[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

HIV Transmission Risk Through Anal Intercourse: systematic review, meta-analysis and

Via International Journal of Epidemiology by Rebecca F Baggaley, Richard G White, and Marie-Claude Boily

Background
The human immunodeficiency virus (HIV) infectiousness of anal intercourse (AI) has not been systematically reviewed, despite its role driving HIV epidemics among men who have sex with men (MSM) and its potential contribution to heterosexual spread. We assessed the per-act and per-partner HIV transmission risk from AI exposure for heterosexuals and MSM and its implications for HIV prevention.

Methods
Systematic review and meta-analysis of the literature on HIV-1 infectiousness through AI was conducted. PubMed was searched to September 2008. A binomial model explored the individual risk of HIV infection with and without highly active antiretroviral therapy (HAART).

Results
A total of 62 643 titles were searched; four publications reporting per-act and 12 reporting per-partner transmission estimates were included. Overall, random effects model summary estimates were 1.4% [95% confidence interval (CI) 0.2–2.5)] and 40.4% (95% CI 6.0–74.9) for per-act and per-partner unprotected receptive AI (URAI), respectively. There was no significant difference between per-act risks of URAI for heterosexuals and MSM. Per-partner unprotected insertive AI (UIAI) and combined URAI–UIAI risk were 21.7% (95% CI 0.2–43.3) and 39.9% (95% CI 22.5–57.4), respectively, with no available per-act estimates. Per-partner combined URAI–UIAI summary estimates, which adjusted for additional exposures other than AI with a ‘main’ partner [7.9% (95% CI 1.2–14.5)], were lower than crude (unadjusted) estimates [48.1% (95% CI 35.3–60.8)]. Our modelling demonstrated that it would require unreasonably low numbers of AI HIV exposures per partnership to reconcile the summary per-act and per-partner estimates, suggesting considerable variability in AI infectiousness between and within partnerships over time. AI may substantially increase HIV transmission risk even if the infected partner is receiving HAART; however, predictions are highly sensitive to infectiousness assumptions based on viral load.

Conclusions
Unprotected AI is a high-risk practice for HIV transmission, probably with substantial variation in infectiousness. The significant heterogeneity between infectiousness estimates means that pooled AI HIV transmission probabilities should be used with caution. Recent reported rises in AI among heterosexuals suggest a greater understanding of the role AI plays in heterosexual sex lives may be increasingly important for HIV prevention.

For the full study click here.

HIV transmission risk during anal sex 18 times higher than during vaginal sex

via Aidsmap, by Roger Pebody

The risk of HIV transmission during anal intercourse may be around 18 times greater than during vaginal intercourse, according to the results of a meta-analysis published online ahead of print in the International Journal of Epidemiology.

Moreover, as well as this empirical work the researchers from Imperial College and the London School of Hygiene and Tropical Medicine carried out a modelling exercise to estimate the impact that HIV treatment has on infectiousness during anal intercourse. They estimate that the risk of transmission from a man with suppressed viral load may be reduced by as much as 99.9%.

Anal intercourse drives the HIV epidemic amongst gay and bisexual men. Moreover a substantial proportion of heterosexuals have anal sex but tend to use condoms less frequently than for vaginal sex, and this may contribute to heterosexual epidemics in sub-Saharan Africa and elsewhere.

Rebecca Baggaley and colleagues conducted a systematic review and meta-analysis (an analysis of all the medical research that meets predefined requirements) of the risk of HIV transmission during unprotected anal intercourse. The same authors have already conducted similar reviews of the transmission risk during vaginal sex and oral sex.

Despite the importance of the topic, only 16 studies were judged to be relevant enough to include in the review. While 12 were conducted with gay or bisexual men, others collected data on heterosexuals who frequently had anal intercourse. All studies were from Europe or North America.

Read the rest.

Does Africa Need a Rectal Microbicide? The answer - YES!

A rectal microbicide as a new HIV prevention technology is urgently needed in Africa for the large number of people practicing anal sex.

Current HIV prevention efforts are unable to contain or reduce the spread of HIV infection through anal sex.

One of the highlights of Microbicides 2010 was the presentation Does Africa need a rectal microbicide?  by Salim S. Abdool Karim (Slim), Pro Vice-Chancellor (Research): University of KwaZulu-Natal, Director: CAPRISA, Professor in Clinical Epidemiology, Columbia University and Adjunct Professor of Medicine, Cornell University.

The information Slim presented painted a deadly serious picture of neglect, denial, and criminalization with regard to the prevalence of anal sex among both men and women, as well as the near invisibility of gay men and other men who have sex with men in Africa despite harrowing rates of HIV. However, it was heartening and inspiring to have some serious. long-awaited attention paid to these issues - made all the better coming from one of the world's top researchers in the field.

Click here for his slides.


What follows is an excellent summary of the presentation by Henry Neondo via African Science News

Africa ripe for rectal microbicides

Africa needs microbicides for both vaginal and rectal use in prevention of mucosal infection of HIV, a mini-symposium at the ongoing International Microbicides Conference in Pittsburgh, Pennsylvania, US was told. The symposium heard that the contribution to HIV flame in Africa by the anal route is still under-reported and that time to unpack the myth was long overdue.

According to Dr Salim S. Abdool Karim, Pro Vice-Chancellor (Research), Univesity of KwaZulu Natal and Director of the Center for the AIDS Programme of Research in South Africa, CAPRISA, Africa needs to take a leap from the assumptions that HIV is spread only through the penile route.

“But a rectal microbicide as a new HIV prevention technology is urgently needed in Africa for the large number of people practicing anal sex---namely the men who have sex with men, bisexual men and women”, he said.

Dr Karim said although data on anal sex is as rare as data on the true situation of HIV in men who have sex with men throughout Africa, anonymous surveys in various parts of Africa show interesting pictures.

In Cape Town, South Africa, a survey of 2593 men and 1818 women showed that 14% of men and 10% of women had anal intercourse in the past three months.

In KwaZulu Natal, South Africa, 40.8% of the surveyed reported practicing anal intercourse. Worse, 30% of these reported never or rarely using condom during an intercourse.

Dr Karim said consistent use of condom in anal sex was lower that peno-vaginal intercourse.

The same scenario is reflected in Kenya and Nigeria, which report that 12% of public secondary schools students practice anal sex.

In all these countries, people who do not have knowledge of any HIV infected persons, a poor knowledge of increased HIV risks and distant HIV test often tended to have unprotected anal intercourse.

Recent studies on MSM sex workers indicate widespread existence of MSM groups in Africa. The study showed at least 739 MSM sex workers in Mombasa, Kenya and 496 in Johannesburg, South Africa. Further, it is reported that HIV prevalence among MSMS in Egypt is 6.2% and 14% in South Africa, 21%  in Senegal and 33% in Zambia.

But no one can tell of the true picture. The situation, said Dr Karim is not helped by the whole challenges surrounding men who have sex with men in Africa.

Through out Africa, MSM and their needs are largely ignored in HIV prevention and treatment efforts.

“Current HIV prevention efforts are unable to contain or reduce the spread of HIV infection through anal sex”, he said.

This is largely enforced by partly legislation, socio-cultures and out right infringement on human rights.

He said same sex relations are criminalized in 37 out of 54 African countries and are punishable by death in four of these.

For example in countries such as Malawi, where 21.4% men who have sex with men live with the virus that causes AIDS, a court jailed two men for 14 years for what it termed gross indecency and unnatural acts.

In Uganda, a Bill is still pending in the Parliament that could provide for a death sentence for anyone practicing homosexuality.

Most AIDS prevention messages are targeted at the heterosexual men and women emphasizing the risks of transmission through peno-vaginal sex and not through anal intercourse.

Dr Karim said the needs of the many women who are unable to get men to use condoms in anal sex are ignored.

HIV is not a gay disease

via guardian.co.uk, by Chris Ward

The gay community is very aware of HIV. Indeed, the infection used to go by the name of gay-related immune deficiency (Grid) before it was discovered to have been transmitted through other non-sexual means such as intravenous drug use. It seems that history can leave quite a mark, not just in the perceptions of individual members of society, but within the guidelines of public organisations too. It is still the case, although hopefully not for much longer, that once a man has had sex with another man, even with a condom, they are banned from giving blood for life.

In every year since 1999, most new diagnoses of HIV have been through heterosexual contact. Although many point out that a good chunk of these infections are believed to have been contracted abroad, statistically meaning that in the UK you are still less likely to be infected if you engage in heterosexual activities, the numbers are still very chilling. It proves convincingly that many heterosexuals do not consider HIV to be an infection likely to affect them. The myth of the gay disease may have heightened awareness of HIV among gays, but it has also sent a wave of complacency across the heterosexual community.

Read the rest.

 

What gay men can teach straights about safe sex

via Salon.com, by Tracy Clark-Flory

Women are skipping the condoms when it comes to, well, the backdoor.

It seems women have a safe sex blind spot when it comes to anal sex, according to a new report by the New York City Health Department. Far fewer women consistently use condoms during anal sex than men who sleep with men; 23 percent and 61 percent, respectively.

It's easy to understand how some women might rationalize condomless anal sex, much like virginity pledges who, conveniently enough, don't count oral or anal sex as sex. If it doesn't "count" as sex sex, and there is no risk of pregnancy, why use protection? But, boy, does it ever count: As the report's press release explains, "past studies suggest that anal exposure to HIV poses 30 times more risk than vaginal exposure." Sadly, the new study finds that women who have anal sex without condoms are less likely to get regular STD tests than women who consistently use protection.

Read the rest.

Health Department Highlights Health Risks of Unprotected Anal Sex among Heterosexual Women in New York City

[press release]

New survey suggests that women are less likely than men to use protection during anal intercourse

Unprotected anal sex poses well known health hazards for men, but new research suggests that the practice is a significant health issue for women as well. More than 100,000 New York City women engage in anal intercourse each year, according to a new report from the Health Department, and many are not taking the steps needed to prevent HIV and other sexually transmitted infections.
Read the rest.

Ten percent of South African women report anal sex in the past three months

via Aidsmap, by Roger Pebody

A cross-sectional survey has found that 14% of men and 10% of women in Cape Town, South Africa, report having heterosexual anal intercourse. Condoms are used at roughly equivalent frequency as for vaginal sex, it is reported in the online edition of Sexually Transmitted Infections.

The study’s authors believe that while anal intercourse needs to be addressed in behavioural interventions, it makes only a minor contribution to the South African epidemic.

However, the authors of an accompanying editorial argue strongly that this conclusion is premature, and point out that unaccounted-for anal intercourse could skew the findings of microbicide trials.

Anal intercourse between men and women has generally not received as much attention as anal intercourse between men. However, there is evidence (especially from the United States) that anal sex is practised by large numbers of sexually active adults, suggesting that it may play an important role in HIV transmission amongst heterosexuals.

Read the rest.

Related: Check out the presentations below from the IRMA teleconference exploring this subject

Implications of Anal Intercourse and Rectal use of Products in Vaginal Microbicide Trials (Ian McGowan) 

Measuring Anal Intercourse in Microbicide Studies (Pamina Gorbach)

Adding the Female Condom to the Public Health Agenda on Prevention of HIV and Other STIs Among Men and Women During Anal Intercourse

June 2009, Vol 99, No. 6 | American Journal of Public Health 985-987
© 2009 American Public Health Association
DOI: 10.2105/AJPH.2008.141200

Adding the Female Condom to the Public Health Agenda on Prevention of HIV and Other Sexually Transmitted Infections Among Men and Women During Anal Intercourse

Elizabeth A. Kelvin, PhD, MPH, Raymond A. Smith, PhD, Joanne E. Mantell, PhD, MSPH and Zena A. Stein, MA, MBBCh

The authors are with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York. Zena A. Stein is also with the G. H. Sergievsky Center, Columbia University, New York.

Correspondence: Requests for reprints should be sent to Elizabeth A. Kelvin, PhD, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr, Unit 15, New York, NY 10032 (e-mail: eak34@columbia.edu).



Legal barriers to conducting public health research on methods of protection for anal intercourse were lifted in the United States in 2003 when the US Supreme Court invalidated all state antisodomy laws. Although research funding has been available for the development of rectal microbicides, the female condom, which has already been approved for vaginal use, has not been evaluated for anal use.

Although there is no evidence that the female condom is safe for anal intercourse, it has already been taken up for off-label use by some men who have sex with men. This demonstrates the urgent need for more protection options for anal intercourse and, more immediately, the need to evaluate the safety and efficacy of the female condom for anal intercourse.

In the United States, anal intercourse is a common practice. Among men aged 25 to 44 years in the United States, 3.9% report having had anal intercourse with another man, and 40% report having had anal intercourse with a woman. Among women aged 25 to 44 years in the United States, 35% report having had heterosexual anal intercourse.1 Hence, discussions about anal intercourse should not assume that the practitioners are all men who have sex with men (MSM). In fact, there are an estimated 4 times more women than there are MSM practicing receptive anal intercourse in the United States.2 Unprotected anal intercourse is the sexual activity associated with the highest risk of HIV infection.3

Despite the fact that it is a common practice among heterosexual as well as homosexual couples,1 anal intercourse has long been subject to religious prohibition, criminal sanction, and social stigma worldwide.4 Scriptures in Leviticus (18:22 and 20:13) have traditionally been interpreted to prohibit anal intercourse, at least between men, under punishment of death for both partners, and the story of Sodom in Genesis chapter 19 provided a name for the act: sodomy. Medieval Christianity condemned anal intercourse along with other nonprocreative activities such as fellatio, homosexual contact, and sexual activity with animals.5 With the emergence of secular governments, "sins against nature" became codified in the law as "crimes against nature" through the enactment of antisodomy statutes. Although, in theory, any sexual activities not leading to procreation, such as male–female oral and anal sexual intercourse, were illegal, in practice, these statutes were applied primarily in cases of male–male sexual activity.5

As late as 1961, antisodomy laws in the United States were included in the criminal statutes of all 50 states of the union. By 1985, half of the states had repealed or struck down these laws, but in that year the US Supreme Court upheld the constitutionality of the remaining laws in the case of Bowers v Hardwick. The court ruled that the equal protection provisions of the 14th Amendment did not extend to anal intercourse and that majority disapproval of such a sexual activity was sufficient to pass a "rational-basis" standard under US constitutional law.6

Bowers v Hardwick occurred during the early years of the AIDS epidemic, which was understood at that time to affect mainly MSM. The ruling effectively reinforced the US government in its reluctance to sponsor research on the particular sexual activity associated with the highest risk of HIV infection.2 The US Food and Drug Administration has never approved a male or female condom specifically for use in anal intercourse, at least in part because antisodomy laws made anal intercourse an illegal activity in some states.7,8

In 2003, the US Supreme Court, in the case of Lawrence v Texas,9 invalidated the remaining state antisodomy laws as they apply to behavior between consenting adult civilians in private. In overturning their own precedent in Bowers v Hardwick just 17 years earlier, the Supreme Court may have been responsive to rapidly evolving social attitudes and scientific knowledge about homosexuality, as well as about HIV transmission and human sexuality in general.

The 6-to-3 ruling in Lawrence v Texas was notably broad, stating that "liberty gives substantial protection to adult persons in deciding how to conduct their private lives in matters pertaining to sex" and that the antisodomy law in question "furthers no legitimate state interest which can justify its intrusion into the individual's personal and private life."9 Thus, the period following Lawrence v Texas marks the first time in US history that anal intercourse has not been subject to criminal prosecution. It also offers an ideal opportunity for the development of a new public health research agenda on anal intercourse—one unfettered by legal constraints.

In 2004, the National Institute of Allergy and Infectious Diseases awarded a grant to the University of California, Los Angeles, and collaborative institutions to develop a pipeline for testing the anal use of microbicides. In 2007, the first rectal microbicide safety trial was conducted to evaluate the candidate product, UC-781.4 However, we do not yet have an effective microbicide for vaginal use, and the development of candidate rectal microbicides lags farther behind that of vaginal products.10 Consideration of whether technology already available for vaginal intercourse should be evaluated for anal intercourse is surely overdue. One candidate that might be considered for this crossover from vaginal to anal use is the female condom.

Although there is some research supporting equal efficacy of the female condom compared with the male condom in preventing sexually transmitted infections (STIs) when used vaginally,11–15 there is at present no data on female condom efficacy during anal use. However, because both male and female condoms act similarly as physical barriers, it may be reasonable to assume that using a female condom for anal intercourse would be safer than using no protection at all. Observational studies in the United States indicate that some MSM already use the female condom for anal intercourse.16–18 According to interviews we conducted in 2002 with 78 health care providers in 5 different health care settings in New York, some health care providers in the United States are presenting the female condom as an option for their MSM clients,19 and Population Services International, a non-profit, social marketing organization, has implemented social marketing of the female condom to MSM in Thailand20 and Myanmar.21

Furthermore, our search on the Internet for the phrase "female condom for anal sex" or variants thereof found that numerous Web sites address use of the female condom for anal intercourse, in some cases providing detailed instructions. We also looked at the Web sites of all 50 state departments of health in the United States to see if use of the female condom for anal intercourse was mentioned. Although we found anal use of the female condom mentioned on 7 state department of health Web sites, the content of the messages was inconsistent. For example, although the Web sites of 5 health departments in the United States and Canada support the use of the female condom for anal intercourse and even provide instructions on how to insert the device,22–26 the Web site of the New York State Department of Health warns that "female condoms should not be used for anal sex, as they do not provide adequate protection."27

In addition, among those health departments that do support anal use of the female condom, the specific instructions provided on their Web sites differ with regard to use of the inner ring. The Massachusetts22and Hawaii23 state department of health Web sites indicate that the inner ring should be removed prior to use for anal intercourse, whereas the Web sites of the District of Columbia Department of Health,24the Seattle and King County Department of Health,25 and the STD Resource.com site of the Vancouver Department of Health26 instruct users to leave the ring in or take it out, depending upon individual preference. Finally, the "STDs and Condoms Fact Sheet" of the Texas State Department of Health provides no instructions to potential users and simply states, "Most condoms go over a man's penis. A newtype of condom was designed to fit into a woman's vagina. This ‘female’ condom can also be used to protect the anus."28 Thus, the absence of consistent messages and rigorous research has relegated use of the female condom for anal intercourse to a subject of conjecture, contradiction, and potential misinformation rather than one based on sound scientific evidence.

Because of the current lack of alternatives for protection during anal intercourse, people have experimented with the off-label use of new products to meet their needs. The determination of some couples to find new forms of protection for anal intercourse underscores the need for alternatives to the male condom. However, before promoting the female condom for anal intercourse, research is urgently needed. With the male condom, the sexual anatomy of the penetrative partner, the penis, is the same in both anal and vaginal intercourse, and therefore, the lack of US Food and Drug Administration approval of male condoms for anal intercourse has not been problematic. However, the female condom has features specifically designed for insertion into the vagina, most notably a flexible inner ring that is secured by the cervix. When used in the anus, the female condom may not be easy to insert, comfortable, or even safe. In addition, the female condom can be inserted into the vagina up to 8 hours prior to intercourse,29 but this may not be true when using the product in the anus.

Therefore, studies are needed to determine the optimal methods for using the female condom during anal intercourse, especially with regard to the inner ring. The few safety studies that have been conducted to date have provided different instructions regarding the inner ring and have had numerous other flaws, including small sample size, high loss to follow-up, and poor adherence to protocol, making them inconclusive (Jobst RG, Johns JS, unpublished manuscript, 1994).16,30 Additional research on the safety of the female condom for anal intercourse is needed to address the limitations of the previous studies, and clinical trials comparing the efficacy of the female condom to that of the male condom are also needed to help those who practice anal intercourse decide how best toprotect themselves from rectalacquisition of HIV and other STIs.

Once the necessary studies have been conducted and safety and efficacy have been demonstrated, the marketing of the female condom for anal intercourse should be widespread and must consider the diversity of the potential users in terms of gender, sexual orientation, and sexual practices. Perhaps one reason why the female condom has not become more popular is because it is being marketed only to women and only for vaginal sexual intercourse. The more popular male condom, on the other hand, is recommended for both vaginal and anal intercourse and, although it is worn by a male partner, it is generally marketed to and purchased by both men and women. One study among women who practice anal intercourse found that they frequently do so in conjunction with vaginal intercourse and, thus, need a condom that can be used for both activities.30 By making the female condom less gender specific and diversifying its use to include anal intercourse, the female condom may become even more acceptable than it is now. A first step toward this end would, obviously, be a different name for the female condom.

The public health community needs to advocate for studies to examine the safety and efficacy of current vaginal products, as well as new products, for anal use. Because we lack an effective microbicide at this time, the potential of the female condom as an HIV- and STI-prevention barrier for anal intercourse urgently needs to be explored. In addition, this research may help guide future studies on microbicides for anal use when they become available. The goal of the public health agenda must be to provide more safer-sex options to all, regardless of gender, sexual orientation, and sexual practices, as soon as possible.



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22. Massachusetts Department of Public Health. Be safer, use condoms. 2007. Available at: http://www.mass.gov/dph/cdc/factsheets/condoms.pdf. Accessed September 5, 2007.
23. Hawaii State Department of Health. HIV basic information. 2007. Available at: http://www.hawaii.gov/health/healthy-lifestyles/std-aids/hiv-aids/basic-information.html. Accessed September 25, 2007.
24. District of Columbia Department of Health. Instructions for using a female condom for anal sex. 2007. Available at: http://doh.dc.gov/doh/cwp/view,a,1371,q,602668.asp. Accessed September 4, 2007.
25. Public Health Seattle and King County. How to use a condom and other types of barriers. 2007. Available at: http://www.metrokc.gov/health/apu/std/condomuse.htm. Accessed September 25, 2007.
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Relationship between heterosexual anal sex, injection drug use and HIV infection among black men and women

ABSTRACT

J M H Risser PhD , P Padgett PhD, M Wolverton MPH and W L Risser MD PhD


US blacks carry a disproportionate risk of heterosexually transmitted HIV. This study aimed to evaluate the association between self-reported heterosexual anal intercourse and HIV. Using respondent-driven sampling (RDS), we recruited and interviewed 909 blacks from areas of high poverty and HIV prevalence in Houston, Texas, and who reported heterosexual sex in the last year. All individuals were tested for HIV. Weighted prevalence values were calculated to account for non-random recruitment associated with RDS. The weighted population prevalence of HIV infection was 2.4% and 2.5% among men and women, respectively. Education, employment status, income and crack cocaine use were not associated with HIV infection. Lifetime injection drug use (odds ratio [OR] 3.31, 95% confidence interval [CI] 1.31–8.33%) and heterosexual anal intercourse (OR 2.41, 95% CI 1.02–5.73%) were associated with HIV infection. Individuals who reported both injection drug use and heterosexual anal intercourse had 6.21 increased odds of HIV (95% CI 2.47–15.61%). Our results suggest that heterosexual anal sex may be a vector for HIV transmission, especially in the context of injection drug use. Prevention strategies directed at curbing the HIV epidemic among black heterosexuals require that we correctly identify the risks so that appropriate interventions can be developed.

Heterosexual Anal Sex in the Age of HIV

People are inundated with “safe sex” messages and condom advertisements, but heterosexual penetrative penile-anal sex is rarely, if ever mentioned in these, leaving a gaping hole in people’s knowledge and awareness.

by Zoe Duby University of Cape Town

Research on sexual transmission of HIV consistently finds unprotected anal intercourse to be a highly predictive risk factor for sero-conversion. Despite this, most AIDS prevention messages targeted at heterosexuals continue to solely emphasise vaginal (and increasingly but still only occasionally oral) sexual transmission without mention of anal sex. This omission is influenced by the deeply entrenched taboos surrounding this sexual practice, as well as a lack of acknowledgment of its prevalence and significance as a heterosexual behaviour.

Partly as a consequence of this omission, the potential health risks of unprotected anal sex continue to be severely underestimated in the heterosexual community. Although knowledge seems to be high amongst the gay community, this appears not to be the case amongst heterosexuals. Evidence of this lies in the reportedly universal lower use of condoms for anal sex than for vaginal sex by heterosexuals. Data suggests that some people choose to practice anal sex due to misconceptions about the risks it poses. Anal sex is sometimes not considered to be “real sex” and evidence suggests that young girls choose anal sex as a means of preserving their virginity and as a form of contraception.

Evidently there are significant gaps in knowledge and awareness of the risks of unprotected anal sex amongst heterosexuals; many people choose to have anal sex as a “safe” alternative, thinking that it is not possible to transmit HIV through anal intercourse. This is largely due to the lack of information available that explicitly depicts and differentiates all potential sexual transmission vectors – vaginal, anal and oral. People are inundated with “safe sex” messages and condom advertisements, but heterosexual penetrative penile-anal sex is rarely, if ever mentioned in these, leaving a gaping hole in people’s knowledge and awareness.

The censure and stigmatisation of a commonly practiced sexual behaviour not only puts people at greater risk but also creates an atmosphere of shame and disgust around what for many people may be a desirable, pleasurable and consensual part of sexual relationships and intimate interaction.

Why do heterosexuals have anal sex?

i. Virginity
Virginity maintenance is one of an array of reasons given for young people electing to have oral and anal sex over penile-vaginal penetrative sex; the substitution of non-vaginal sexual activities for vaginal intercourse is a means of maintaining “technical virginity.”

Religion and culture play a key role in condoning or prohibiting certain sexual practices. Ample data supports the assertion that young girls in Christian, Islamic and traditional societies throughout Africa practice anal sex in order to protect their vaginal virginity. In many cultures, a high value is placed by the family and society on safeguarding girls’ virginity until marriage. In addition, evidence shows that young people in the United States who pledge to remain virgins are more likely to have engaged in ‘alternative sexual behaviour’, in order to preserve their virginity. Research shows that among those who have not had vaginal intercourse, pledgers have shown to be more likely than their non-pledging peers to have engaged in both oral and anal sex. In communities with a higher proportion of virginity pledgers, overall STI rates are actually higher than in other settings. Reasons for this may lie in the lack of sex education that young people in conservative religious communities receive.

…a lot of my religious friends… who are trying to hold on to some sort of sanctity of waiting until they’re married to have sex – feel that oral sex and anal sex are sex that they can have that’s still not full sex in their eyes… I think that the youth… today… are searching for these things that don’t make them lose their virginity – but allow them to still sort of engage in sexual activity… like they think all their peers are.. It’s like a loophole – it’s like they’re desperate to hold onto their virginity – but they’re not scared to engage in other acts so that they look cool... [Respondent 1, Duby, 2008]

In some communities virginity until marriage is less an established religious issue than a traditional cultural preference. In some communities “virginity testing” is practiced. Young girls are examined before marriage to ensure that their hymen is intact. Discovery of a ruptured hymen brings shame to a girl and her family, and can jeopardise her eligibility for marriage. As a result of the high value placed on virginity and hymen maintenance (a falsity as the hymen can be ruptured in non-sexual activity such as tampon use or physical exercise) it appears that young people choose to have oral and anal sex instead.

In an era of abstinence and HIV prevention programmes advocating delayed sexual initiation, it can be argued that the social pressure to remain a virgin actually contributes to young women’s risk of infection, acts as a barrier to their adoption of preventive behaviours and encourages the subsitution of alternative non-vaginal sexual practices. Some young adults have unprotected anal sex unaware of the high risk of HIV and STI transmission it poses.

Research on adolescent sexual behaviour in the past has been largely limited to vaginal intercourse, thus accurate prevalence statistics for non-vaginal genital activity amongst adolescents are unavailable. Research and sexual health programmes have traditionally used the classification of an individual as ‘sexually active’ based on vaginal intercourse. This means that ‘technical virgins’ who are engaging in non-vaginal sexual activities are omitted from discussions on sexual risk, potentially excluding many sexually active young people and consequently placing them at greater risk.

ii. Contraception
In a similar vein to virginity maintenance, evidence suggests that heterosexual anal sex is also practiced as a means of contraception. Young women wishing to avoid pregnancy but still desirous of sexual activity choose anal sex as an alternative means of attaining sexual pleasure without fear of conception.

…the main reason for having anal sex, other than it just being nice for the guy – is ejaculation. He can come inside you and there’s no risk. [Female respondent, Duby, 2008]

Sexual partners wanting to have non-reproductive “flesh to flesh” sex without the presence of any form of contraception and without the physical barrier of a condom, may choose to have anal sex so that there will be no chance of conception if the male ejaculates inside the female.

…it’s a nice way because then there’s no stress if he comes inside you… [Female respondent, Duby, 2008]

iii. Misconceptions: Misinformed and Unaware
Sadly, available evidence suggests that anal sex is sometimes practiced as a form of “safe sex”, ironically as a means of avoiding HIV transmission. Due to the silence around the topic of heterosexual anal sex and its omission from discussion on safe sex, the assumption is made that it must be safe. Health care providers themselves are also often unaware of the risks of anal sex. The false impression created that anal sex is safer than vaginal sex may be due to its lack of address in health education. Safe sex promotion and HIV prevention strategies unwittingly encourage misperceptions that anal sex is a ‘safer’ form of sex. Evidence from anecdotal reports suggest that some people practice anal sex (either with a female or a male) because they believe it will protect them from STIs/HIV. The reason for this is because they have heard no discussion about the risks of infection through anal sex.

Condom Use and Anal Sex
Despite anal sex having been identified as the most predictive risk factor for sero conversion in heterosexual HIV transmission, its risks are still underestimated by the vast majority of sexually active heterosexuals. This is illustrated by data showing that reported rates of condom use are universally lower for heterosexual anal intercourse than vaginal, and that far more women engage in unprotected anal sex than gay men. The male homosexual population are more sensitised to condom use for anal sex than heterosexuals. This can be attributed to the fact that HIV and STI programs targeted at the general population do not specifically address anal sex, whereas prevention programmes aimed at the gay population do. Another reason may be that condoms are primarily used by women for contraceptive purposes rather than protecting against STIs. Due to the failure of prevention programmes to sensitise heterosexuals to the high risk of infection of HIV and other STIs through unprotected anal intercourse, the widespread assumption that HIV transmission between heterosexuals is synonymous with penile-vaginal penetrative sex is inadvertently reinforced. Most literature on HIV and AIDS does not pay heed to heterosexual anal sex, although contrary to the popular association of anal sex with homosexual men, numerically more heterosexuals engage in anal sex than homosexuals. But due to the highly stigmatised and hidden nature of heterosexual anal sex as a topic, both male and female heterosexuals are less likely to discuss and negotiate safe sex approaches to anal intercourse than homosexual men.

iv. Peer group pressure: “because everyone else is doing it”
In contrast to the pressure to maintain virginity exerted by religious and traditional communities, the power of the peer group should not be underestimated. Young people are subject to the powerful force of wanting to conform, of needing to be accepted into social groups. In ‘school yard’ discussions about sex prestige may be gained through sexual prowess and sexual experience. Some youths, in an effort to win respect and admiration from peers may exaggerate and boast about sexual experiences, in order to appear ‘mature’. Banter about adventurous and exciting new sexual positions, that may only be entirely theoretical, may exert pressure on more inexperienced teenagers to try out ‘what everyone else is doing’. Sexual prowess, expressed in terms of numerous sexual partners or claimed wide sexual experience, is linked to both peer and general social recognition, especially of a masculine profile.

v. Menstruation
Anal sex is sometimes used as an alternative form of penetrative sex when a woman is menstruating. Anal sex can constitute a more ‘convenient’ form of penetrative intercourse when a woman is menstruating, avoiding embarrassment, discomfort and the ‘messiness’ of blood on the bed sheets and bodies of both sexual partners.

…when she (my friend) had her period, they (her and her boyfriend) used to always just have anal sex instead, because then she could wear a tampon, and so that there didn't have to be any blood. [Female respondent, Duby, 2008]

Interviewer: You mentioned before that anal sex was something you did in your first relationship when you were menstruating – why?
Female respondent: Um – just because… firstly you didn’t want to get blood everywhere, all over the sheets and stuff, and secondly I didn’t feel very comfortable with getting blood on him… I felt like… I dunno – I just didn’t like the thought of that. And I never really asked him about what he thought about that – and then sometimes it can be a bit painful to have (vaginal) sex when you’re menstruating. [Duby, 2008]

Additionally, in some societies menstrual blood is seen as a dirty polluting substance, potentially dangerous for men to come into contact with.

vi. For money
In the world of commercial sex work, evidence suggests that men will pay more for anal sex, with added value if it is without a condom. Motivation for commercial sex workers to engage in anal intercourse with their clients lies in the offer of higher financial benefits for anal sex than for vaginal sex. Evidence also suggests that more economically or socially vulnerable sex workers, as well as drug-abusing women, are more likely to offer unprotected anal intercourse for clients, being more driven by financial incentives than their less vulnerable and more financially secure co-workers.

vii. For him
Some feminist writers have argued that women have only come to understand their sexual pleasure and desire in terms of a patriarchally defined female sexuality which serves the male. In the process women are denied their own sexual subjectivity and pleasure. However it may be informative to examine the personally perceived moral obligations that a woman has to fulfill and satisfy her sexual partner’s desires, needs and fantasies. Popular contemporary media often compounds the perception that good sex in a relationship is the woman’s responsibility (however it would not be fair to say that men do not also come under pressure to provide sexual pleasure to women).

…my partner is always eager to do that (have anal sex)… and then I’m always kind of like “I don’t know” – so I think that mutual enjoyment out of it would be nice… which is probably why I really want to explore it a little more… I think it’s… it’s selfish in a way – you know you don’t want to be too giving in a sexual relationship – you want to get just as much enjoyment out of it as him at the same time… so I suppose it’s about getting to that point where we’re both enjoying it as much as the other. [Female respondent, Duby, 2008]

Many heterosexual women feel compelled to provide anal sex to their male partner, believing it to be more pleasurable for him. Women accommodate the perceived needs and desires of men, incorporating male needs into their own perceptions of what they want themselves. Many heterosexual women express the concern that if they fail to provide the sex that their male partner desires, they will be rejected; the provision and accomodation of a male partner’s needs enhances security within a relationship. This is especially the case in cultures where women’s sexual pleasure is not recognised or valued.

…he didn't make me do it (have anal sex) if I really didn’t want to, but I did it because it was interesting for him to… explore this activity... this feeling… [Female respondent, Duby, 2008]

Interviewer: So why do you think men enjoy anal sex?
Female respondent: I think… in an animalistic sense, it’s more the power… the control, without it really even being rape – you know it’s not violent, it’s not… the person is allowing you to do it… and it probably makes them feel powerful – and you know it’s supposed to be tighter as well…

Interviewer: And do you feel, when you’re in that situation, do you feel it makes you more submissive?
Female respondent: Definitely. Because I’m not submissive by nature – and I suppose that’s why it feels a bit weird emotionally because you know I am literally not in control... I mean even from my experience of a partner’s reaction during anal sex, he kind of gets very… like an animal in a way… and he kind of loses a bit of himself and it becomes kind of… It’s difficult to explain... it has happened where it got to the point where I was like “ok, enough”… and they haven’t heard me… by choice – to put it bluntly… and that’s not… that’s not nice… that’s not cool, and that’s very sort of demoralising – and afterwards you really do feel violated… [Duby, 2008]


viii. Domination/submission
…some women enjoy it (anal sex) mostly because it pleases their partner and some women enjoy it because they do like the sensation – or they like being maybe more submissive or something like that… [Female respondent, Duby, 2008]

Penile-anal sex is sometimes viewed as more aggressive and transgressive than penile-vaginal sex, involving the domination of one partner over the subordinate other.

I think it’s definitely… the most vulnerable position a woman can be in… it obviously depends on the partner as well … what space he’s in when he initiated it... If it’s more because he’s not thinking about you in the process... there have been times when it’s been great, but sometimes it just makes you feel violated… even though you love the person that you’re with – and you care for them, you still feel a little bit violated after that… It also depends on how it’s received – how it’s valued… by the partner – because if it’s kind of like as they say “wham bam thank you maam”, then it’s sort of not appealing after that – but if it’s – if something does happen emotionally - and you do feel closer to that person and you can see that it’s reciprocated, then it becomes more intriguing, and then you think “maybe it won’t be so bad”… [Female respondent, Duby, 2008]

I think it’s quite a submissive thing to do… to be on the receiving end of it – I think there’s much more of a power dynamic than I think there is with ‘normal sex’…. That was all part of it – that was just part of the fantasy and the – you know what makes it fun…. and for him – I think that’s why he liked it as well - I think partly because you know you’re not facing each other – so it’s more about just the sex than about the love or anything…. [Female respondent, Duby, 2008]

ix. Love and intimacy
Some people feel that anal sex requires greater intimacy between sexual partners; couples may practice it out of the desire to expand their physical and intimacy boundaries, to “get closer” to each other and perhaps explore previously uncharted territory together.

…there’s a comfort level that goes above and beyond the comfort level of just having regular sex with somebody. Just to be able to do that and not feel gross and self-conscious about it… [Female respondent, Duby, 2008]

Due to both the physically and morally sensitive nature of anal sex, sometimes it is more symbolically imbibed than vaginal sex, involving a further degree of intimacy and trust between individuals (in the case of consensual anal sex).

x. Sexual adventure and sensation seeking
The historical association of anal sex with deviancy and pathology gives the impression that anal sex is something only practiced by perverse individuals. This of course is not the case; consensual anal sex constitutes a pleasurable part of many healthy sexual relationships. Heterosexual couples may practice anal sex out of a desire to try new things, experience novel sensations, explore physical boundaries and anatomical regions. Curiosity may induce temptation to try new sexual acts and positions.

…it’s like bungee jumping – you know you’re going to get scared – and you know it’s not going to be pleasant for the first few minutes but you know afterwards you’ll think: that wasn’t so bad… [Female respondent, Duby, 2008]

…it was mostly just because it was… just a different sensation or whatever… [Female respondent, Duby, 2008]

The first time I did it, I had to get used to the feeling – you know because it’s something that’s completely different from anything you’ve felt before… [Female respondent, Duby, 2008]

The ‘accomplishment motive’ may be particularly relevant to adolescents practicing anal sex, feeling they are under pressure to do everything that their peers have done. Alfred Kinsey referred to this desire that some people have to ‘keep score’ and have sex in every position available and known about, to attain a sense of achievement.

Interviewer: So what would you say are your key motivations for having anal sex?
Female respondent: I think just curiosity… to finally prove whether I’m going to like it or not… I don’t think I’ve explored it enough… to be honest… Just curiosity – I need to get it out of the way… otherwise I’ll just be wondering… [Duby, 2008]

xi. Sexual choice and variety
Sex is a consumer product in the context of the consumerist society we live in. There is a plethora of sexual choices and lifestyles that the (‘free’ and ‘modern’) individual sifts through and samples as a means through which to express the self. With sex shops, pornographic material, sex toys and sex shows becoming increasingly accessible and popular, we are inundated with imagery of the weird and wonderful world of adventurous and exciting sex. Within this jungle of sexual opportunities we are encouraged to find our sexual selves. In a context free from coercion, exploitation and economic pressure, the modern Western individual reaches sexual self-realisation through conscious choice.

Until now safe sex messages and HIV prevention programmes have retained a limited and narrow view of sex. Only recently have condom and lubricant manufacturers cottoned onto this thirst for sexual adventure and fun in the affluent West, and have increasingly geared certain products towards this and away from boring, outdated and conventional sex.

Interviewer: What would you say your motivations for trying anal sex the first time were?
Male respondent: I suppose curiosity… it feels like a part of my sexuality – maybe aspects of… aspects of it that intrigued me or aroused me – um… yeah all those reasons – and maybe I could even ask myself whether boredom, sexual boredom was initially a reason… [Duby, 2008]


xii. Subversion and deviance
The Christian influenced Western world has been largely conditioned by the pervasive philosophy of sex as a sin. In the dualistic notion of the temptation of the ‘forbidden fruit’, desire is increased by the forbidden nature of a sexual act, and sexual activity itself is enhanced by the very fact of transgression. The risk of ‘defying rules’ creates an aura of excitement and ‘additional thrill’. Arousal may be substantially increased if the sexual act is perceived to be an ‘illegitimate activity’.

…with my last sexual partner, I would often say to her, I feel like something nasty tonight… some days we’d be on the same page and other days we wouldn’t… I don’t know if subversion is the right word but something… you know sometimes you feel a little destructive – and letting your hair down and being a little nasty... is attractive… [Male respondent, Duby, 2008]

Some individuals choose to practice anal sex because of its moral positioning as “deviant”. In an attempt to challenge society and break from mainstream culture, people seek to indulge in behaviour, sexual and otherwise, that they perceive to be in opposition to societal norms and expectations. By making the conscious decision to practice anal sex they may be engaging in a discourse of subversion. The individual choosing to assert their agency in experimenting with sex and breaking away from socially ascribed sex norms and positions may get some satisfaction from the sense of subversion and escape from societal control.

…just because it is so taboo – I think that’s what makes it more appealing. [Female respondent, Duby, 2008]


Conclusion
Evidence for the high incidence of heterosexual anal sex increases, alongside scientific knowledge about the high risks of HIV and STI transmission through penile-anal intercourse. It can no longer be ignored. As long as the cloak of denial and taboo remains over the subject of heterosexual anal sex, not only are people continually being denied access to comprehensive information and health service provision catering to all their sexual health needs, but they are not being given the opportunity to make informed choices about practicing safe sex and thus protecting themselves and their partners from HIV infection.

The censure and stigmatisation of a commonly practiced sexual behaviour not only puts people at greater risk but also creates an atmosphere of shame and disgust around what for many people may be a desirable, pleasurable and consensual part of sexual relationships and intimate interaction.

Pervading moral judgements are hard to change but in creating and allowing space for discussion and expression of sexuality, sexual attitudes and sexual desires, dialogue will inevitably lead to a greater acceptance and acknowledgement of what has for so long been hidden and ignored. Research must begin to address heterosexual anal sexual practices more attentively to enable greater understanding of sexual motives and sexual behaviour, which in turn will inform HIV prevention programmes.


Interview data referenced from:
Duby, Zoe 2008. Heterosexual anal sex in the age of HIV: An exploratory study of a silenced subject Unpublished Master’s dissertation, Department of Sociology, Graduate School of Humanities, University of Cape Town

Can treatment-as-prevention end the pandemic?

AIDS activists around the world cautiously praised the findings of an important new study published today in the medical journal The Lancet. The study, by a group of scientists from the HIV/AIDS and STOP TB departments at the World Health Organization (WHO), uses mathematical models to test the effectiveness of a strategy that includes universal annual HIV testing and immediate treatment for those who are found to be HIV positive. The authors hypothesize that this strategy, if fully implemented, could reduce HIV rates in Southern Africa to 1 in 1000 by 2016 and to 1% prevalence in fifty years.

IRMA is pleased to see the recognition of treatment as an important element in a full spectrum of prevention options. We would like to point one one element from the study summary which is an annoyingly recurring phrase in global HIV policy and studies. The summary states: "We used data from South Africa as the test case for a generalised epidemic, and assumed that all HIV transmission was heterosexual."

To quote from our very own excellent report (if we do say so ourselves), Less Silence, More Science: Advocacy to Make Rectal Microbicides a Reality:

"By focusing almost exclusively on gay men, MSM, and the West when developing policy related to anal intercourse (AI) in the context of HIV prevention programming, we neglect to identify the prevalence of AI between women and men as well as the HIV prevalence among, and indeed, the mere existence of, gay men and other MSM in Asia, Africa and other parts of the developing world. This neglect costs lives. In its ground-breaking report Off the Map, the International Gay and Lesbian Human Rights Commission decried the wall of silence that surrounds AIDS and same-sex practices in Africa. The situation in developing countries outside of Africa is often much the same regarding the collective blind eye turned toward MSM and anal sex practices between women and men.

Precious little research has examined the role of AI in HIV transmission in developing countries. However, studies in Senegal, Ghana, Kenya and Sudan indicate that rates of HIV prevalence among MSM are significantly higher than in the general population. This has also been demonstrated in most countries of Latin America, and in several countries and cities in Asia.

The illegality of AI in many countries and jurisdictions, the strong taboo and homophobia associated with anal sex, and the imprecise language we use to describe populations and behaviours conspire to render these realities invisible. We tend to conflate sex acts with identity through the use of imprecise, misleading language. Phrases like “heterosexual transmission” mask the fact that women and men who identify as heterosexual engage in AI. This lack of clarity, honesty and specificity negates that a significant portion of the pandemic is likely driven by unprotected anal intercourse in regions broadly characterized as being “driven by heterosexual HIV infection.” In this construct, heterosexual HIV transmission automatically translates to vaginal intercourse. While identity, sexual orientation and sexual practices may be related, they are not always so clearly delineated. “HIV infection via unprotected vaginal intercourse” would be a more accurate phrase than “heterosexually acquired HIV infection”.

These are more than innocuous semantics; language matters. Inaccurate language impacts quite concretely on program design and delivery; on research design, particularly for microbicides; on stigma faced by communities, including gay men and other MSM; and, on the deceptive absence of other populations that engage in AI, including heterosexual men and women, lesbians, and bisexuals across the globe." (p.13-14)

The Lancet, Early Online Publication, 26 November 2008
doi:10.1016/S0140-6736(08)61697-9Cite or Link Using DOI

Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model
Reuben M Granich MD a , Prof Charles F Gilks DPhil a, Prof Christopher Dye DPhil b, Prof Kevin M De Cock MD a, Brian G Williams PhD b

Background
Roughly 3 million people worldwide were receiving antiretroviral therapy (ART) at the end of 2007, but an estimated 6·7 million were still in need of treatment and a further 2·7 million became infected with HIV in 2007. Prevention efforts might reduce HIV incidence but are unlikely to eliminate this disease. We investigated a theoretical strategy of universal voluntary HIV testing and immediate treatment with ART, and examined the conditions under which the HIV epidemic could be driven towards elimination.
Methods
We used mathematical models to explore the effect on the case reproduction number (stochastic model) and long-term dynamics of the HIV epidemic (deterministic transmission model) of testing all people in our test-case community (aged 15 years and older) for HIV every year and starting people on ART immediately after they are diagnosed HIV positive. We used data from South Africa as the test case for a generalised epidemic, and assumed that all HIV transmission was heterosexual.
Findings
The studied strategy could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving ART, to an elimination phase, in which most are on ART, within 5 years. It could reduce HIV incidence and mortality to less than one case per 1000 people per year by 2016, or within 10 years of full implementation of the strategy, and reduce the prevalence of HIV to less than 1% within 50 years. We estimate that in 2032, the yearly cost of the present strategy and the theoretical strategy would both be US$1·7 billion; however, after this time, the cost of the present strategy would continue to increase whereas that of the theoretical strategy would decrease.
Interpretation
Universal voluntary HIV testing and immediate ART, combined with present prevention approaches, could have a major effect on severe generalised HIV/AIDS epidemics. This approach merits further mathematical modelling, research, and broad consultation.

For the full article: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61697-9/fulltext.

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