Anal intercourse therefore the threat of HIV transmission

Key points

  • For unprotected anal sex by having an HIV-positive partner with a completely suppressed viral load, the believed risk of illness is zero.
  • If HIV just isn’t completely suppressed by effective therapy, anal sex without condoms is a high-risk path of intimate HIV transmission for the insertive and receptive partner.
  • Intimately transmitted infections as well as the partner that is HIV-positive recently contaminated boost the chance of transmission.

In the event that partner that is HIV-positive using antiretroviral therapy and contains a completely suppressed viral load (‘undetectable’), the possibility of HIV transmission through rectal intercourse is zero.

The PARTNER-2 research implemented 783 male partners where the partner that is HIV-positive an invisible viral load with no condoms were utilized in anal sex. No HIV transmission from HIV-positive partners took place and the researchers concluded that the risk of HIV transmission in these circumstances was effectively zero (Rodger) after 1596 couple-years of follow-up and 77,000 acts of unprotected anal intercourse.

If viral load is detectable, condomless rectal intercourse is an extremely efficient means of transmitting HIV, which is considered a high-risk task both for lovers, even though the precise level of danger can rely on numerous facets.

The risk of infection has been estimated at 1.38% (one in 72 chance) and 0.11% (one in 909 chance) for the receptive and insertive partners respectively for each condomless act with an untreated HIV-positive partner.

However, it could be 10 to 25 times higher in the event that good partner is recently contaminated. Research reports have identified other factors that further raise the chance of transmission.

Dangers to insertive and receptive lovers

There is certainly a extensive belief among gay males that the insertive partner (‘top’) are at really low danger of HIV disease. It is a fact that HIV illness happens less frequently in guys who entirely make the role that is insertive in males who take part in both roles, or males whom practise receptive anal sex only (Jin).

Nevertheless, being the insertive partner in condomless sex continues to be a high-risk task. The risk that is per-act the insertive partner in rectal intercourse is related to the per-act danger for a man (insertive) partner in genital intercourse.

The receptive partner (‘bottom’) reaches threat of disease from HIV within the semen and pre-seminal liquids (‘pre-cum’) of this partner that is infected. Rectal muscle is delicate and simply damaged, which could supply the virus immediate access to the bloodstream. Nevertheless, such tissue damage just isn’t required for disease to happen: the rectal tissue it self is abundant with cells that are straight vunerable to infection.

The partner that is insertive‘top’) normally susceptible to illness, as you will find high quantities of HIV in rectal secretions, along with bloodstream through the rectal tissues (Zuckerman). This creates a threat of transmission into the partner that is insertive the muscle when you look at the urethra as well as on the pinnacle associated with the penis – particularly underneath the foreskin.

A few systematic reviews of research reports have determined that condomless receptive anal sex posed more or less ten to twelve times greater danger of illness than insertive intercourse that is anal.

Insertive anal intercourse refers towards the work of penetration during anal sex. The partner that is insertive the ‘top’.

The past area of the big intestine just over the anal area.

viral load

Dimension for the level of virus in a bloodstream test, reported as amount of HIV RNA copies per milliliter of bloodstream plasma. The VL is a essential indicator of hiv development and of exactly how well treatment solutions are working.

intimately transmitted infections (STIs)

Although HIV is intimately transmitted, the expression is usually utilized to chlamydia, gonorrhoea, syphilis, herpes, scabies, trichomonas vaginalis, etc.

Receptive rectal intercourse relates towards the work to be penetrated during anal sex. The partner that is receptive the ‘bottom’.

The newest breakdown of the proof estimated that for every condomless work with an HIV-positive partner, the possibility of disease ended up being 1.38percent ( one out of 72 opportunity) when it comes to receptive partner and 0.11% ( one in 909 possibility) for the insertive partner (Patel).

Nevertheless, lots of the studies had been performed before antiretroviral therapy after diagnosis became the norm and so are prone to over-estimate the possibility of illness.

Anal sex between women and men

Anal sex between women and men has generally speaking perhaps maybe perhaps not received the maximum amount of attention as rectal intercourse between males. Nevertheless, there was proof that rectal intercourse is practised by many intimately active grownups. This season, 11percent of females and 13% of males in the uk report having intercourse that is anal days gone by 12 months, with more youthful generations being more prone to report it (Mercer).

Unprotected heterosexual anal intercourse probably plays a crucial role in HIV transmission among heterosexuals, although dependable quotes miss (Baggaley).

Current illness

The very first couple of weeks or months after HIV has entered a body that is person’s their viral load is normally very high plus they are extremely infectious.

Viral load could be the term utilized to explain the total amount of HIV circulating in the human body. As viral load rises, therefore does infectiousness. Having said that, whenever viral load is so low as become invisible, there’s absolutely no danger after each of HIV transmission.

For instance, a research of heterosexual partners in Rakai, Uganda, where one partner had been HIV good and also the other HIV negative in the beginning of the research, indicated that the probability of HIV transmission is greatest in the 1st two . 5 months following infection that is initial HIV, and that this correlated with greater viral load amounts during the early HIV infection. The scientists estimated that in accordance with infection that is chronic infectiousness during primary illness ended up being improved 26-fold (Hollingsworth).

As individuals are often unacquainted with their disease at this time, they are not using therapy and may accidentally expose intimate lovers to HIV. those who have HIV without realising it are much very likely to be concerned in HIV transmission than individuals who understand they will have HIV, while the latter can get therapy.

Intimately sent infections

Many infections that are sexually transmitted especially people who cause ulceration, including herpes simplex 2 (HSV-2), syphilis, gonorrhoea, and chlamydia, increase HIV-negative partners’ danger of acquiring HIV during genital sexual intercourse. HIV-negative people who have recurrent STIs are at increased ongoing threat of HIV illness.

In individuals coping with HIV who are maybe not using HIV therapy, STIs additionally cause increased genital shedding of HIV, which escalates the danger of transmitting HIV to other people. Nevertheless, STIs don’t raise the danger of HIV transmission from people that are using effective HIV treatment and possess an invisible load that is viral. Within the PARTNER study, there was clearly maybe not really a solitary hiv transmission even though many research individuals had STIs.

There’s two main reasons for the effect of STIs on HIV transmission. Firstly, numerous (while not all) STIs could cause ulcers, sores or lesions. They offer an immediate real path of entry for HIV within an uninfected individual. Next, resistant cells which are, by themselves, prone to HIV infection – such as activated T-cells and dendritic cells – are vulnerable to show up in greater numbers in the web site of a disease.

“Being the insertive partner in condomless intercourse continues to be a high-risk task.”

The strongest proof is for herpes virus kind 2 (HSV-2). A meta-analysis discovered that having HSV-2 had been connected with a heightened danger of acquiring HIV both in the general populace (a rise of 270%) as well as in greater risk teams such as for instance intercourse employees and males who possess intercourse with guys (170%). Having a present hsv-2 disease had been related to an nearly fivefold (470%) increased chance of acquiring HIV, most likely because genital ulceration, viral shedding and irritation into the vaginal tract are most unfortunate in brand brand brand new HSV-2 infections and have a tendency to decrease with time (Looker).

Individual papillomavirus (HPV), the explanation for genital warts, is connected with an elevated danger of HIV disease in females whether or not it really is an HPV kind that triggers warts that are genital a kind related to cervical cancer (Houlihan). The existence of HPV in cells when you look at the penis additionally boosts the chance of purchase in males (Rositch).


Poppers are nitrite-based inhalants, trusted as a drug that is recreational homosexual guys in several nations. Specially popular to be used during receptive rectal intercourse, sniffing poppers relaxes the rectal sphincter muscle tissue, making sexual intercourse easier and pleasure that is intensifying.

Nonetheless, making use of poppers during unprotected, receptive intercourse that is anal than doubles the possibility of HIV infection (Macdonald). This might be because poppers enhance blood circulation to your tissues that are rectal heightening their susceptibility to illness. Poppers usually do not impact the insertive partner’s danger of disease.

Rectal douching

Rectal douching may be the insertion of a fluid, such as for instance plain tap water or soapsuds, to the anus via an instrument, to clean the rectum before or after rectal intercourse and is an activity that is common homosexual and bisexual men. Nonetheless, it might harm the rectal liner and remove protective obviously occurring germs. If the douching that is same, showerhead or other device is employed by each person, infections may be transmitted this way.

A synthesis of 24 studies revealed that rectal douching ended up being related to an almost threefold increased likelihood of disease with HIV and an even more than twofold escalation in the possibility of a sexually transmitted illness other than HIV (Li).

Even though it is feasible that this outcome could just be due to behavioural distinctions, the majority of the studies done multiple analyses to consider prospective confounders such as for example regularity of intercourse and partner figures.

Anal bleeding

Rectal blood also raises the risk of illness, and may be caused by haemorrhoids, specific STIs such as for instance anal warts, herpes lesions, the previous usage of intercourse toys, or by fingering and fisting.

Male circumcision

There are lots of information from low and middle-income nations to declare that circumcision could be protective, but just for males who solely simply take the insertive part (Yuan).

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