Heterosexual Anal Sex Activity in the Year After an STD Clinic Visit

Model-based predictions of protective HIV pre-exposure prophylaxis adherence levels in cisgender women

Most human immunodeficiency virus (HIV) infections occur in cisgender women in resource-limited settings. In women, self-protection with emtricitabine/tenofovir disoproxil fumarate pre-exposure prophylaxis (FTC/TDF-PrEP) constitutes a major pillar of HIV prevention. However, clinical trials in women had inconsistent outcomes, sparking uncertainty about adherence requirements and reluctance in evaluating on-demand regimens. We analyzed data from published FTC/TDF-PrEP trials to establish efficacy ranges in cisgender women. In a 'bottom-up' approach, we modeled hypotheses in the context of risk-group-specific, adherence-efficacy profiles and challenged those hypotheses with clinical data. We found that different clinical outcomes were related to the proportion of women taking the product, allowing coherent interpretation of the data. Our analysis showed that 90% protection was achieved when women took some product. We found that hypotheses of putative male/female differences were either not impactful or statistically inconsistent with clinical data. We propose that differing clinical outcomes could arise from pill-taking behavior rather than biological factors driving specific adherence requirements in cisgender women.

Extragenital Sexually Transmitted Infection Testing Among Louisiana Parish Health Units, 2016-2019

BACKGROUND

The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) get tested annually for urethral and rectal chlamydia (CT) and gonorrhea (NG), and pharyngeal NG. There are no national recommendations to screen women and heterosexual men at extragenital sites. We assessed extragenital CT/NG screening among men and women at Louisiana's Parish Health Units (PHU).

METHODS

The Louisiana STD/HIV/Hepatitis Program piloted extragenital screening at 4 PHUs in February 2016 and expanded to 11 PHUs in 2017. Sexual histories were used to identify gender of sex partners and exposed sites. Because of billing restrictions, up to 2 anatomical sites were tested for CT/NG.

RESULTS

From February 2016 to June 2019, 70,895 urogenital and extragenital specimens (56,086 urogenital, 13,797 pharyngeal, and 1,012 rectal) were collected from 56,086 patients. Pharyngeal CT positivity was 160 of 7,868 (2.0%) among women, 54 of 4,838 (1.1%) among men who have sex with women (MSW) and 33 of 1,091 (3.0%) among MSM. Rectal CT positivity was 51 of 439 (11.6%) among women and 95 of 573 (16.6%) among MSM. Pharyngeal NG positivity was 299 of 7,868 (3.8%) among women, 222 of 4,838 (4.6%) among MSW, and 97 of 1,091 (8.9%) among MSM. Rectal NG positivity was 20 of 439 (4.6%) among women and 134 of 573 (23.4%) among MSM.Urogenital-only screening would have missed: among women, 173 of 3,923 (4.4%) CT and 227 of 1,480 (15.3%) NG infections; among MSW, 26 of 2,667 (1%) CT and 149 of 1,709 (8.7%) NG infections; and among MSM, 116 of 336 (34.5%) CT and 127 of 413 (42.1%) NG infections.

CONCLUSIONS

Many CT/NG infections would have been missed with urogenital-only screening. Men who have sex with men had much higher extragenital infection rates than women and MSW.

Anal Intercourse among Heterosexual Young Adults: A Population-Based Survey in Switzerland

Anal intercourse (AI) among heterosexuals is an understudied and taboo subject. This 2017 Swiss national study aimed to describe the characteristics and motivations of heterosexual young adults practicing AI. Participants with any same-sex experience, same-sex attraction or non-heterosexual identity were excluded. The Federal Statistical Office provided the initial sample and potential participants were recruited through postal mail inviting them to an online survey (response rate 15.1%). The sample comprised 3892 participants (52% males; 54% of the overall sample, mean age 26.3 years). Overall, 55% of women and 56% of men had never experienced AI, 17% and 12% had done it once and 28% and 32% more than once, respectively. We found that participants engaging in AI had higher odds of practicing intercourse while intoxicated, being younger at first sexual experience, not using a condom at last intercourse and reporting a history of sexual transmitted infections. The main reason reported by both genders for engaging in their first AI was being curious followed by being in love. In conclusion, AI is a widespread practice among heterosexual young adults and health professionals should be especially attentive to it.

2021 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens

This guideline intents to offer guidance on the diagnosis and management of patients with gastrointestinal symptoms and a suspected sexually transmitted cause. Proctitis is defined as an inflammatory syndrome of the anal canal and/or the rectum. Infectious proctitis can be sexually transmitted via genital-anal mucosal contact, but some also via digital contact and toys. Neisseria gonorrhoeae, Chlamydia trachomatis (including lymphogranuloma venereum), Treponema pallidum and herpes simplex virus are the most common sexually transmitted anorectal pathogens. Shigellosis can be transferred via oral-anal contact and may lead to proctocolitis or enteritis. Although most studies on these infections have concentrated on men who have sex with men (MSM), women having anal intercourse may also be at risk. A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available. The symptoms of proctitis include anorectal itching, pain, tenesmus, bleeding, constipation and discharge in and around the anal canal. The majority of rectal chlamydia and gonococcal infections are asymptomatic and can only be detected by laboratory tests. Therefore, especially when there is a history of receptive anal contact, exclusion of anorectal infections is generally indicated as part of standard screening for sexually transmitted infections (STIs). Condom use does not guarantee protection from STIs, which are often spread without penile penetration. New in this updated guideline is: (i) lymphogranuloma venereum proctitis is increasingly found in HIV-negative MSM, (ii) anorectal Mycoplasma genitalium infection should be considered in patients with symptomatic proctitis after exclusion of other common causations such N. gonorrhoeae, C. trachomatis, syphilis and herpes, (iii) intestinal spirochetosis incidentally found in colonic biopsies should not be confused with syphilis, and (iv) traumatic causes of proctitis should be considered in sexually active patients.

Promoting safer sex in the context of heterosexual anal intercourse: A scoping review

AIMS AND OBJECTIVES

To locate and summarise existing literature regarding safer sex practices specific to heterosexual anal intercourse and identify promising health promotion strategies.

BACKGROUND

Much of the literature regarding anal intercourse and safer sex is related to men who have sex with men. However, some studies suggest there are more women than men engaging in unprotected receptive anal intercourse. The risks associated with this sexual practice have been well documented, although many healthcare providers fail to ask about anal intercourse while addressing safer sex in the heterosexual population.

DESIGN

The study was based on Arksey and O'Malley's 2005 five-step methodology.

METHODS

A search was conducted of MEDLINE; CINAHL; PsycInfo; Cochrane; and PubMed. Databases were searched from 1990-2020. The 72 studies selected were classified according to their main area of focus. A grey literature search was also included. This scientific submission has been assessed for accuracy and completeness using the PRISMA-ScR guideline criteria (File S1).

RESULTS

The literature in this area is heterogeneous in terms of method and topic. Prevalence and incidence (n = 26) in addition to sexually transmitted infection risks (n = 26) related to heterosexual anal intercourse are well understood. However, there is limited information on condom use (n = 6), factors that influence heterosexual anal intercourse (n = 10) and health promotion strategies for this population and practice (n = 4). Two websites that mentioned heterosexual anal intercourse risk reduction activities were included.

CONCLUSIONS

Although heterosexual anal intercourse appears to be an increasingly common sexual practice, very little is known about health promotion strategies nurses might use for encouraging safer sex in this population.

RELEVANCE TO CLINICAL PRACTICE

Increased awareness of the prevalence and risks of heterosexual anal intercourse could enhance nurses' harm reduction strategies. Screening for sexually transmitted infections may be based on incorrect assumptions about sexual practices or due to stigma linked with anal intercourse. Reducing unprotected heterosexual anal intercourse will reduce sexually transmitted infections and their long-term sequelae.

Receptive anal sex contributes substantially to heterosexually acquired HIV infections among at-risk women in twenty US cities: Results from a modelling analysis

PROBLEM

Receptive anal intercourse (RAI) is more efficient than receptive vaginal intercourse (RVI) at transmitting HIV, but its contribution to heterosexually acquired HIV infections among at-risk women in the USA is unclear.

METHOD OF STUDY

We analysed sexual behaviour data from surveys of 9152 low-income heterosexual women living in 20 cities with high rates of HIV conducted in 2010 and 2013 as part of US National HIV Behavioral Surveillance. We estimated RAI prevalence (past-year RAI) and RAI fraction (fraction of all sex acts (RVI and RAI) at the last sexual episode that were RAI among those reporting past-year RAI) overall and by key demographic characteristics. These results and HIV incidence were used to calibrate a risk equation model to estimate the population attributable fraction of new HIV infections due to RAI (PAF_RAI ) accounting for uncertainty in parameter assumptions.

RESULTS

Receptive anal intercourse prevalence (overall: 32%, city range: 19%-60%) and RAI fraction (overall: 27%, city range: 18%-34%) were high overall and across cities, and positively associated with exchange sex. RAI accounted for an estimated 41% (uncertainty range: 18%-55%) of new infections overall (city range: 21%-57%). Variability in PAF_RAI estimates was most influenced by uncertainty in the estimate of the per-act increased risk of RAI relative to RVI and the number of sex acts.

CONCLUSION

Receptive anal intercourse may contribute disproportionately to new heterosexually acquired HIV infections among at-risk low-income women in the USA, meaning that tools to prevent HIV transmission during RAI are warranted. The number of RVI and RAI acts should also be collected to monitor heterosexually acquired HIV infections.

Rectal Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among Women Reporting Anal Intercourse

OBJECTIVE

To examine the prevalence and treatment of rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among women reporting receptive anal intercourse in a network of sexually transmitted disease or sexual health clinics and estimate the proportion of missed infections if women were tested at the genital site only.

METHODS

We conducted a cross-sectional analysis of C trachomatis and N gonorrhoeae test results from female patients reporting receptive anal intercourse in the preceding 3 months during visits to 24 sexually transmitted disease clinics from 2015 to 2016. Primary outcomes of interest were 1) anatomic site-specific C trachomatis and N gonorrhoeae testing and positivity among women attending selected U.S. sexually transmitted disease clinics who reported receptive anal intercourse and 2) the proportion of rectal infections that would have remained undetected if only genital sites were tested.

RESULTS

Overall, 7.4% (3,743/50,785) of women reported receptive anal intercourse during the 2 years. Of the 2,818 women tested at both the genital and rectal sites for C trachomatis, 292 women were positive (61 genital only, 60 rectal only, and 171 at both sites). Of the 2,829 women tested at both the genital and rectal sites for N gonorrhoeae, 128 women were positive (31 genital only, 23 rectal only, and 74 at both sites). Among women tested at both anatomic sites, the proportion of missed C trachomatis infections would have been 20.5% and for N gonorrhoeae infections, 18.0%.

CONCLUSION

Genital testing alone misses approximately one fifth of C trachomatis and N gonorrhoeae infections in women reporting receptive anal intercourse in our study population. Missed rectal infections may result in ongoing transmission to other sexual partners and reinfection.

Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States, 2011-2015

BACKGROUND

Heterosexual anal and oral sex are related to the acquisition and transmission of sexually transmitted diseases (STDs). As common reportable STDs (chlamydia, gonorrhea, and syphilis) in the United States are increasing, it is important to understand recent oral and anal sexual behaviors.

METHODS

We examined the prevalence and correlates of heterosexual anal and oral sex, associated condom use, and having multiple partners among men and women aged 15 to 44 years.

RESULTS

Approximately one third of women and men had ever engaged in anal sex, including 11% of adolescents (15-19 years). Most women and men had ever received or given oral sex (at >75%). Six percent and 7% of women and men, respectively, used a condom at last oral sex compared with 20% and 30% who used a condom at last anal sex. Having multiple sex partners in the past year was most common among adolescents, never or formerly married persons, and those who had a nonmonogamous partner. Less than 10% reported multiple anal sex partners in the past year. A substantial minority had multiple oral or anal sex partners; black women and men had the highest reports of oral sex partners by race/ethnicity.

CONCLUSIONS

Anal and oral sex are common sexual practices. Given the low rates of condom use during these behaviors, it is important that recommendations for sexual risk assessments are followed. Tailored messaging regarding risk for STD and human immunodeficiency virus acquisition during oral and anal sex may benefit adolescents, singles, and divorced individuals. Future discussions regarding the benefits of extragenital STD testing for heterosexuals may be useful.

A Daily Diary Analysis of Condom Breakage and Slippage During Vaginal Sex or Anal Sex Among Adolescent Women

BACKGROUND

Adolescent women are disproportionately impacted by the adverse outcomes associated with sexual activity, including sexually transmitted infections (STI). Condoms as a means of prevention relies on use that is free of usage failure, including breakage and/or slippage. This study examined the daily prevalence of and predictors of condom breakage and/or slippage during vaginal sex and during anal sex among adolescent women.

METHODS

Adolescent women (N = 387; 14 to 17 years) were recruited from primary care clinics for a longitudinal cohort study of STIs and sexual behavior. Data were daily partner-specific sexual diaries. Random intercept mixed-effects logistic regression was used to estimate the fixed effect of each predictor on condom breakage/slippage during vaginal or during anal sex (Stata, 13.0), adjusting model coefficients for the correlation between repeated within-participant diary entries.

RESULTS

Condom slippage and/or breakage varied across sexual behaviors and was associated with individual-specific (eg, age and sexual interest) and partner-specific factors (eg, negativity). Recent behavioral factors (eg, experiencing slippage and/or breakage in the past week) were the strongest predictors of current condom slippage and/or breakage during vaginal or anal sex.

CONCLUSIONS

Factors associated with young women's condom breakage/slippage during vaginal or during anal sex should be integrated as part of STI prevention efforts and should be assessed as part of ongoing routine clinical care.

Purulent Proctitis Caused by Prevotella bivia in a Homosexual Male

A 32-year-old homosexual male presented with suprapubic pain. Computed tomography showed rectal wall thickening. Flexible sigmoidoscopy showed small pockets of pus that were opened with mucosal biopsies, and additional pus was diffusely expressed from the rectal wall by applying blunt pressure with the biopsy forceps. Cultures from the pus grew Prevotella bivia. Symptoms resolved after treatment with doxycycline and metronidazole. Proctitis due to P. bivia was not previously reported.

Patterns of Extragenital Chlamydia and Gonorrhea in Women and Men Who Have Sex With Men Reporting a History of Receptive Anal Intercourse

BACKGROUND

Screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in men who have sex with men is risk based. Despite high frequencies of oral and receptive anal intercourse (RAI) among women, extragenital screening is not recommended.

METHODS

Women (n = 175) and men who have sex with men (n = 224) primarily recruited from a sexually transmitted infection clinic reporting a lifetime history of RAI completed a structured questionnaire and clinician-collected swab samples from the rectum, pharynx, vagina (women), and urine (men). CT and GC were detected using 2 commercial nucleic acid amplification tests (Aptima Combo 2; Hologic, Inc, Bedford, MA; Xpert CT/NG, Cepheid Innovation, Sunnyvale, CA).

RESULTS

The median age of the population was 26 years, 62% were white, and 88% were enrolled from a sexually transmitted disease clinic. Men were more likely than women to have GC (22.8% vs. 3.4%) and CT (21.9% vs. 12.6%). In men versus women, GC was detected in 16.5% versus 2.3% of pharyngeal swabs, 11.6% versus 2.3% of rectal swabs, and 5.4% versus 2.9% of urine samples or vaginal swabs. C. trachomatis was detected in 2.2% versus 1.7% of pharyngeal swabs, 17.4% versus 11.4% of rectal swabs, and 4.5% versus 10.3% for urogenital sites in men versus women. Overall 79.6% of CT and 76.5% of GC in men and 18.2% of CT and 16.7% of GC in women were detected only in the pharynx or rectum.

CONCLUSION

Reliance on urogenital screening alone misses most of GC and CT in men and more than 15% of infections in women reporting RAI.

Prevalence and Correlates of Heterosexual Anal Intercourse Among Men and Women, 20 U.S. Cities

Heterosexual anal intercourse (HAI) is not an uncommon behavior and it confers a higher risk of HIV transmission than vaginal intercourse. We examined data from heterosexuals recruited in 20 US cities for the 2013 National HIV Behavioral Surveillance system. We assessed correlates of reporting HAI in the previous year. Then, among people reporting HAI in the past year, we assessed what event-level factors are associated with having HAI at last sex. Thirty percent of women and 35 % of men reported HAI in the past year. Among people who had HAI in the past year, those who had HAI at last sex were more likely to have a partner who was HIV-positive or of unknown status or to have exchanged money or drugs for sex at last sex. Information that highlights the risk of HIV transmission associated with HAI would complement existing HIV prevention messages focused on heterosexuals in the U.S.

Contextual Factors Surrounding Anal Intercourse in Women: Implications for Sexually Transmitted Infection/HIV Prevention

BACKGROUND

Our objectives were to describe women's reasons for engaging in anal intercourse (AI), contextual factors surrounding AI, and how these vary by current rectal sexually transmitted infection (STI) status, and to assess women's knowledge and concerns about rectal infections.

METHODS

Between January 2011 and June 2013, we conducted semistructured, qualitative interviews among 40 women attending public sexually transmitted disease clinics in Los Angeles County, California. Women were eligible if they were at least 18 years of age, reported AI in the past 90 days, and were tested for rectal Chlamydia trachomatis and Neisseria gonorrhoeae. Interviews, which were guided by the theory of gender and power, were transcribed and coded to explore contextual factors surrounding AI.

RESULTS

On average, participants reported having 3 AI partners in their lifetime and most (n = 30) reported being in a serious relationship with a main/regular sex partner at the time of the interview. Motivations for engaging in AI and feelings about AI varied by rectal STI status. Women with a rectal STI more prominently conveyed the idea that AI was intended to please their sexual partner, whereas those who did not have a rectal STI reported AI more as a way to increase intimacy and personal sexual gratification. Almost all women (regardless of rectal STI status) reported limited to no knowledge about the risk of rectal STIs.

CONCLUSIONS

Among women, risk of acquiring rectal STIs may vary by reason for engaging in unprotected AI as well as other contextual factors. Providers should consider addressing these contextual factors to reduce risk.

Condomless Anal Intercourse Among Males and Females at High Risk for Heterosexual HIV Infection

BACKGROUND

Understanding and addressing heterosexual HIV transmission requires attention to the range and context of heterosexual sexual behaviors. We sought to determine population-based prevalence of condomless anal intercourse (CAI) among individuals at increased heterosexual HIV risk in Baltimore and to identify demographic, behavioral, and health-related correlates.

METHODS

Data were from a cross-sectional study of 185 males and 198 females at increased heterosexual risk for HIV recruited using respondent-driven sampling as part of Centers for Disease Control and Prevention's National HIV Behavioral Surveillance Project in Baltimore, August-December 2010. Bivariate and multivariate logistic regression examined factors associated with heterosexual CAI.

RESULTS

The sample was majority African American, with a mean age of 38 years among men and 34 years among women. Forty-two percent of men (95% confidence interval, 30.9%-52.0%) and 38% of women (95% confidence interval, 29.4%-47.2%) reported any CAI in the past year, with variance by partner type and sex. Among men, CAI was significantly associated with homelessness, casual and exchange partners, same-sex partner in past year, and substance use. Among women, CAI was significantly associated with lower education, casual and exchange partners, same-sex partner in past year, multiple partners, and substance use. In adjusted sex-specific models, males and females with increasing numbers of partners were more likely to engage in CAI.

CONCLUSIONS

It is important to recognize the efficiency of transmission of HIV and other sexually transmitted infections through CAI. There is a need to broaden heterosexual sexual health promotion and HIV/sexually transmitted infection prevention to adequately and appropriately address risks and prevention strategies for anal intercourse.

The Human Papillomavirus Vaccine: Current Perspective and Future Role in Prevention and Treatment of Anal Intraepithelial Neoplasia and Anal Cancer

The incidences of human papillomavirus (HPV)-related anal cancer and its precursor lesion, anal intraepithelial neoplasia, are rising in the U.S. and globally. Five-year survival rates with current modalities of treatment for anal cancer are generally favorable for localized and regional disease. For metastatic disease, the relative survival rate is poor. Major contributing factors for the increase in anal cancer incidence include increasing receptive anal intercourse (hetero- and homosexual), increasing HPV infections, and longer life expectancy of treated people who are seropositive for human immunodeficiency virus. Because treatment outcomes with systemic therapy in patients with advanced disease are so poor, prevention may be the best approach for reducing disease burden. The association of a major causative agent with anal cancer provides an excellent opportunity for prevention and treatment. The advent of the HPV vaccine for anal cancer prevention and treatment is a significant milestone and has the potential to greatly impact these cancers. The data regarding potential use of the HPV vaccine in anal cancer prevention and treatment are reviewed.

IMPLICATIONS FOR PRACTICE

The incidences of human papillomavirus (HPV)-related anal cancer and its precursor lesion, anal intraepithelial neoplasia, are on the rise in the U.S. and globally. Based on recent studies, the HPV vaccine is approved for prevention of the infection and development of HPV-related anal cancer. In addition, several small studies have shown that the vaccine may be useful as adjuvant therapy for anal cancer. There is a need for public health strategies aimed at education of both patients and practitioners to improve the use of the vaccine for prevention of HPV-related anal cancer. The development of a therapeutic vaccine is a work in progress.

Correlates of Heterosexual Anal Intercourse among Women in the 2006-2010 National Survey of Family Growth

INTRODUCTION

Heterosexual anal intercourse (HAI) is common among U.S. women. Receptive anal intercourse is a known risk factor for HIV, yet there is a paucity of data on HAI frequency and distribution in the United States. Condom use is lower with HAI vs. vaginal intercourse, but little is known regarding of correlates of HAI with and without condoms.

AIMS

The aims of this study were to describe recent (past 12 months) and lifetime HAI among sexually active reproductive-aged U.S. women, and to characterize women who engage in HAI with and without condoms.

METHODS

We analyzed a sample of 10,463 heterosexually active women aged 15-44 years for whom anal intercourse data were available in the 2006-2010 National Survey of Family Growth.

MAIN OUTCOME MEASURES

Weighted bivariate and multivariable analyses were used to determine HAI prevalence and correlates. Primary outcomes were lifetime HAI, recent (last 12 months) HAI, and condom use at last HAI.

RESULTS

In our sample, 13.2% of women had engaged in recent HAI and 36.3% in lifetime HAI. Women of all racial and ethnic backgrounds and religions reported recent anal intercourse. Condom use was more common at last vaginal intercourse than at last anal intercourse (28% vs. 16.4%, P < 0.001). In multivariable analysis, correlates of recent HAI included: less frequent church attendance, younger age at first intercourse, multiple sexual partners, history of oral intercourse, history of unintended pregnancy, and treatment for sexually transmitted infections (all P < 0.05). Correlates of lifetime HAI were similar, with the addition of older age, higher education, higher income, and history of drug use (all P < 0.05).

CONCLUSION

Women of all ages and ethnicities engage in HAI, at rates higher than providers might realize. Condom use is significantly lower for HAI vs. vaginal intercourse, putting these women at risk for acquisition of sexually transmitted infections.

Human papillomavirus vaccine trials and tribulations: Clinical perspectives

Human papillomavirus (HPV) affects hundreds of millions of people worldwide and is associated with both benign and malignant neoplasms in men and women. It is a double-stranded DNA virus with an icosahedral capsid. Forty HPV types are known to infect mucosal keratinocytes. If not cured by the immune system, the infection can lead to genital warts, mucosal dysplasia, or cancer. The most common oncogenic types are 16 and 18. The vaccine to prevent HPV and its associated morbidity and mortality has existed since 2006. Several variations protect against an increasing number of HPV types. The recommended vaccination age is before sexual exposure; administration of the vaccine to children has been controversial. This continuing medical education review evaluates the current HPV vaccines available to clinicians. Part I focuses on the debate over who should be vaccinated, at what age, and in which populations.

An Electronic Daily Diary Study of Anal Intercourse in Drug-Using Women

Women (N = 138) with histories of illicit drug use were recruited into an electronic diary study that used Android smartphones for data collection. The diary was to be completed each day for 12 weeks using an "app" created in HTML5 and accessed over the Internet via smartphone. Data collection included information on sexual behaviors with up to 10 partners per day and contextual factors surrounding sexual behavior such as drug use before/after, type of sexual behavior (oral, vaginal, anal), and other activities such as using condoms for vaginal and anal intercourse and use of sexual lubricants. The sample was predominantly African American (58 %); 20 % Latina, 20 % White and 2 % reported as Other. Most women reported either less than a high school education (33 %) or having a high school diploma (33 %). The mean age was 39 years (SD = 11.78). Anal intercourse occurred on days when women also reported using illicit drugs, specifically methamphetamine and cocaine. Anal intercourse was not an isolated sexual activity, but took place on days when vaginal intercourse and giving and receiving oral sex also occurred along with illicit drug use. Anal intercourse also occurred on days when women reported they wanted sex. HIV prevention interventions must address the risks of anal intercourse for women, taking into account concurrent drug use and sexual pleasure that may reduce individual harm-reduction behaviors.

Broadly Neutralizing Anti-HIV Antibodies Prevent HIV Infection of Mucosal Tissue Ex Vivo

Broadly neutralizing monoclonal antibodies (nAbs) specific for HIV are being investigated for use in HIV prevention. Due to their ability to inhibit HIV attachment to and entry into target cells, nAbs may be suitable for use as topical HIV microbicides. As such, they would present an alternative intervention for individuals who may not benefit from using antiretroviral-based products for HIV prevention. We theorize that nAbs can inhibit viral transmission through mucosal tissue, thus reducing the incidence of HIV infection. The efficacy of the PG9, PG16, VRC01, and 4E10 antibodies was evaluated in an ex vivo human model of mucosal HIV transmission. nAbs reduced HIV transmission, causing 1.5- to 2-log10 reductions in HIV replication in ectocervical tissues and ≈3-log10 reductions in HIV replication in colonic tissues over 21 days. These antibodies demonstrated greater potency in colonic tissues, with a 50-fold higher dose being required to reduce transmission in ectocervical tissues. Importantly, nAbs retained their potency and reduced viral transmission in the presence of whole semen. No changes in tissue viability or immune activation were observed in colonic or ectocervical tissue after nAb exposure. Our data suggest that topically applied nAbs are safe and effective against HIV infection of mucosal tissue and support further development of nAbs as a topical microbicide that could be used for anal as well as vaginal protection.

Prevalence and Frequency of Heterosexual Anal Intercourse Among Young People: A Systematic Review and Meta-analysis

We aim to assess if heterosexual anal intercourse (AI) is commonly practiced and how frequently it is practiced by young people. We searched PubMed for articles published 1975 to July 2014 reporting data on the proportion of young people (mean age <25) practicing heterosexual AI (AI prevalence) and on number of AI acts (AI frequency). Stratified random-effects meta-analysis and meta-regression were used to produce summary estimates and assess the influence of participant and study characteristics on AI prevalence. Eighty-three and thirteen of the 136 included articles reported data on lifetime AI prevalence and monthly AI frequency, respectively. Estimates were heterogenous. Overall summary estimates of lifetime AI prevalence were 22 % (95 % confidence interval 20-24) among sexually active young people, with no statistically significant differences by gender, continent or age. Prevalence increased significantly with confidentiality of interview method and, among males and in Europe, by survey year. Prevalence did not significantly differ by recall period. An estimated 3-24 % of all reported sex acts were AI. Reported heterosexual AI is common but variable among young people worldwide. To fully understand its impact on STI spread, more and better quality data on frequency of unprotected AI, and trends over time are required.

Behavioral and psychosocial correlates of anal sex among male clients of female sex workers in Tijuana, Mexico

Most studies of heterosexual sex risk practices have focused on condomless vaginal sex despite evidence that condomless anal sex has a significantly higher risk of HIV transmission. The present study focused on male clients' anal sex practices with female sex workers (FSWs) in Tijuana, Mexico, where an HIV epidemic is growing among high-risk groups. Logistic regression analyses were used to identify psychosocial and behavioral correlates of anal sex among male clients. Our sample of HIV-negative men (N = 400) was predominantly Latino (87.5 %), born in Mexico (78.8 %), never married (36.8 %) or in a regular or common-law marriage (31.5 %), and employed (62.8 %), with an average age and education of 37.8 and 9.2 years, respectively. Eighty-nine percent identified as heterosexual and 11 % as bisexual. By design, 50 % of the sample resided in Tijuana and the other 50 % in San Diego County. Nearly half (49 %) reported at least one incident of anal sex with a FSW in Tijuana in the past 4 months; of those participants, 85 % reported that one or more of their anal sex acts with FSWs had been without a condom. In a multivariate model, anal sex with a FSW in the past 4 months was associated with bisexual identification, methamphetamine use with FSWs, repeat visits to the same FSW, higher scores on perceived stigma about being a client of FSWs, and sexual compulsivity. Prevention programs are needed that address the behavioral and psychosocial correlates of heterosexual anal sex in order to reduce HIV/STI transmission risk among male clients, FSWs, and their sexual network members.

Why women engage in anal intercourse: results from a qualitative study

This study used qualitative methods to assess why women engage in heterosexual anal (receptive) intercourse (AI) with a male partner. Four focus groups which comprised women from diverse ethnicities were conducted. All groups were digitally recorded for transcription; transcripts were analyzed using the methods of grounded theory to determine themes. Women's reasons for engaging in anal intercourse with a male partner can be described in broad categories including that the women wanted to have anal intercourse, either because of their own desire, to please a male partner, or they were responding to a quid pro quo situation. The riskiness of AI was assessed within relationship contexts. Past experience with AI including emotional and physical reactions was identified. Among the negative physical experiences of AI were pain and disliking the sensation, and uncomfortable side effects, such as bleeding of the rectum. Negative emotional experiences of AI included feelings of shame, disgust, and being offended by something her male partner did, such as spitting on his penis for lubrication. Positive physical experiences included liking the sensation. Many of the women also endorsed positive emotional experiences of AI, including that it was more intimate than vaginal sex, and that it was something they reserved only for special partners. The majority of AI episodes were unplanned and not discussed prior to initiation. Pain during AI was mitigated by the use of lubricants or illicit drugs. Even those women who found pleasure in AI expressed a preference for vaginal intercourse.

Sexual behaviors and partner-specific correlates of heterosexual anal intercourse among truck drivers and their wives in South India

It is important to know about patterns of sexual behaviors among married couples in order to develop effective HIV prevention strategies for them. Herein we describe the sexual behaviors, estimate prevalence of anal intercourse (AI) among truck drivers ("truckers") and their wives, and determine partner-specific demographic and behavioral correlates of AI. We carried out a cluster-sampled cross-sectional survey among 18-49 year-old wives and their trucker husbands in a south Indian district. Data were collected by same-gender research team members with color-coded computer-assisted interviews. We used random intercept logistic regression to identify the independent correlates of AI. Thirteen percent of 475 wives and 467 truckers reported ever having AI with their spouse. Of those who responded, 55 % of 40 wives and 47 % of 36 truckers never used condoms during AI. Of those who responded, 22 of 32 wives and 24 of 32 husbands felt that condoms were unnecessary during AI. Reporting ever having AI was associated with younger age and higher education of both husband and wife. AI reported by wives was associated with having sexual partner(s) other than husband (adjusted OR 8.8 [95 % CI 3.2-24.0]), correctly answering all HIV knowledge items (adjusted OR 4.9 [95 % CI 1.9-12.5]), husband's sexual debut occurring before marriage (adjusted OR 1.9 [95 % CI 1.0-3.5]), and husband's high HIV risk perception (adjusted OR 2.5 [95 % CI 1.2-5.4]). AI reported by truckers was associated with having sex with a male or transgender (adjusted OR 4.0 [95 % CI 1.2-13.3]). Reported prevalence of AI was high considering that in India anal sex is non-normative, heavily stigmatized and, criminal. Indian heterosexual mobile populations need to be informed about the greater risk of HIV infection consequent to unprotected AI.

Order of orifices: sequence of condom use and ejaculation by orifice during anal intercourse among women: implications for HIV transmission

BACKGROUND

For women, the order of penile insertion, condom use, and ejaculation by orifice during sexual events affects the probability of HIV transmission and design of HIV prevention methods.

METHODS

From October 2006 to June 2009, 431 women in Los Angeles and Baltimore in a rectal health study reported the sequence of penile insertion, condom use, and ejaculation by orifice location by computer-assisted self-interview. Multinomial logistic regression identified predictors of condom use by orifice among women who reported vaginal intercourse (VI) during their last anal intercourse (AI) event.

RESULTS

Of the 192 reporting on a last AI event, 96.3% (180/187) reported VI. Of these, 83.1% had VI before AI. Including the 36% who ejaculated in both the rectum and vagina, 66% report any ejaculation in the vagina and 45% in the rectum. One-third used a condom for both VI and AI, <10% for VI only or AI only, and half used no condoms. After adjusting for race, partner type, and substance use, compared with women who used condoms for both VI and AI at last AI, being older (units = 5 years) [adjusted odds ratio (AOR) = 0.76; 95% confidence interval (CI): 0.60 to 0.96], with serodiscordant partners (AOR = 0.22; 95% CI: 0.08 to 0.61), and HIV-positive with seroconcordant partners (AOR = 0.15; 95% CI: 0.04 to 0.54) were associated with not using condoms.

CONCLUSIONS

For most of the women in our study VI accompanied AI, with AI usually occurring after VI. This evidence for use of multiple orifices during the same sexual encounter and low use of condoms across orifices supports the need for a multicompartment HIV prevention strategy.

Exposure to pornographic videos and its effect on HIV-related sexual risk behaviours among male migrant workers in southern India

Objective

Research on pornography and its association with HIV-related sexual behaviours is limited in India. This study aims to examine the prevalence and correlates of viewing pornographic videos and examine its associations with HIV-related sexual risk behaviours among male migrant workers in India.

Methods

Data were drawn from a cross-sectional survey conducted in 2007–08 across 21 districts in four states of India. Respondents included 11,219 male migrants aged 18 years or older, who had migrated to at least two places in the past two years for work. Bivariate and multivariate methods were used to examine the association between viewing pornography and HIV-related sexual risk behaviours.

Results

Two-fifths (40%) of the migrants had viewed pornographic videos in one month prior to the survey. Migrants aged 25–29 years, literate, unmarried and away from native village for more than five years were more likely to view pornography than their counterparts. Migrants who viewed pornographic videos were more likely to engage in paid (Adjusted odds ratio [AOR]: 4.2, 95% confidence interval [CI]: 3.7–4.8) and unpaid sex (AOR: 4.2, 95% CI: 3.7–4.7), report inconsistent condom use in paid sex (AOR: 2.3, 95% CI: 1.7–3.0) and experience STI-like symptoms (AOR: 1.7, 95% CI: 1.5–1.8) than their counterparts.

Conclusions

The findings regarding migrants' exposure to pornography and its linkage with high HIV risk behaviour suggest that the HIV prevention programmes for migrants need to be more innovative to communicate on the negative-effects of viewing pornography. More importantly, programmes need to find alternative ways to engage migrants in infotainment activities during their leisure time in an effort to reduce their exposure to pornographic videos as well as risky sexual behaviours.

Sexually transmitted infections in men who have sex with men

Homosexuality is a global human phenomenon. Although the American Psychiatric Association removed homosexuality from its list of disorders more than 35years ago, homophobia among physicians is still widely prevalent. Men who have sex with men (MSM) form a relatively new epidemiological risk group for STI. To perform correct management, clinicians evaluating men with male-male sex contacts for STI related complaints or STI screening must obtain a thorough sexual history. Emerging STI like lymphogranuloma venereum, hepatitis C, and multidrug resistant N. gonorrhea strains have been described first in MSM. STI related proctitis often occur in MSM. Within the MSM population, HIV positive patients form a special group affected by STI related diseases, such as anal carcinoma and neurosyphilis. The final part of this review concludes with recommendations to reduce the STI burden in MSM.

Female users of internet-based screening for rectal STIs: descriptive statistics and correlates of positivity

BACKGROUND

Internet-based screening for vaginal sexually transmitted infections (STI) has been shown to reach high-risk populations. Published studies of internet-based screening for rectal STIs in women are needed. Our objectives were to describe the female users of a rectal internet-based screening intervention and assess what factors correlated with rectal positivity for STIs.

METHODS

The website http://www.iwantthekit.org offers free STI testing via home self-sampling kits. Women could order vaginal and rectal kits, both containing questionnaires. Rectal and vaginal swabs were tested for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis using nucleic acid amplification tests. Data were analysed from 205 rectal kits from January 2009 through February 2011. Self-reported characteristics of participants were examined, and correlates of rectal STI positivity were analysed.

RESULTS

Of the 205 rectal samples returned and eligible for testing, 38 (18.5%) were positive for at least one STI. The women were young (mean age 25.8 years), mostly African-American (50.0%), and only 14.0% always used condoms. After adjusting for age and race, Black race (AOR=3.06) and vaginal STI positivity (AOR=40.6) were significantly correlated with rectal STI positivity. Of women testing positive for rectal STIs who also submitted vaginal swabs, 29.4% were negative in the vaginal sample.

CONCLUSIONS

Internet-based rectal screening can reach populations that appear to be at high risk for rectal STIs (18.5% prevalence) and led to the diagnosis of STIs in women who would not have been diagnosed vaginally. Black race and vaginal STI positivity were highly correlated with rectal STI positivity.

Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention

Introduction

Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.

Methods

Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.

Results

Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.

Conclusion

Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.

2013 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens

Proctitis is defined as an inflammatory syndrome of the distal 10-12 cm of the anal canal, also called the rectum. Infectious proctitis can be sexually transmitted via genital-anal mucosal contact, but some also via mutual masturbation.N. gonorrhoeae,C. trachomatis(including lymphogranuloma venereum), Herpes Simplex Virus andT. pallidumare the most common sexually transmitted anorectal pathogens. Shigellosis can be transferred via oral-anal contact and may lead to proctocolitis or enteritis. Although most studies on these infections have concentrated on men who have sex with men (MSM), a significant proportion of women have anal intercourse and therefore may also be at risk. A presumptive clinical diagnosis of proctitis can be made when there are symptoms and signs, and a definitive diagnosis when the results of laboratory tests are available. The symptoms of proctitis include anorectal itching, pain, cramps (tenesmus) and discharge in and around the anal canal. Asymptomatic proctitis occurs frequently and can only be detected by laboratory tests. The majority of rectal chlamydia and gonococcal infections are asymptomatic. Therefore when there is a history of receptive anal contact, exclusion of anorectal infections is generally indicated as part of standard screening for sexually transmitted infections (STIs). Condom use does not guarantee protection from bacterial and protozoan STIs, which are often spread without penile penetration.

Gender differences in heterosexual anal sex practices among women and men in substance abuse treatment

Heterosexual anal intercourse (HAI) is an understudied risk behavior among women and men in substance abuse treatment. Rates of HAI for women (n = 441) and men (n = 539) were identified for any, main and casual partners. More men (32.8 %) than women (27.1 %) reported engaging in HAI in the previous 90 days. These rates are higher than those reported for both men (6.0-15.9 %) and women (3.5-13.0 %) ages 25-59 in the National Survey of Sexual Health and Behavior. Men were significantly more likely to report HAI with their casual partners (34.1 %) than women (16.7 %). In a logistic regression model generated to identify associations between HAI and variables previously shown to be related to high risk sexual behavior, being younger, bisexual, and White were significantly associated with HAI. For men, having more sex partners was also a significant correlate. HAI is a logical target for increased focus in HIV prevention interventions.

Preventing HIV infection in women

Although the number of new infections has declined recently, women still constitute almost half of the world's 34 million people with HIV infection, and HIV remains the leading cause of death among women of reproductive age. Prevention research has made considerable progress during the past few years in addressing the biological, behavioral, and social factors that influence women's vulnerability to HIV infection. Nevertheless, substantial work still must be performed to implement scientific advancements and to resolve many questions that remain. This article highlights some of the recent advances and persistent gaps in HIV prevention research for women and outlines key research and policy priorities.

Prevalence and correlates of rectal Chlamydia and gonorrhea among female clients at sexually transmitted disease clinics

BACKGROUND

The prevalence and correlates of rectal sexually transmitted infections are well described among men who report receptive anal intercourse (AI); however, little is known about the epidemiology of rectal sexually transmitted infections among women.

METHODS

We conducted a cross-sectional study of women attending public sexually transmitted disease clinics in Los Angeles County, California. Women were eligible for inclusion in this study if they reported AI in the previous 90 days, were tested for rectal chlamydia and gonorrhea, and were seen between January 2008 and December 2010.

RESULTS

Among the 2084 clinic visits by women in this analysis, chlamydia and gonorrhea percent positivity by anatomic site was 12% (n = 144) for urogenital chlamydia, 14.6% (n = 171) for rectal chlamydia, 3.3% (n = 66) for urogenital gonorrhea, and 3.0% (n = 60) for rectal gonorrhea, with 25% of chlamydia cases and 19% of gonorrhea cases having rectal-only infections. Among women 25 years or younger, rectal infections were higher in visits in which women reported sex with an injection drug user (46.5% vs. 15.5%; P < 0.01) or sex with a HIV-positive partner (66.7% vs. 15.8%; P = 0.02). Among women older than 25 years, rectal infections were higher in visits where women reported substance use (10.6% vs. 5.8%; P ≤ 0.01). In multivariable models controlling for age and the presence of a urogenital infection, these associations remained.

CONCLUSIONS

Chlamydia and gonorrhea positivity was high among women reporting AI, and a large proportion of these cases would be missed in the absence of rectal testing. The high-risk behaviors of women with rectal infections highlight the need for rectal screening recommendations.

Intimate partner violence and anal intercourse in young adult heterosexual relationships

CONTEXT

Although intimate partner violence and anal intercourse are common in young adult relationships, few studies have examined whether these behaviors are associated with each other.

METHODS

Data from 6,280 women aged 18-28 who took part in Wave 3 of the National Longitudinal Study of Adolescent Health were used to examine the association between physical and sexual intimate partner violence and anal intercourse in 10,462 relationships. Multivariate hierarchical random effects models were used to adjust for the clustered survey design and for the multiple relationships reported per participant.

RESULTS

Physical violence occurred in 29% of relationships, sexual violence in 11% and anal intercourse in 14%. The odds that a couple had had anal intercourse were greater among relationships that included physical violence perpetrated by both partners or only by the woman than among nonviolent relationships (odds ratios, 1.7 and 1.9, respectively). The odds of anal intercourse were also elevated among sexually abusive relationships, although only if the woman was the sole victim or the sole perpetrator (1.3 and 2.0, respectively). In relationships that included anal intercourse, the odds of condom use were lower if the woman was a victim of physical violence than if no violence occurred (0.2). Sexual violence was not associated with condom use.

CONCLUSION

Women in physically violent relationships may be at increased risk for STDs because of their elevated exposure to unprotected anal intercourse. More information on the context surrounding anal intercourse and intimate partner violence is needed to understand the nuances of this association.

HIV antibody testing and its correlates among heterosexual attendees of sexually transmitted disease clinics in China

Background

This study was conducted to determine the prevalence of HIV antibody testing and associated factors among heterosexual sexually transmitted disease (STD) clinic attendees in China.

Methods

A self-administered questionnaire was administered among 823 attendees of 4 STD clinics of Zhejiang Province, China in October to December 2007. Psychosocial and behavioural factors associated with HIV antibody testing were identified in both genders using univariate and multivariate analyses.

Results

Of all 823 STD clinic attendees, 9.3% of male and 18.0% of female attendees underwent HIV antibody testing in the most recent 6 months, and 60% of the participants had gotten no educational/behavioral intervention related to HIV prevention. The correlates for HIV antibody testing in the most recent 6 months as identified by multivariate analysis were ever condom use [odds ratio (OR), 10.37; 95% confidence interval (CI), 1.32–81.22]; ever anal/oral sex (OR, 3.13; 95% CI, 1.03–9.50) during their lifetime; having ever received three to seven types of behavioural interventions in the most recent 6 months (OR, 3.70; 95% CI, 1.32–10.36) among male subjects; and ever condom use (OR, 12.50; 95% CI, 2.20–71.01), STD history (OR, 3.86; 95% CI, 1.26–11.86) over their lifetime, or having ever received three to seven types of behavioural interventions in the most recent 6 months (OR, 8.68; 95% CI, 2.39–31.46) in female subjects. A lifetime experience of casual/commercial sex partners was strongly negatively associated with HIV testing in female subjects (OR, 0.08; 95% CI, 0.01–0.83).

Conclusion

The low prevalence of HIV antibody testing and behavioural intervention among STD clinic attendees indicates a need for more targeted, intensive behavioural interventions to promote HIV antibody testing in this population.

Anal intercourse and HIV risk among low-income heterosexual women: findings from Chicago HIV behavioral surveillance

Background:

Anal intercourse (AI) is a highly efficient route for HIV transmission and has not been well elucidated among heterosexual (HET) women. Heterosexual women living in impoverished urban areas in the US are at increased risk for HIV acquisition. We aim to describe rates of AI and characteristics associated with AI among heterosexual women at increased risk for HIV acquisition living in Chicago.

Methods:

The Chicago Department of Public Health conducted a survey of HET during 2007 as part of the National HIV Behavioral Surveillance System. Venue-based, time-location sampling was used to select participants from venues in high-risk areas (census tracts with concurrently high rates of heterosexual AIDS and household poverty). Eligible participants were interviewed anonymously and offered a HIV test.

Results:

In total, 407 heterosexual women were interviewed. Seventy-one (17%) women reported having AI in the past 12 months, with 61 of the 71 (86%) reporting unprotected AI. In multivariate analysis, women who engaged in AI were more than three times as likely to have three or more sex partners in the past 12 months (OR=3.27, 95% CI 1.53-6.99). AI was also independently associated with STI diagnosis in the past 12 months (2.13, 95% CI 1.06-4.26), and having sexual intercourse for the first time before the age of 15 years (2.23, 95% CI 1.28-3.89).

Conclusion:

AI was associated with multiple high risk behaviors including a greater number of sexual partners, STI diagnosis, and earlier age at first sex. The combination of risk factors found to be associated with AI call for new HIV prevention services tailored to the needs of women and young girls living in poverty.

A comparison of condom use errors and problems for heterosexual anal and vaginal intercourse

Condom use errors and problems were compared for anal and vaginal intercourse among a convenience sample of heterosexual men aged 18-66 years (n = 757). Men completed an online questionnaire for the last male condom use event for penile-anal (10.4%) or penile-vaginal (89.6%) intercourse. The prevalence of condom use errors and problems was similar regardless of intercourse type with a few exceptions; those reporting anal intercourse were significantly more likely to report using water-based (P < 0.001) and oil-based (P = 0.037) lubricant and to remove condoms before sex was finished (P < 0.001). The large majority of the sample (93.8%) reported at least one of the nine errors assessed and almost half (46.2%) reported at least one of the seven problems, indicating that many adults may need assistance with these issues. Condom use promotion programmes designed for heterosexual adults are needed that address condom use errors and problems for penile-anal as well as penile-vaginal intercourse.

Heterosexual anal sex experiences among Puerto Rican and black young adults

CONTEXT

Heterosexual anal sex is not uncommon in the United States, and it poses risk for STDs. However, who engages in it and why are not well understood, particularly among young adults.

METHODS

In 2006-2008, data on sexual health-related topics were collected in surveys (483 respondents) and qualitative interviews (70 participants) with black and Puerto Rican 18-25-year-olds in Hartford and Philadelphia. Bivariate and multivariate analyses of survey data assessed predictors of anal sex with the most recent serious heterosexual partner. Interview transcripts were analyzed for anal sex experiences and reasons for and against engaging in this behavior.

RESULTS

Some 34% of survey respondents had had anal sex; this behavior was more common with serious partners than with casual partners (22% vs. 8%). Black respondents were less likely than Puerto Ricans to report anal sex (odds ratio, 0.3); women were more likely to do so than were men (2.9). In the qualitative cohort, perceptions of anal sex as painful and unappealing were the predominant reasons for not having anal sex, whereas sexual pleasure and, in serious relationships, intimacy were the main reasons for engaging in it. Condom use during anal sex was rare and was motivated by STD or hygiene concerns.

CONCLUSIONS

Heterosexual anal sex is not an infrequent behavior and should be considered in a broad sexual health context, not simply as an indicator of STD risk. Health providers should address it openly and, when appropriate, as a positive sexual and emotional experience.

Unprotected anal intercourse and sexually transmitted diseases in high-risk heterosexual women

OBJECTIVES

We examined the association between unprotected anal intercourse and sexually transmitted diseases (STDs) among heterosexual women.

METHODS

In 2006 through 2007, women were recruited from high-risk areas in New York City through respondent-driven sampling as part of the National HIV Behavioral Surveillance study. We used multiple logistic regression to determine the relationship between unprotected anal intercourse and HIV infection and past-year STD diagnosis.

RESULTS

Of the 436 women studied, 38% had unprotected anal intercourse in the past year. Unprotected anal intercourse was more likely among those who were aged 30 to 39 years, were homeless, were frequent drug or binge alcohol users, had an incarcerated sexual partner, had sexual partners with whom they exchanged sex for money or drugs, or had more than 5 sexual partners in the past year. In the logistic regression, women who had unprotected anal intercourse were 2.6 times as likely as women who had only unprotected vaginal intercourse and 4.2 times as likely as women who had neither unprotected anal nor unprotected vaginal intercourse to report an STD diagnosis. We found no significant association between unprotected anal intercourse and HIV infection.

CONCLUSIONS

Increased screening for history of unprotected anal intercourse and, for those who report recent unprotected anal intercourse, counseling and testing for HIV and STDs would likely reduce STD infections.

Acceptability of UC781 gel as a rectal microbicide among HIV-uninfected women and men

We studied the overall acceptability of UC781 gel formulation when applied rectally. Ten women and twenty-six men, all HIV-uninfected, were enrolled in a Phase 1, randomized, blinded, placebo-controlled safety and acceptability study of the vaginal microbicide gel UC781 applied rectally. Participants were randomized to three groups: 0.1% UC781 gel, 0.25% UC781 gel, or a placebo gel. Acceptability was assessed using structured questionnaires and qualitative in-depth interviews. After using UC781 gel rectally for seven consecutive days, participants’ reports suggest that a UC781 gel formulation is highly acceptable and comparable to a placebo gel. The gels received favorable ratings overall and on attributes such as color, smell and consistency. All of the participants reported high intentions to use a gel like the one they used in this study. Acceptability research is essential in early phases of microbicide development to identify potential problems, understand user preferences, and introduce changes if needed.

Young adult sexual health: current and prior sexual behaviours among non-Hispanic white US college students

BACKGROUND

Less is known about the sexual health of young adults than about adolescents, despite 20 to 24-year-olds' greater risk of unintended pregnancy and sexually transmissible infections. This paper provides information on college students' prior and current sexual practices including oral sex, vaginal intercourse, anal intercourse and masturbation.

METHODS

We analysed data from a cross-sectional sexuality survey of students from two university campuses in the USA, one Mid-western and one South-western (n = 1504). The sample consisted of non-Hispanic white, never-married students who identified as heterosexual.

RESULTS

Of 16 possible combinations of four sexual activities (solitary masturbation, oral sex, vaginal intercourse and anal intercourse), only four contained more than 5% of respondents: masturbation, oral sex and vaginal intercourse (37%); oral sex and vaginal intercourse only (20%); all four (14%); and none (8%). Twenty percent had ever engaged in anal intercourse. Women were significantly less likely than men to have ever masturbated (48 v. 92%). Analyses exhibited several sexual health challenges, including lack of verbal sexual consent, alcohol use proximal to sex and lack of contraceptive use.

CONCLUSIONS

Although few young adults are substituting it for vaginal intercourse, anal intercourse is increasingly common and safer sex efforts should encourage condom use during both sexual activities. Masturbation should be encouraged as an alternative to higher risk sexual practices and an essential aspect of sexual well being. Finally, practitioners should continue to address specific threats to college students' sexual health, including alcohol use and non-verbal consent.

HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention

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.

Factors associated with event level anal sex and condom use during anal sex among adolescent women

PURPOSE

To examine the distribution of and factors associated with event-level heterosexual anal sex and of event-level condom use during anal sex among adolescent women.

METHODS

Adolescent women (N=387; age 14-17 years at enrollment) were recruited from primary care clinics for a longitudinal cohort study of sexually transmitted infections and sexual behavior. Data were taken from daily sexual diaries; generalized estimating equation logistic regression assessed the likelihood of anal sex or condom use during anal sex on a given day.

RESULTS

Heterosexual anal intercourse is a small but nonrandom event-level component in adolescent women's sexual behavior. About 30% of anal sex events were condom protected. Mood, partner, and situational factors predicted anal sex, but not condom use during anal sex; within-day and recent behavior factors were the strongest influences on both outcomes.

CONCLUSIONS

Our findings suggest the importance of providers' screening adolescent women patients during office visits about anal sex and about condom use during anal sex, as well as asking questions about the context of these behaviors to appropriately tailor risk reduction counseling.