Bloodborne HIV: Don't Get Stuck!

[return to first circumcision page]

This page discusses options for men to avoid getting HIV through sex with women. Other pages in the website discuss options for men to protect themselves from blood-borne HIV during skin-piercing healthcare and cosmetic services, and (briefly) how men can avoid HIV if they have sex with other men.

Men get more options over time

Men’s options before 2007: Before three circumcision trials reported results in 2005-2007, men in Africa already had ABC options — Avoid, Be faithful, use a Condom — to avoid getting HIV from sex. Condoms are >90% effective (from studies in countries with safe healthcare; although many studies in Africa show men getting HIV even if they use condoms, no such study shows HIV came from sex rather than blood-borne risks).

Reports from circumcision trials in 2005-7 give men two more options: The three circumcision trials (Kenya, South Africa, Uganda) reported in 2005-7 provide evidence for two additional options for men to avoid getting HIV through sex with women (caution: evidence is weak; trials did not trace any man’s infection to a specific sex partner or blood exposure):

• circumcision reduces men’s risk to get HIV by more than 50%;
• waiting at least 10 minutes after sex to wash or wipe genitals reduces men’s risk to get HIV by more than 70%.

Although the trials show two options for men to protect themselves, circumcision has been the only option WHO, UNAIDS, and USAID have promoted on the basis of trial results. In 2007, WHO proposed 20 million men in Africa be circumcised by 2015.[1] In 2016 UNAIDS proposed an additional 27 million men circ’d through 2020 (on top of 9.1 million circ’d through 2015).[2]

More options emerge in the decade to 2018:  More testing and treatment improved men’s options over the next decade to 2018.

• In 2007, only a minority of HIV-positive adults knew they were infected. This has changed. Testing is more available; self-test kits are available as well. As of 2017, 75% of HIV-positive people in Africa knew they were infected.[p 70 in reference 3]
• In 2006, only 8.5% of HIV positive adults in Africa were on antiretroviral therapy (ART). This has changed. Men can encourage HIV-positive sex partners to take antiretroviral therapy (ART); as of 2017, 60% of HIV-positive adults in Africa were on ART.[4] Most had suppressed viral loads, reducing their risk to transmit through sex by more than 90%.
• In 2012, WHO proposed that HIV-negative men in “identified” sero-discordant couples could take oral antiretrovirals (PrEP: pre-exposure prophylaxis) as an “additional intervention” to avoid getting HIV from their infected partner.[5]

Scenarios for men to use one or more options

Married or in long-term partnerships: Testing is a good place to start. Even people are virgins, they could have gotten HIV from a blood exposure. If the woman is infected, she should be encouraged to take ART for her own health. After 3-6 months on ART, her viral load should be suppressed, cutting her risk to transmit by more than 90%. What to do about the remaining risk? Condoms would cut it to near zero. Other options leave risk: Waiting after sex to wash or wipe provides some protection and has no side effects. Circ’ing comes with side effects. PrEP does as well, but might be useful for a few months only if a couple wants to have a baby.

Short-term partnerships: Partners can report recent test results (do you trust the self-report?). Convenient and immediate testing is also available with self-testing kits. If no one is HIV-positive, you have other issues to consider. Condoms prevent pregnancy and other STDs and reduce feelings, but have no other adverse effects. Circumcision does not prevent pregnancy or other STDs, reduces feelings, and has other adverse effects.

Addendum: What to make of evidence waiting to wipe or wash genitals protects men?

According to evidence from Uganda, circumcision and waiting to wash give men only partial protection against HIV. Men who really don’t want HIV should rely on better options (testing, condoms, and ART for HIV-positive partners). However, if a man is very sure, but not 100% sure, that a partner might be HIV-positive, the option to wait at least 10 minutes after sex to wipe or wash is something to keep in mind.

During two circumcision trials in Uganda (2003-08)[6,7] researchers asked men whether and how they cleaned their genitals after sex. Men — both circumcised and intact — who did not wash after sex got HIV at the rate of 0.38% per year, whereas men who washed after sex got HIV more than three times faster, at 1.35% per year.[8] In a separate report from the same study, intact men who cleaned their genitals after sex but waited at least 10 minutes to do so, got HIV at the rate of 0.39% per year. Those who wiped only, without water, got less HIV than men who used water.[9] The study team explained: “…[T]he acid pH of vaginal secretions may impair viral survival… [U]se of water with a neutral pH may facilitate viral survival… [D]elayed cleansing may reduce viral infectivity by prolonged exposures to vaginal secretions.”[10]

Despite these results, men in African continue to wash after sex. For example, in a follow-on study in 2006-11 in the same community that produced the evidence reported above, more than 90% of intact men in Rakai, Uganda, washed their genitals after sex. Washing was still dangerous: Intact men who washed got HIV at the rate of 1.35% per year, whereas intact men who didn’t got HIV at the rate of only 0.62% per year.[11]

Evidence that leaving vaginal fluids in place after sex protects men from HIV agrees with other evidence that vaginal fluids protect women.[12-15] In addition, some evidence suggests that semen also provides natural protection, that it “contributes…to the relative inefficiency of sexual transmission of HIV…”[16]

References

1. Currran K, Njeuhmeli E, Mirelman A, et al. Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa. PLoS 2011; 8: e1001129. Available at  http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001129 (accessed 10 April 2018).

2. UNAIDS. On the fast-track to end AIDS. Geneva: UNAIDS, 2016. Available at: http://www.unaids.org/sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf (accessed 22 October 2018).

3. UNAIDS. Miles to go: closing gaps, breaking barriers, righting injustices. Geneva: UNAIDS, 2018. Available at: http://www.unaids.org/en/resources/documents/2018/global-aids-update (accessed 21 October 2018).

4. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Available at: http://www.unaids.org/en/resources/documents/2018/HIV_estimates_with_uncertainty_bounds_1990-present(accessed 19 October 2018).

5. WHO. Consolidated guidelines on the use of antiretroviral drug for treating and preventing HIV infection. Geneva: WHO, 2013. Available at: https://www.who.int/hiv/pub/guidelines/arv2013/download/en/ (accessed 22 October 2018).

6. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet 2007; 369: 657-666. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17321311 (accessed 22 October 2018).

7. Gray RH, Serwadda D, Tobian AAR, et al. Effects of genital ulcer disease and herpes simplex virus type 2 on the efficacy of male circumcision for HIV prevention: analyses from the Rakai trials. PLoS Med 2009; e1000187. Available at: https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000187 (accessed 22 October 2018).

8. Tobian AAR, Ssempijja V, Kigozi G, et al. Incident HIV and herpes simplex virus type 2 infection among men in Rakai, Uganda. AIDS 2009; 23: 1589-1594. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2715553/ (accessed 3 May 2018).

9. Makumbi et al. Male post-coital penile clensing and the risk of HIV-acquisition in uncircumcised men, Rakai District, Uganda. Abstract WEAC1LB, 4^th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Australia, 25 July 2007. Search for “Makumbi” at: http://www.abstract-archive.org/ (accessed 3 May 2018).

10. Collins S. Penile washing directly after sex increased the risk of acquiring HIV: circumcision effective for men in high prevalence populations no protective effect in gay men. i-base, 2007. Search for “Makumbi in: http://i-base.info/ (accessed 22 October 2018).

11. Makumbi FE, Ssempijja V, Sekasanvu J, et al. Postcoital penile washing and the risk of HIV acquisition in uncircumcised men. AIDS 2016; 30: 1669-1673. Abstract available at: https://insights.ovid.com/pubmed?pmid=27243775 (accessed 6 May 2018).

12. Fonck K, Kaul R, Keli f, et al. Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya. Sex Transm Inf 2001; 77: 271-275. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744330/ (accessed 6 May 2018).

13. Low N, Chersich MF, Schmidlin K, et al. Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med 2011; 8: e1000416. Available at: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000416 (accessed 6 May 2018).

14. Smith JA, Daniel R. Human vaginal fluid contains exosomes that have an inhibitory effect on an early step of the HIV-1 life cycle. AIDS 2016; 30: 2611-2616. Abstract available at: https://www.ncbi.nlm.nih.gov/pubmed/27536982 (accessed 6 May 2018).

15. Masese L, McClelland RS, Gitau R, et al. A pilot study of the feasibility of a vaginal washing cessation intevention among Kenyan female sex workers. Sex Transm Infect 2013; 89: 217-222. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23002190 (accessed 6 May 2018).

16. Balandya E, Sheth S, Sanders KK, et al. Semen protects CD4+ target cells from HIV infection but promotes the preferential transmission of R5 tropic HIV. J Immunol 2010; 185: 7596-7604. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071682/pdf/nihms-283633.pdf (accessed 6 May 2018).