Beyond Anal Sex: Sexual Practices of Men Who Have Sex with Men and Associations with HIV and Other Sexually Transmitted Infections

INTRODUCTION:

Unprotected anal intercourse is often used as a single indicator of risky behavior in men who have sex with men (MSM), yet MSM engage in a variety of behaviors that have unknown associations with sexually transmitted infection (STI) and HIV.

AIM:

To assess the prevalence of a wide range of sexual behaviors and their associations with prevalent STI and HIV.

METHODS:

We used a standardized, self-administered survey to collect behavioral data for this cross-sectional study of 235 MSM seeking care in a public clinic for sexually transmitted diseases.

MEAN OUTCOME MEASURES:

Using modified Poisson regression, we generated unadjusted and adjusted prevalence ratios (PRs) to characterize associations between recent participation in each behavior and prevalent STI and HIV.

RESULTS:

Participants' median age was 26 years. One third (35%) were positive for STI. STI prevalence was significantly associated with using sex slings, felching, group sex, fisting, anonymous sex, and sex toys. HIV prevalence was 17% and was significantly associated with fisting, felching, enemas, and group sex.

CONCLUSION:

Multiple behaviors were significantly associated with prevalent STI and HIV in adjusted analyses. To provide a more comprehensive understanding of sexual risk in MSM, prospective studies are needed to examine whether these behaviors are causally associated with HIV and STI acquisition.

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By:  Rice CE1, Maierhofer C2, Fields KS3, Ervin M3, Lanza ST4, Turner AN2.

• 1Department of Biobehavioral Health, The Methodology Center (https://methodology.psu.edu/), College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA. Electronic address: cer5374@psu.edu.
• 2Division of Infectious Diseases, College of Medicine, The Ohio State University, Columbus, OH, USA.
• 3Sexual Health Clinic, Columbus Public Health, Columbus, OH, USA.
• 4Department of Biobehavioral Health, The Methodology Center, College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA. 
• J Sex Med. 2016 Feb 4. pii: S1743-6095(16)00074-6. doi: 10.1016/j.jsxm.2016.01.001.

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Enema Use among Men Who Have Sex with Men: A Behavioral Epidemiologic Study with Implications for HIV/STI Prevention

Enema use or douching is a risk factor for HIV/STI in men who have sex with men (MSM). However, few studies have explored enema use practices. 

We examined the frequency of enema use, type of products used, and reasons to use and not to use before and after receptive anal sex in a large sample of MSM (N = 4,992) recruited from 16 U.S. cities. Through online surveys, we examined personal, behavioral, and environmental factors associated with enema use. 

Most (52 %) participants reported having douched at least once and 35 % reported douching within the last 3 months. While most (88 %) reported enema use before receptive anal sex, 28 % douched after receptive anal sex. Most participants (65 %) used water to douche, 24 % added salt, soap, and/or antibacterial products to water, and 30 % reported using commercially available products. 

Being a man of color, HIV-positive, diagnosed with an STI, identifying as "versatile" in sex, and having more than two unprotected sex partners were significantly associated with recent enema use. 

Douching behavior appears closely associated with HIV/STI risk. Douching with water may be a concern since it may increase HIV/STI infection by damaging the epithelium. 

Development and promotion of a non-damaging, non-water based enema specifically for use in anal sex are recommended. 

In addition, the seemingly contradictory recommendations that water-based lubricant is recommended for anal sex but water-based enemas are dangerous need to be reconciled into a single consistent message.

Reasons not to use enema before anal sex (N=4301)

Reasons not to douche before anal sex	n	%
I do not have receptive anal sex	866	20.1
I do not like douche, find it painful or uncomfortable	256	5.9
No need, I prefer it to be spontaneous/not planned	1975	45.9
I do not mind/prefer anal sex being “dirty”/“natural”	424	9.8
HIV/STI prevention	156	3.6
I don’t know about douching or haven’t thought about it	1141	26.5
Other	264	6.1

Full article at:   http://goo.gl/mIb0UC

By:  Noor SW1, Rosser BR.

• 1Division of Epidemiology and Community Health, University of Minnesota School of Public Health (http://www.sph.umn.edu/), WBOB-300, 1300 2nd St. South, Minneapolis, MN, 55454, USA, snoor@umn.edu. 
• Arch Sex Behav. 2014 May;43(4):755-69. doi: 10.1007/s10508-013-0203-0. Epub 2013 Dec 18.

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Risk Factors for HCV Acquisition among HIV-Positive MSM in Belgium

OBJECTIVE:

To better understand risk factors for the sexual transmission of hepatitis C viral (HCV) infection among men who have sex with men (MSM).

DESIGN:

Case-control study among HIV-infected MSM, attending AIDS Reference Centers in Belgium.

METHODS:

Cases were HIV-infected MSM who were diagnosed with HCV between January 2010 and December 2013. For each case, 2 controls were randomly selected among the HIV-positive MSM who tested negative for HCV around the same time as the cases were identified. Consenting participants were interviewed with a questionnaire on risk factors. Medical records were abstracted to document past episodes of sexually transmitted infections (STIs). Associations between HCV infection and risk factors were explored using bivariate analysis followed by multiple logistic regression analysis.

RESULTS:

A total of 52 cases and 90 controls were recruited. In multivariate analysis, douching before anal intercourse, fisting, having intercourse with HIV-positive men, and a documented gonorrhoea or chlamydial infection in the year before inclusion in the study were independently associated with incident HCV infection.

CONCLUSIONS:

Our study confirmed fisting and suffering from other STIs as risk factors for HCV and suggested an increased risk of HCV associated with serosorting. Furthermore, we identified anal douching as being associated with HCV infection. The role that douching plays in the acquisition of HCV infection and other STIs requires further research, as well as the effect of serosorting on STI transmission.

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By:  Apers L1, Vanden Berghe W, De Wit S, Kabeya K, Callens S, Buyze J, Kenyon C, Florence E, Buvé A.

• 1Departments of *Clinical Sciences; †Public Health, Institute of Tropical Medicine, Antwerp, Belgium; ‡Department of Infectious Diseases, St. Pierre University Hospital, Brussels, Belgium; and §Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium. 

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Douching Practices among Female Sex Workers in Phnom Penh, Cambodia

Several studies indicate that douching has few benefits but numerous adverse health outcomes, including increased risk for sexually transmitted infections and HIV. No published study explores douching practices among Cambodian female sex workers. 

This report provides preliminary data about the prevalence and frequency of douching among female sex workers in Phnom Penh, Cambodia. Survey data were obtained from 81 female sex workers who were taken into custody due to engagement in commercial sex from March to June 2011. 

Results showed that 91% of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD = 3.87) and 4.63 (SD = 3.94), respectively. Half of the participants thought that douching could help to prevent sexually transmitted infections including HIV; 24% were unsure about this. 

Usually, douching after sex was associated with ever obtaining an HIV test and was marginally associated (although not statistically significant) with a higher average number of clients per week and consistent condom use with clients. This suggests that these practices may be related to individual perceptions of sexually transmitted infections/HIV risk or susceptibility. 

Given the commonness of douching and related misperceptions among Cambodian female sex workers, future studies and interventions are needed to prevent adverse health problems.

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By:  Bui TC1, Tran LT2, Ross MW3, Markham CM3.

• 1Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA thanh.c.bui@uth.tmc.edu.
• 2Division of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA.
• 3Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA. 

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Condoms, Lubricants & Rectal Cleansing: Practices Associated with Heterosexual Penile-Anal Intercourse amongst Participants in an HIV Prevention Trial in South Africa, Uganda & Zimbabwe

We investigated condom and lubricant use, rectal cleansing and rectal gel use for penile-anal intercourse (PAI), during in-depth interviews with women from South Africa, Uganda and Zimbabwe who formerly participated in VOICE, a five-arm HIV prevention trial of two antiretroviral tablets and a vaginal gel. 

Few studies have addressed practices related to PAI among women; existing data from Africa on condom and lubricant use for PAI, as well as preparatory practices of PAI such as rectal cleansing, are limited to men who have sex with men. Women demonstrated a lack of awareness of HIV transmission risks of PAI and none of the participants reported using condom-compatible lubricants for PAI. 

Participants described a variety of preparatory rectal cleansing practices. Some participants disclosed rectal use of the vaginal study gel. Understanding practices related to PAI in Africa is critical to microbicide development, as these practices are likely to influence the acceptability, feasibility, and use of both vaginal and rectal microbicide products.

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By: Duby Z1, Hartmann M, Montgomery ET, Colvin CJ, Mensch B, van der Straten A.

• 1Department of Medicine, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa, zoe.duby@gmail.com.  

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Prevalence & Types of Rectal Douches Used for Anal Intercourse: Results from an International Survey

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Vaginal Douching & Association with Sexually Transmitted Infections among Female Sex Workers in a Prefecture of Yunnan Province, China

Vaginal douching is a common practice and has been hypothesised to increase a woman's risk for human immunodeficiency virus and sexually transmitted infections. Our objective was to assess the prevalence of douching and association with sexually transmitted infections, genital symptoms and human immunodeficiency virus/sexually transmitted infections knowledge among female sex workers.

We conducted a cross-sectional study of 837 female sex workers with interviews and laboratory tests for human immunodeficiency virus/sexually transmitted infections in a prefecture of Yunnan Province in southern China.

• Vaginal douching was reported by 84% of the women. 
• We found a higher prevalence of vaginal douching practice among female sex workers of Han ethnicity, and who were single or cohabitating. 
• Douching was also significantly more common among more educated female sex workers and those with greater knowledge about human immunodeficiency virus/sexually transmitted infections and with female sex workers who experienced clinical symptoms in previous 12 months. 
• Douching was linked to higher risks of human immunodeficiency virus and herpes simplex virus type 2 infections after adjusting for confounding factors.

Medical professional and public health workers should correct women's misconception about the effectiveness of douching and discourage women from douching through educational activities. More prospective studies among female sex workers are urgently required to identify the relationship between vaginal douching and human immunodeficiency virus/sexually transmitted infections infection.

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By: Luo L1, Xu JJ2, Wang GX3, Ding GW4, Wang N4, Wang HB5.

• 1Chinese Center for Disease Control and Prevention, Beijing, PR China.
• 2Key Laboratory of Immunology of AIDS, Ministry of Health, First Affiliated Hospital, China Medical University, Shenyang, PR China.
• 3Kaiyuan Center for Disease Control and Prevention, Yunnan, PR China.
• 4National Center for AIDS/STD Prevention and Control, Chinese Center for Disease Control and Prevention, Beijing, PR China.
• 5Peking University Clinical Research Institute, Beijing, PR China 

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Vaginal Douching and Sexually Transmitted Infections among Female Sex Workers: A Cross-Sectional Study in Three Provinces in China

Though vaginal douching is a common practice among female sex workers that could increase the risk of HIV and adverse reproductive health outcomes, it has drawn limited attention. 

From November 2010 to January 2011, a convenience sample of female sex workers was recruited in three cities in China. Face-to-face interviews were conducted to gather socio-demographic and behavioural information. Blood samples were collected for syphilis serological tests. Endo-cervical swabs were collected and tested for Neisseria gonorrhoeae and Chlamydia trachomatis by polymerase chain reaction. A logistic regression model was used to determine factors associated with vaginal douching and the association between vaginal douching and sexually transmitted infection. A total of 1032 eligible female sex workers were enrolled. 

The overall prevalence of any sexually transmitted infection (syphilis, Chlamydia trachomatis or Neisseria gonorrhoeae) and vaginal douching with disinfectant were 23.4% and 23.1%, respectively. Factors independently associated with douching practice included study sites, venue types, ethnicity, having regular partner and sexually transmitted infection history. No significant association was found between vaginal douching and current sexually transmitted infection. Vaginal douching with disinfectant after sex with clients seemed to be a prevalent practice among female sex workers in China. Prevention programmes targeting female sex workers should incorporate components about the adverse health outcomes associated with vaginal douching.

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