Less Silence, More Science: Making Anal Sex Safer

When we think about anal intercourse – and many women and men think about it, and do it, much more often than anyone is willing to admit – we tend to assume that we're talking about gay men at risk for HIV in the Global North.

It's true that anal intercourse is a widely practiced behavior among gay men and other men who have sex with men, with the vast majority (95%) of gay men in the United States reporting having engaged in anal intercourse. But in absolute numbers, seven times more heterosexual women than gay men in the US practice receptive anal intercourse.

In many parts of the world, including North America, Latin America, Western Europe, Australia and New Zealand, unprotected anal intercourse is recognized as a significant driver of the HIV pandemic. But one of the dangerous silences of global HIV prevention efforts has been the neglect of anal intercourse between women and men as well as the HIV prevalence among, and indeed, the very existence of, gay men and other men who have sex with men in Asia, Africa and other parts of the developing world.

This neglect costs lives.

This neglect costs the lives of gay men and other men who have sex with men. Studies have shown that in many parts of Latin America, Africa and Asia, rates of HIV prevalence among gay men and other men who have sex with men are significantly higher than in the general population. In many parts of the developing world, these men and anal sex are highly stigmatized, widely criminalized, and virtually ignored in HIV prevention efforts.

And this neglect costs women's lives, and the lives of men who have sex with women. While rarely discussed in the scientific literature, anal intercourse is increasingly understood as a relatively common practice among heterosexual couples. In the US and UK, between 10% and 35% of heterosexual women report practicing receptive anal intercourse. Lifetime reports of anal intercourse with opposite-sex partners are as high as 40% for US males. Anal intercourse between men and women has been linked to HIV infection in many parts of the world.

Globally, almost all anal intercourse is unprotected. We are more than 26 years into the HIV pandemic, and the receptive partners during anal sex still have no prevention options they can control.

Hope on the Horizon

Appalled at this state of affairs, a group of advocates and researchers have come together to form International Rectal Microbicide Advocates (IRMA). IRMA is a global network of over 600 advocates, policy-makers and leading scientists from 40 countries on six continents forging a robust rectal microbicide research and development agenda.

Currently in development, rectal microbicides are products that could be available in the form of a cream, gel, douche or enema, that may be used to protect against HIV transmission when used during anal intercourse.

International Rectal Microbicide Advocates (IRMA) released Less Silence, More Science: Advocacy to Make Rectal Microbicides in February 2008, at the Microbicides 2008 conference. The report serves as an authoritative reference on rectal microbicide research, and describes global challenges, and key advocacy goals and strategies.

The Current State of Research

Rectal microbicide research is more robust in 2008 than it has ever been, but it is still woefully underfunded. In 2006, only $7 million per year was invested globally in rectal microbicides research. It is conservatively estimated that it will cost at minimum $350 million over the next 10 to 15 years, or roughly $35 million a year to develop a comprehensive rectal microbicide research program. Annual spending needs to increase five-fold to ensure timely discovery and development of a rectal microbicide.

In 2007, IRMA conducted the world's largest survey on anal sex. The purpose of the web-based survey was to gather data on the types of lubricants people use, as well as preferred lube characteristics. Almost 9,000 people responded from 107 countries. The survey showed that a rectal microbicide formulated as a lubricant provides an excellent opportunity to provide protection to those who engage in anal intercourse. Indeed, a rectal microbicide formulated as a lube would probably be highly acceptable, especially if it has no flavor, color or smell, and is available in both thick and liquid consistencies, and with the option of a water or silicone base. The survey also showed that when testing lubricant products for rectal safety and testing candidate rectal microbicides for safety and efficacy, researchers should consider the implications of other substances (saliva, water, vaginal fluid) added to the product.

Getting Things Done

With the promise of widespread acceptance of a lubricant rectal microbicide in hand, IRMA will accelerate research by mapping out the key areas requiring urgent attention to move rectal microbicides research forward; by advocating for a five-fold increase in rectal microbicides funding; by encouraging the testing of commercial lubricants for rectal safety; and by advocating for increased research into global anal intercourse. IRMA will also seek to ensure rectal safety of vaginal microbicides and to integrate rectal microbicides into broader prevention efforts.

For more information on IRMA and rectal microbicides, including a copy of the report, please consult visit this site. You can also sign up for IRM's listserv, and check their blog for more news and updates.

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  • harry834

    making the anal intercourse safer for everyone

  • http://www.wisdomofwhores.com invalid-0

    A rectal microbicide would be great. But given recent disappointments in vaginal microbicide research it’s not something to hope for any time soon.

    Why don’t we start with the battles we can easily win? Simply increasing the use of safe lubricants in anal sex would reduce abrasion and lesions, and reduce the transmission of viruses transmitted through contact with body fluids, including HIV. In many countries, use of safe lubricant is still virtually unknown. In a study in the Indonesian capital Jakarta a few years ago, we found that fewer than a third of gay men had EVER used water-based lube in anal sex and among male and transgender sex workers it was under 15%.

    We started packaging and distributing safe sex packs containing condoms and lube sachets, and then started selling them at subsidised prices. Lube use doubled among gay guys and quadrupled among sex workers in just a year. (As an aside, condoms especially branded for men who have anal sex with one another also sent condom use shooting up).

    Developing new technologies is all well and good, but as you rightly point out it is expensive and time-consuming. Could we start be ensuring that we’re making best use of the technologies we already have?

  • invalid-0

    Thank you so much for raising two very important points which are absolutely true, and which I did not have space to discuss in the original blog.

    First, as disucssed in the report Less Silence, More Science (www.rectalmicrobicides.org), current prevention effrots are woefully inadequate, and should be scaled up significantly. A quote from the report:

    “Clearly, with over 6,800 new infections every day across the world, there is a need to scale up global prevention efforts significantly. The Global HIV Prevention Working Group, convened by the Bill & Melinda Gates Foundation and the Henry J. Kaiser Family Foundation, estimates that globally, only 9% of risky sex acts are undertaken while using a condom, and that prevention services reach less
    than 10% of men who have sex with men and persons who inject drugs, and less than 20% of sex workers.

    The Working Group calls for massive and urgent scaling up of existing global HIV prevention methods. According to the group, “if comprehensive HIV prevention were brought to scale, half of the infections projected to occur by 2015 could be averted… We could slow and even begin to reverse the trajectory of the global HIV epidemic by using the prevention tools currently at our disposal.”

    Second, use of lubricants, and ensuring their safety for rectal use are among the primary golas of IRMA. As you can see in section 3.2 of the report (pages 34-40), IRMA conducted a global survey on lubricants, and is working with researchers to ensure their safety (check section 2.12 also for more information).

    All this to say, as you suggest, that we need both approaches: scaling up exisitng and proven prevention methods, and developing new prevention tools.

  • invalid-0

    I think the reality that significant numbers of heterosexual women have anal intercourse in a critically important part of the discussion, and needs to be mentioned much, much more often — “gay men” and “anal intercourse” are generally conflated, to the exclusion of any other parameter. That said, I think we still know almost nothing (because you can’t find research dollars for this sort of thing) about heterosexual women and anal sex, and we should be very careful about how we talk about it. The word “practice,” above (for example) might lead to the conclusion that heterosexual women and gay men who have sexual intercourse do so at the same rate, which may or may not be true. We also know very little about why heterosexual women have anal intercourse when they do — one common assumption is that it’s widely used to avoid pregnancy, but that ignores a host of other questions (power, pleasure, boredom, experimentation, etc.) that are all relevant about all sexual practices.

    The need for development of an effective rectal microbicide is abundantly clear — but the need for a deeper understanding of sexual practices, negotiating strategies, communication, etc. is also clear, since the answers to those questions will help us effectively promote and utilize vaginal and rectal microbicides once they are developed.

  • invalid-0

    Sexual intercourse is no longer an act of the mythical love, it has become a fixable commodity, exploitable, tangible, predictable and manipulateable. We just need to understand the mechanism, while forming the necessary tools with associated political catalysts. Historically we can discern the roots back to embedded eugenics programs, it just takes a little carpet lifting to understand the idea. To understand human nature is not so hard, just look out the window, stop subscribing to your local shepard express, turn off the idiot box, as well as perhaps lowering your endorphin stimuli requirements.
    As for rectal aficiados, children/youth in experimentation learn the no go area is up front, and either gender suffices for relief on either side of the encounter, thus creating the neo age thinking. As for heterosexual woman taking it up the wazzoo, my mind doesn’t go there, especially with the complimentary fellatio. Oh, yuk. With the current CDC reports we find a very strange thing, mission accomplished, then wasn’t that part of the plan anyway.

  • http://www.rectalmicrobicides.org invalid-0

    To Earl’s point, we certainly need more information about the set, setting, context, incidence and prevalence of anal intercourse among men and women, among men, and every other gender variant between in every region of the world.

    While we have some data, it is not nearly enough to have a full understanding. But here is what we DO know – unprotected anal intercourse is about 10 to 100 times more efficient at transmitting HIV in comparison to unprotected vaginal intercourse. Therefore, even a low prevalence/incidence of unprotected anal intercourse can have (and is likely having) a significant impact on the HIV epidemic in both the Western and the Developing worlds.

    And many in the prevention world are very keen to have safe, effective and acceptable rectal and vaginal microbicides, none of us would ever suggest that our work ends there. A microbicide will be but another tool – it will never be a silver or golden bullet, it will be an OPTION. And things like communication, negotiation, and gaining an understanding of our messy and complicated lives will continue to be KEY.

    Jim Pickett
    IRMA Chair

  • invalid-0

    As a young person who has been working in the field of sexual and reproductive rights in an environment where the open discuse on issues on sex is viewed as a taboo and a no go area,Where do you start from?, you are at a cross road yet, you must push ,advocate .But i think there is need to be more creative in our advocacy .WE IN THE DEVELOPING WORLD HAS NOT BEEN PART OF ANY DEVELOPMENT OF ANY STRATEGY to psh for wider acceptance of any prevention intervention of sexually transmited infections through the anus(ANAL).
    There is the need to get us involve in all the proceses,more especialy we the young persons.
    I am also a zonal cordinator of the sexual minorities against AIDS in Nigeria(SEMAAN). We are dying pls this is an open plea can we in nigeria working with the larger lgbti constituency form a coalition or a network on this? is there already existing network in Nigeria that you know of pls let me know, and what kind of assistance can we get from a group like yours? thank you
    Thaddeus Ugoh
    programm officer
    advocates for human righs,
    zonal cordinator ,Sexual Minorities Against Aids in Nigeria,(SEMAAN)
    mobile- 08064089987,08052361249
    address–no 1 mevo close ,setraco junction,mpape,Abuja-Nigeria

  • invalid-0

    HI JIM ,

  • http://www.rectalmicrobicides.org invalid-0

    Thaddeus – I will e-mail you some info privately, but would like to encourage you to join up with (IRMA) International Rectal Microbicide Advocates – we have over 600 members from 46 countries, many from Nigeria. We have a listserv that connects our group, a website and a blog – each are filled with info and resources for advocates, scientists, policy makers and funders from all over the world to utilize.

    You can check out a couple of posts from Nigerians, who just joined IRMA at the Microbicides 2008 conference recently held in Delhi, on IRMA’s blog here – http://www.irma-rectalmicrobicides.blogspot.com

    I also recommend reading the report that MarcAndre mentions in his post above.

    We would welcome your creative advocacy and will help link you to other groups and individuals in Nigeria and around the world doing this important work. Let me know if I can add you to our list and we will go from there my friend!

    IRMA Chair

  • marc-andre-leblanc

    As Jim suggested, definitely join IRMA, read the report, and take a look at the postings from other Nigerians on the IRMA blog. They were so motivated after attending the Microbicides 2008 conference that they formed an IRMA chapter in Lagos!

    Thaddeus, you are absolutely right about the need for increased participation from developing countries in all this advocacy. We are determined to make this happen with IRMA, and would appreciate your input, as well as the input from others around the world. While the fact that much global organizing of advocacy efforts happen electronically, IRMA can support advocates from developing countries to join our teleconferences, and we are commited to finding creative means of meaningful engagement. Let's discuss how we can all work together!

  • invalid-0

    From the National Health and Social Life survey done in the early 1990s in the US we have data on anal intercourse in last sex event and lifetime. The data are available in two publications, one of which is titled Sex and Society. If I were in my office I would give you the exact figures, but in my recollection it is about 10% in last event and 25% lifetime, though don’t quote me on these. It also varies by certain demographic variables, including ethnicity, with reported rates among Hispanic men significantly higher than among other men.

  • invalid-0

    None of that made any sense.