HIV and gay sex

What is meant by “gay”?
Gay people, or homosexuals, are people who are sexually and romantically attracted to members of their own sex. Increased societal acceptance in recent times, as well as gay advocacy, has lead more gay people to be open about their sexuality.

However, gay people still frequently experience prejudice and pressure to conform to society’s heterosexual “norm”, which is that people are expected to form sexual relationships with members of the opposite sex. This can cause many gay people, particularly adolescents and young adults, to believe that their sexual orientation is abnormal and shameful, and that they should keep it hidden.

Not everyone can be neatly labelled “gay” or “straight” (heterosexual). Some people are bisexual - attracted to members of both sexes. The reality is that most people, in terms of sexual orientation, are somewhere along a continuum between being strictly heterosexual or homosexual. For example, some people consider themselves to be primarily homosexual, but have had previous heterosexual experiences. Many men who have sex with other men, such as prisoners and male sex workers, may not define themselves as gay or bisexual. Some bisexual people may not consider themselves part of the gay community.

HIV/Aids and the gay community
HIV was first recognised in the male gay community over 20 years ago, which initially lead many people to think of it mistakenly as a “gay disease”. As numbers of heterosexual people infected with HIV continue to rise, this misconception is fading, although discrimination against gay men on the grounds that they are associated with HIV/Aids, persists. Gay activists responded rapidly to the challenge posed by the epidemic in the 1980s, and their promotion of Aids awareness and safer sex practices helped to slow infection rates in the gay community.

Gay organisations play a vital role in allowing gay people, and especially HIV-positive gay people, to feel that they have a support structure and are not living in isolation. HIV-positive gay people may lack the conventional support structures available to heterosexuals, such as the family unit. Despite increasing acceptance, some gay people are still doubly rejected by their families – because of both their sexual orientation and their HIV-positive status.

Gay men and the risk of HIV infection
Worldwide the majority of people with HIV/Aids are heterosexual. However, in the developed world HIV infection rates are much higher among homosexual than heterosexual men, and this is likely to also apply to South Africa. (Accurate infection rates among gay South Africans are not known.)

HIV infection among gay men occurs mainly through unprotected anal sex and, to a lesser extent, through unprotected oral sex. Some gay men become infected through sharing drug needles.

With the largest heterosexual epidemic in the world, resources in South Africa have generally not been directed towards the relatively small group of homosexual men. (The priority target group for HIV prevention in South Africa is the youth.) Gay activists have criticised the fact that attention has been paid to other high-risk groups, such as sex workers and migrant labourers. Another reason for the relative lack of focus on the gay community may be the widespread denial that homosexuality exists within the black South African community.

Certain behaviours put gay men at risk of contracting HIV. Gay men have a reputation for sexual promiscuity, but in fact many are in long-term, faithful relationships with one partner. Nevertheless, gay relationships do not have a well-recognised and well-established moral code in the way that heterosexual relationships and marriages do. There is less expectation for gay people to be monogamous (faithful to one partner), and this may encourage promiscuity and increase the risk of HIV. Gay teenagers also often lack guidance about sexual issues, which may make them more vulnerable to high-risk activities.

Common sexual practices among gay men that significantly increase the risk of HIV infection include:

• Unprotected anal sex, with the risk higher for the partner being penetrated. HIV can enter through the mucous membrane (lining) of the anus and rectum. Anal sex can also cause small tears in the anal lining and on the penis, making it easier for the virus to enter.
• Rough sex play that causes abrasions or bleeding of the skin or mucous membranes.
• Unprotected oral sex, with the risk higher if there is exposure to semen.

Safer male gay sex:

• Safer sex involves not letting one person’s body fluid (semen and blood are the main concerns) get into someone else's body. HIV can enter the bloodstream via the anus and rectum, penis, mouth, eyes and breaks in the skin (such as cuts or open sores).
• Use a condom for anal and oral sex. A water-based lubricant helps prevent condoms breaking.
• Avoid sharing sex toys. If a sex toy is shared, cover it with a condom. HIV cannot live long outside the body, but it can be transmitted on the surface of sex toys.

Male rape and sexual abuse, although not nearly as prevalent as sexual violence against women, are not uncommon. Young male prisoners are especially vulnerable. Forced anal penetration carries a high risk of HIV infection, and victims of male rape should receive post-exposure prophylaxis.

Gay women and the risk of HIV infection
There is a common misconception that women cannot get HIV from having sex with other women. Although woman-to-woman HIV transmission is considered to be low-risk, there are recorded cases and transmission risks have not yet been well studied. Factors that may increase risk include:

• Sex during menstruation
• Contact with vaginal discharge caused by vaginitis (vaginal inflammation).
• Genital ulcers caused by sexually transmitted infections.
• Sexual practices that involve breaking the skin, such as shaving and piercing.
• Sharing sex toys for vaginal or anal penetration. Sex toys can cause bleeding or abrasions of the vaginal or anal lining, making it easier for HIV to enter the body.
• Some women who have sex with women also have sex with men, increasing the risk of infection.

Safer female gay sex:

• Safer sex involves not letting one person’s body fluid (blood, vaginal fluid and breast milk) get into someone else's body. HIV can enter the bloodstream via the vagina, anus and rectum, mouth, eyes, and breaks in the skin (such as cuts or open sores).
• Remember that infection is possible if you get your partner’s body fluid on your hands and then touch your own vagina. This can be avoided by wearing gloves.
• Cover the vulva (external genitals) with plastic wrap or a cut-open condom, or wear a dental dam during oral sex.
• Avoid sex during menstruation.
• Avoid sharing sex toys. If a sex toy is shared, cover it with a condom.