Less Silence, More Science: Making Anal Sex Safer

Marc-Andre LeBlanc

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 gay men and other men who have sex with men in Asia, Africa and other parts of the developing world.

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.

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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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