Use of Saliva as a Lubricant in Sexual

Use of Saliva as a Lubricant in Sexual Practices Among Homosexual Men: Clues to the Route of KSHV Transmission Presented to the International Rectal Microbicide Advocates, 14 May 2009 Butler, L. M. , Osmond, D. , Graves Jones, A. , & Martin, J. (2009) Use of saliva as a lubricant in anal sexual practices among homosexual men. Journal of Acquired Immunodeficiency Syndromes, 50 (2): 162 -167.

KSHV Transmission in Homosexual Men • KSHV seroprevalence: § HIV- homosexual men: 15 -30% § HIV+ homosexual men: 40 -60% § Other populations: < 10% • Spread by intimate contact • Exact route of transmission unknown • Saliva harbors KSHV most commonly

Objective Examine prevalence and determinants of saliva use among homosexual men as a lubricant during insertive and receptive: § penile-anal intercourse § fisting/fingering

San Francisco Young Men’s Health Study § Began in 1992 § Household probability sample § Homosexual & Bisexual men § Ages 18 -29 § 21 census tracts with highest AIDS incidence

Methods Serial 6 month follow up § Self-administered questionnaire § No. of partners: insertive & receptive sexual practices § HIV-serostatus of partners § Saliva use in insertive & receptive practices • e. g. , Thinking about the times when you have put your penis into another man’s rectum (you were the “top”), how often have you used your saliva as a lubricant (“lube”)? • e. g. , Thinking about the times when another man has put his finger or fist into your rectum, how often do you think the other man used his own saliva (spit) as a lubricant (“lube”)?

Characteristics of 283 Participants

Lifetime Saliva Use in Insertive and Receptive Sexual Acts

% of Participants Saliva Use in Receptive Penile-Anal Intercourse: Lifetime Never Once Sometimes Most Times Frequency of Saliva Use Always

Saliva Use in Receptive Sexual Acts: Prior 6 Months % of Participants Penile-Anal Intercourse No. of Partners Fisting/Fingering No. of Partners

Proportion of Participants who Used Saliva During Penile-Anal Intercourse: Prior 6 months By Participant and Partner Serostatus

Consistency of Saliva Use in Receptive Anal Intercourse Over Time (1 year) Concordance = 79%

Determinants of Saliva Use in Insertive Anal Intercourse

Determinants of Saliva Use in Receptive Anal Intercourse

Saliva Use Despite Otherwise “Safe Sex” Practices

Conclusions Among homosexual men: § Saliva is commonly used as a lubricant in penile-anal intercourse and fingering/fisting. § Even when conventional “safe sex” is practiced, saliva is commonly being introduced into the rectum § HIV-infected individuals (the most vulnerable for KS) are at particular risk of being exposed to saliva from other HIV-infected persons (the most apt to be KSHV-infected) § No obvious socioeconomic/cultural determinants

Implications § Use of saliva during penile-anal intercourse and fisting/fingering needs to be considered as a potential mode of KSHV transmission § Although common, saliva use is not universal, perhaps in part explaining the non-uniformity of KSHV in homosexual men § Use of saliva in these acts must also be considered a potential mode of spread for other pathogens (e. g. , hepatitis B) § Greater awareness and education about KSHV needed (only 6. 4% of homosexual men aware of KSHV) § Consideration is warranted for altering safe sex guidelines