- Condoms, PrEP, and Treatment as Prevention (TasP) are the most effective forms of protection against HIV before exposure. PEP is an effective means of protection against HIV after possible exposure. Condoms are the only form of protection against other STDs
- While it’s safer to top than to bottom, either person can get STDs if not using condoms (and HIV, if neither one of you is on PrEP or HIV treatment)
- Use lots of water- or silicone-based lube to prevent tearing during sex, especially when using condoms
- Get screened for STDs and HIV every three months if you’re sexually active. Ask your doctor about screening for HPV-related anal cancers, as well as penile and mouth cancers, especially if you are HIV-positive or a bottom
Unprotected anal sex is the easiest way for STDs/HIV to be transmitted during sex, although the exact degree of risk can depend on many factors. Acute HIV infection increases the likelihood of transmission during anal sex dramatically, and it is at this stage that most people are unaware they have been infected.
While topping is generally less risky than bottoming, both are considered high-risk activities without protection. Studies have suggested that bottoming without protection poses 18 times more risk for HIV infection than does vaginal sex without protection, and as much as 14 times more risk than topping without protection. In fact, bottoming without protection is the most common method of HIV transmission in MSM. Bottoming is riskier because the rectal tissue is not only already more susceptible than our external skin to the spread of infection, it also lacks natural lubrication – which can lead to small tears during penetration that can give STDs and HIV direct access to the bloodstream. The chance of HIV infection for a bottom is greatest when someone cums in their butt. Still, pulling out does not greatly reduce risk of transmission, as pre-cum has been shown to contain high levels of HIV. Poppers, and possibly douching, can increase risk for bottoms, because poppers increase the blood flow to rectal tissues and douching flushes out the mucus layers that lubricate and protect the rectal/gut wall, facilitating the entry of HIV.
For tops, HIV can be present at high levels in secretions and blood from the rectal tissues and can then enter through the lining of the urethra, or through small cuts, abrasions or open sores on the penis. Research has shown that men who are circumcised have a lower risk of becoming infected with HIV and other STDs or transmitting these infections if they already have them. This is because circumcised men have much fewer bacteria living on and around the penis, which gives them an advantage when it comes to fighting off infections like HIV.
Many other factors can also increase the likelihood of HIV infection during anal sex. Having an existing STD can make both partners more susceptible, since inflamed tissue or open sores provide an easier route for HIV transmission.
In addition, rectal bleeding, caused by numerous things including hemorrhoids, certain STDs, herpes lesions, the prior use of sex toys, and fingering/fisting, can increase the risk for both partners. If you notice uncontrolled rectal bleeding, you should seek medical attention right away.
Luckily, there are ways to reduce the chances of getting anything more than pleasure from anal sex. Using plenty of water- or silicone-based lube can prevent chafing and tears and make for a smoother ride. It’s important, particularly for the bottom, to relax before insertion and remember to take a break if anything starts to feel painful.
Protection from HIV infection can take on a number of forms, including condoms (male and female), PrEP, and Treatment as Prevention (TaSP). PEP is an effective means of protecting yourself against HIV after possible exposure. Remember, though, that condoms are the best way to prevent passing along STDs.
If you don’t use these methods, there are also a number of alternative risk reduction strategies that, while not nearly as reliable or effective, have been shown to lead to better health outcomes than doing nothing at all. These include:
• strategic positioning, or sero-positioning, which means the negative partner takes only the top role with partners of positive or unknown status
• withdrawal, or having the top pull out before cumming in the bottom’s butt
• serosorting, or choosing partners whom you believe to have the same HIV status as you
• negotiating safety, or agreeing, between two HIV negative partners, that unprotected sex with a regular HIV-negative partner is acceptable, while agreeing to disclose test results and sex outside the partnership (and limit risk with outside partners) (CDC on negotiated safety).
Whether you like to top or bottom, it’s always a good idea to communicate with your partner about your HIV status and ask about his.
Also consider asking your doctor about screening for HPV-related anal cancers, as well as for penile and mouth cancers, especially if you are HIV-positive or bottom, and if any strange warts or lumps appear in those areas.
Helpful resources on how to have better anal sex:
• The Gay Men’s Health Charity
• Down an’ Dirty: Douching
Adapted from HIV=, POZ, WebMD, SFAF, National LGBT Cancer Network, NAM: aidsmap