by IRMA advocate Bisi Alimi (pictured in purple, with IRMA advocate Kadiri Audu at the recent Project ARM – Africa for Rectal Microbicides meeting held in Addis Ababa, Ethiopia.)

While I was in secondary school, I was always told that anal sex is something between two men. Many anti-gay activists have used this sexual practice as a means of attacking the gay movement. It is the core of the sodomy law in Africa and the buggery law in other part of the world.

However, recent studies have shown an increasing number of heterosexual people in Africa, mostly young people, are practising anal sex on a daily basis.
While the notion of sex in itself is a very difficult topic to tackle in the African setting, the mere fact that more and more straight couples in Africa are embarking on a rectal sexual journey for pleasure gives a call for concern – because most of this is unprotected by condoms. An act of unprotected anal intercourse is 10 to 20 times more likely to result in HIV transmission compared to an act of unprotected vaginal intercourse, due to the different biological characteristics of the rectum which make it much more susceptible to infection.

What do we know?

According to Morenike Ukpong, at IRMA’s recently concluded Project ARM – Africa for Rectal Microbicides strategic meeting in Addis Ababa held in advance of the 2011 ICASA, over 12% of young people in Nigeria are practising anal intercourse. In different studies done across Africa on the prevalence of anal sexual practice among heterosexuals, similar results were found.

An anonymous survey of 2,593 men and 1,818 women in Cape Town conducted by Kalichman et. al (2009) found out that 14% of men and 10% of women have engaged in anal sex in the last 3 months. Of this, only 67% of the men and only 50% of the women used condoms.

Rates among truck drivers in South Africa are also very high (Ramjee et. al 2002).

A recent study found that 42% of truck drivers are consistently engaging in anal intercourse with female sex workers. Not surprisingly, a high percentage of female sex workers reported ever having practiced anal intercourse. A recent study in Kenya reports 40% of female sex workers said they had practiced anal intercourse at least once (Schwandt et. all 2006).

This is not the end of revealing data. In Lane et. all (2006) , results showed that young people between the ages of 15-24 in South Africa engage in anal sexual behaviour. There is only a small difference between the sexes, with 5.5% of young males engaging in anal sexual behaviour and 5.3% of females.

More interesting is Matasha (1998). This study found that among primary school pupils in Tanzania, 9% had anal sex as their first sexual experience.

Taken together, these studies show that there is previously unknown frequent anal sexual behaviour among heterosexuals. However, the focus on anal sex and health for many years has been the limited to gay/MSM communities.

What are we getting wrong?

The focus of HIV prevention in Africa has always been primarily targeted at vaginal sex, and thereby prevention messages have by and large been to use condoms. We are now finding though that as straight people engage in anal sex, the likelihood of using condoms diminishes. For many, anal intercourse may be a form of virginity protection, or as a means to prevent pregnancy, and there is a common belief that anal intercourse carries no risk for HIV infection.

Dr. Karim of the famous CAPRISA 004 study argued that this sexual behaviour- when unprotected – could be driving a sizable amount of new HIV infections in Africa. In agreeing with him, I asked the question “is it time for us to broaden our scope of what HIV transmission looks like in Africa?”

If we still argue that HIV transmission in Africa is mainly heterosexual, are we assuming that the risk is only from unprotected vaginal intercourse? Or are we going to acknowledge the prevalence of unprotected anal intercourse among heterosexuals and address heterosexual transmission more broadly and honestly?

Not only we are overlooking the reality and the prevalence of this sexual behaviour among the general heterosexual population, but we are also missing the chance to reassess our prevention strategy and provide safer anal intercourse education irrespective of gender or sexual orientation.

Coupled with the myth that only MSM practice anal intercourse is a troublesome lack of knowledge about the ways to practice safer anal intercourse. One area in particular where accurate knowledge is lacking is the safe use of lubricants. In a presentation at the Project ARM strategic meeting by Brian Kanyemba from the Desmond Tutu HIV Foundation, he said that many people were using all kinds of things as a lubricant: olive oil, Vaseline, Vicks and even mayonnaise – none of which are condom-compatible.

Gay and straight couples need to know the facts about anal intercourse, and need condoms and condom-compatible lubricants to engage in this behaviour in a safer way.

Hope, and the future

Anal sex is a pleasurable sexual activity, and it can be safe when certain conditions are met. One of these conditions is using condoms with condom-compatible lubrication.

Another answer to safer anal sex is rectal microbicides – which would be a lube or a gel with anti-HIV properties.

The development of a safe and effective rectal microbicides could help everyone engaging in anal sex have a more pleasurable and safer sexual experience.

It is important to know however that it is not a replacement for condom use, but could be used as an additional option for protection. Ideally, one day we will have rectal microbicides that not only protect against HIV, but other STDs as well.

This sounds very promising, but while there is ongoing research, there is no microbicide product out there in the market yet. That does not mean we should not be hopeful.

As we drive towards zero HIV infection, it is also important we started looking at other prevention technologies that will be very easy for people to use without actually affecting their established sexual behaviours.

As IRMA’s rectal microbicides advocates sat down to work at the Project ARM meeting in Addis, one of the interesting things that came out was the need to intensify advocacy for rectal microbicides in many ways. This includes engaging with our community to let people know that anal sex is a human behaviour, both homosexual and heterosexual.

There is increasing need for information on anal sex and health and active involvement of NGOs in Africa. This campaign should also include NGOs working with African communities all over the world. We should also start the discussion with women, both young and old, that there is a need for more education around safer anal sex.

Rectal microbicides are looking like the part of future of HIV prevention, but for this dream to be achieved there is the need for everyone to be involved in the process – on both the research and advocacy fronts.

From civil societies to clinicians, doctors to government officials, international organizations and funders the world over, we need to all join the fight.

But while we await the rectal microbicides reality, we should not forget that when we talk anal sex, we should also scream… AND LUBE!!

As without the right use of the right lube, anal sex will not only be painful and unpleasant, but also puts the receptive partner in greater danger of receiving sexually transmitted infections- including HIV.

Anal sex is great, condom use is pleasure, but don’t forget AND LUBE.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article’s content, whether in support or in opposition.]