via Australian Federation of AIDS Organisation, by Eric Glare

This article describes the biological role of anal mucus and its association with the gastrointestinal immune system, which harbours a persistent reservoir of HIV that potentially leads to infectious anal mucus. ERIC GLARE argues that all HIV prevention discussions should highlight the role anal mucus plays in HIV transmission.

Strategic positioning, where an HIV-negative man takes the insertive role inunprotected anal intercourse with an HIV-positive partner in order to reduce his risk of infection, has been associated with an intermediate incidence of HIV in cohorts of Sydney men who have sex with men (MSM).

Circumcision of the insertive partner and an undetectable blood plasma viral load in the receptive partner are two factors often cited as contributing to risk reduction in strategic positioning practices, despite there being a paucity of data on HIV transmission by anal intercourse in men who take the insertive role in male-to-male sex.

Men who practise strategic positioning are attempting to take perceived risks into account to form personalised boundaries around anal intercourse but, until recently, a comprehensive understanding of HIV transmission through insertive unprotected anal intercourse has not been widely canvassed in research literature.

A 2008 study of risk factors associated with HIV seroconversion in gay men in England identified that some men taking the insertive role in anal intercourse contracted HIV because they did not perceive that they were at risk of infection. GMFA, a gay men’s health charity based in the UK, responded with a campaign called Arse Facts that identified anal mucus as a body fluid containing HIV at potentially infectious levels.

Anal mucus is increasingly being mentioned in Australian campaigns as the infectious body fluid potentially infecting the insertive partner during unprotected anal intercourse. At times, the explanation of the role that anal mucus plays in transmitting HIV to the insertive partner has been relegated to in-depth discussions of topics such as risk reduction, but is frequently left out of more introductory information about HIV transmission (e.g.,and some campaigns discuss the risk of insertive anal intercourse without mentioning any body fluids involved.

Some campaigns warn that even if an HIV-positive person has an undetectable blood plasma viral load they might have higher viral load in anal mucus, particularly if they also have another STI. However, it should also be noted that a recent study, looking at men who have sex with men, found that plasma and rectal viral load were correlated, and that STI in the rectum did not increase the likelihood of detecting HIV in anal mucus, including those that had low or undetectable levels of HIV in their blood. This study suggests that a lower HIV viral load in blood plasma would also mean a lower viral load in anal mucus.

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