Safer Sex and HIV

According to the National Institutes of Health (NIH), practicing safe sex involves the following:

  • Use barrier protection for both vaginal and anal intercourse
  • Withdraw the penis prior to climax and ejaculate outside the partner
  • Avoid all low- and high-risk sexual activity, even with protection

Some sexual behaviors have never been connected to transmission of HIV. Dry kissing (kissing that does not involve the tongues or contact with mucous membranes inside the mouth) and touching are not routes of transmission. These are considered no-risk behaviors.

High-risk Sexual Behaviors

High-risk sexual behavior is statistically correlated with HIV infection. The three statistically significant high-risk sexual behaviors known to transmit the virus from one partner to another include the following:

  • Penile-anus sex (penis in contact with the anus)
  • Penile-vaginal sex (penis in contact with the vagina)
  • Brachio-anal sex (finger(s) or hand in contact with the anus)
  • Unprotected sex (sex without a condom or other barrier)

Most HIV infections are transmitted through penile-anal and penile-vaginal contact. The risk for transmission is dramatically reduced with the use of condoms. However, in rare cases, HIV has been transmitted via penile-anal and penile-vaginal sex, even when condoms were used.

Factors that increase risk for transmission include the following:

  • Enema or rectal douching before anal intercourse
  • Anal or vaginal irritation or infection, including the following:
    • Chlamydia
    • Condyloma
    • Gonorrhea
    • Herpes
    • Syphilis
    • Trichomonas
  • Sexual activity that may damage the mucosal lining of the vagina or rectum
  • Tampon use (Tampons can cause vaginal dryness and cellular abnormalities. Sanitary napkins are recommended.)
  • Vaginal dryness (A water-based lubricant is recommended.)

Safer Sex for Patients with HIV Who Have CD4+ Counts Less Than 200

Patients with compromised immune systems are at increased risk for contracting opportunistic infections. Intestinal infections are especially debilitating for patients who have HIV, and it is essential to practice safe sex to lower the risk for transmitting HIV and other infectious viruses and bacteria.

People with low CD4+ counts should avoid any contact with oral and rectal fluids by practicing the following safer sex behavior:

  • Limit the number of partners with whom they are "deep kissing."
  • Use dental dams or plastic wrap as a barrier during cunnilingus (vaginal-oral sex) and anilingus (anal-oral sex).

The NIH warns that studies have not been done to prove that dental dams, plastic wrap, or latex condoms that have been cut open can effectively prevent transmission of HIV or other STDs.

STDs and HIV

Studies have shown that people who have other sexually transmitted diseases (STDs) carry an increased risk for HIV infection. Treating or preventing STDs may also help prevent HIV infection. Studies are being done to evaluate the impact of aggressive STD prevention programs on HIV transmission.

Condoms and HIV

Latex Condoms for Men
Latex condoms are an effective barrier against the transmission of HIV and most other STDs. Condoms made of biological products such as lambskin are not effective, because HIV can pass through the pores.

One compelling study examined HIV transmission rates in heterosexual couples with one infected partner. Of the 123 couples who regularly used condoms, none of the uninfected partners became infected, compared to 12 new infections in the 122 couples who did not use condoms.

Condoms should be purchased from a source that can guarantee product reliability and freshness. Heat, pressure, and age can break down latex. Condoms should not be used more than 5 years after the manufacture date. If the condom looks deteriorated or discolored, or feels sticky or brittle, it should be discarded. If the packaging is torn or damaged, the condoms should not be used.

Condoms are easily torn if they are handled roughly or with sharp fingernails, so care should be taken while putting them on and taking them off. Petroleum or oil-based lubricants (e.g., Vaseline, baby oil) can break down latex and should not be used. Water-based lubricants (e.g., KY Jelly) should be used and are usually labeled "For use with latex condoms or diaphragms."

Polyurethane Condoms for Men
Newer condoms made of synthetic materials, such as polyurethane, are now available for people who are allergic to latex. Ask your doctor, pharmacist, or other health care provider which materials have been proven effective to prevent transmission of HIV and other STDs.

How to Use a Condom

Incorrect use accounts for more rips and breaks in condoms than any other factor. If not used correctly, a condom can slip off or down the penis during intercourse. To use a condom correctly, do the following:

  • Use a new condom for each sexual act (vaginal, anal, or oral intercourse).
  • Do not put the condom on too late and do not take it off too early—leave it on from start to finish.
  • Put the condom on as soon as erection occurs and before there is contact between the penis and the partner's vagina, anus, or mouth.
  • Put the condom on by holding it at the tip and unrolling it onto the erect penis. Leave a small amount of space at the tip and make sure there is no air trapped there.
  • Use water-based lubrication to prevent the condom from breaking. Do not use oil-based lubricants—they degrade latex.
  • Withdraw immediately after ejaculation and hold the condom firmly to the base of the penis so it does not slip off.

Polyurethane Condoms for Women
HIV infections are increasing more rapidly among women, according to the NIH. Women contract the virus primarily through unprotected sex with an infected male partner.

Latex condoms provide adequate protection when used correctly and consistently, but they require the consent and cooperation of the male partner. Many men will not use condoms, and in many situations and cultures, women are not empowered to negotiate condom use or to say "No." How can women protect themselves if their male partner will not use latex condoms? Women may use the polyurethane condom for women.

Polyurethane condoms for women fit inside the vagina and cover some of the vulva, the area outside the vagina. They can be used with a water-based or oil-based lubricant. The NIH warns that there is not conclusive evidence that these condoms effectively prevent HIV transmission. Polyurethane condoms for women are expensive and some argue that, like men's condoms, they should be distributed free.

Nonoxynol-9 (N-9) is an ingredient found in contraceptive foams and jellies. Early in the AIDS epidemic, many activists advocated the use of N-9 with condoms, because N-9 is a viricide (substance that destroys viruses) that would decrease HIV transmission. However, recent studies show that the use of N-9 with a condom does not improve protection and may damage the mucosal lining of the vagina, increasing the risk for infection. Women who use N-9 without a condom have a 50% higher rate of infection.

Microbicides and HIV

Researchers are developing microbicides, which are substances that destroy viruses and bacteria, to be applied inside the vagina before having sex. Efforts are being made to produce a fast-acting, unnoticeable, inexpensive, safe product that will destroy HIV. Women who are interested in using microbicides should ask their doctor or other health care provider about clinical trials and other information.

To protect yourself and your partner:

  • Stay informed and make smart choices.
  • Do not let drinking or drugs interfere with your decisions.
  • Do not let the fear or embarrassment of talking about sex keep you from protecting yourself.
  • Remember that people are not always honest about their past sexual experiences, nor do most people who are infected with HIV look any less healthy than uninfected people. If in doubt, be cautious.
  • Talk about HIV before having sex. Do not wait until passion keeps you from protecting yourself or your partner.
  • Abstinence—not having sex—is the surest way not to contract HIV and other STDs.
  • If you have sex, limit the number of sexual partners.
  • The safest sex is between two partners who are not infected with HIV, who have never used injectable drugs, and who have never had another sex partner.
  • Always use a latex condom or other form of barrier protection during sex. Though not foolproof, condoms are highly effective at preventing transmission of HIV and other STDs.
  • Know how to use a condom correctly and how to store condoms so that they do not degrade.
  • Explore sexual activities that do not involve intercourse.

If you have questions or concerns about either you or your partner, talk to an HIV counselor. In the United States, call the CDC National HIV/AIDS hotline:

  • 1.800.342.2437 (English)
  • 1.800.344.7432 (Spanish)
  • 1.800.243.7889 (TDD)

Low-risk Sexual Behaviors

Sexual behaviors that are not a proven route of HIV transmission are considered low risk. However, any close contact of bodily fluids poses some risk. HIV can be transmitted through low-risk sexual behaviors, although the chances are slight.

Since HIV is transmitted via contact of bodily fluids with mucous membranes or the bloodstream, any of the following behaviors could possibly transmit the virus.

  • Oral-oral contact, or kissing—If one or both partners have oral bleeding or oral disease, there is direct contact with the bloodstream that greatly increases the risk for transmission. Dry kissing carries no risk.
  • Penile-oral sex, or fellatio—Ejaculate can contain a greater amount of virus than saliva. If there is any oral or penile bleeding or disease, there is direct contact with the bloodstream that greatly increases the risk for transmission.
  • Vaginal-oral sex, or cunnilingus—Vaginal secretions can contain the virus. If there is oral or vaginal bleeding (including menstruation), there is direct contact with the bloodstream that greatly increases the risk for transmission.
  • Vaginal-vaginal sex, or tribadism—Vaginal secretions can contain the virus. If there is vaginal bleeding (including menstruation), there is direct contact with the bloodstream that greatly increases the risk for transmission.
  • Anal-oral sex, or anilingus—Anal secretions and feces can contain the virus. Any rectal or oral bleeding or disease greatly increases the risk for transmission.
  • Urino-oral contact, or oral contact with urine—Some ejaculate may remain in a man's urethra after ejaculation. Any urinary or oral bleeding or disease greatly increases the risk for transmission.
  • Brachio-vaginal sex, or fingers or a fist inserted into the vagina—Partners should wear latex gloves and use a water-based lubricant. If there is any bleeding or disease in the hands or vagina, brachio-vaginal contact should be avoided.
  • Brachio-rectal sex, or fingers or a fist inserted into the rectum—Partners should wear latex gloves and use a water-based lubricant. If there is any bleeding or disease in the hands or rectum, brachio-anal contact should be avoided.
  • Sex toys—Sex toys that have not been cleaned properly should not be re-used. Toys not made of latex should not be used because they may harbor traces of infected bodily fluids.

Publication Review By: Stanley J. Swierzewski, III, M.D.

Published: 30 Nov 2000

Last Modified: 12 Aug 2015