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HIV Transmission:Guidelines for Assessing RiskA RESOURCE FOR EDUCATORS, COUNSELLORSAND HEALTH CARE PROVIDERSFifth Edition

HIV TRANSMISSION: Guidelines for Assessing Risk6. Assessing Risk of Hepatitis C TransmissionPart 1. Sexual ActivitiesKissing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Oral Sex: Fellatio . . . . . . . . . . . . . . . . . . . . . 41Oral Sex: Cunnilingus . . . . . . . . . . . . . . . . . . 42Oral Sex: Anilingus . . . . . . . . . . . . . . . . . . . . 42Intercourse: Penile–Vaginal . . . . . . . . . . . . . . 43Intercourse: Penile–Anal . . . . . . . . . . . . . . . . 43Fingering (Anal and Vaginal) . . . . . . . . . . . . 44Fisting (Anal and Vaginal) . . . . . . . . . . . . . . . 44Masturbation by Partner . . . . . . . . . . . . . . . . 45Using Insertive Sex Toys . . . . . . . . . . . . . . . . 45Sadomasochistic Activities . . . . . . . . . . . . . . . 45Contact with Feces . . . . . . . . . . . . . . . . . . . . 46Urination . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Vulva-to-vulva rubbing . . . . . . . . . . . . . . . . . 46Docking . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Breast milk . . . . . . . . . . . . . . . . . . . . . . . . . . 47Cultural Practices . . . . . . . . . . . . . . . . . . . . . 47Part 2. Drug UseI . . . . . . . . . . . . . . . . . . . . . . . . 47Injection Drug Use . . . . . . . . . . . . . . . . . . . . 47Non-Injection Drug Use . . . . . . . . . . . . . . . . 48Part 3. Other Activities Involving NeedlesTattooing, Piercing, Electrolysis andAcupuncture . . . . . . . . . . . . . . . . . . . . . . 48Part 4. Maternal TransmissionBreast Feeding . . . . . . . . . . . . . . . . . . . . . . . 49Vertical Transmission . . . . . . . . . . . . . . . . . . 49Part 5. Artificial Insemination, Blood Transfusion andOrgan Transplants . . . . . . . . . . . . . . . . . . . . . 49Part 6. OtherBranding and Scarification . . . . . . . . . . . . . . 49Esthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Fighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Intentional Exposure to Blood . . . . . . . . . . . 50Occupational Exposure . . . . . . . . . . . . . . . . . 50Sharing toothbrushes, razors etc. . . . . . . . . . . 51Polyurethane Condoms . . . . . . . . . . . . . . . . . 54Male Condom Use . . . . . . . . . . . . . . . . . . . . 54Buying and Storing . . . . . . . . . . . . . . . . . . . . 54Female Condom Use . . . . . . . . . . . . . . . . . . 55The Female Condom for Anal Intercourse? . . 56Dental Dams . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Plastic Wrap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Latex Gloves and Finger Cots . . . . . . . . . . . . . . . 56Cervical Bariers . . . . . . . . . . . . . . . . . . . . . . . . . . 578. Increasing and Reducing Risk of HIV:Biological FactorsA. Mucosal Immunity and HIV . . . . . . . . . . . . 59Sexually Transmitted Infections . . . . . . . . . . . 59Common Vaginal Infections . . . . . . . . . . . . . 59Open Cuts, Sores, Lesions, Ulcers, Burns andRashes . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Vaginal Drying . . . . . . . . . . . . . . . . . . . . . . . 60Circumcision . . . . . . . . . . . . . . . . . . . . . . . . 60Saliva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Crack Cocaine . . . . . . . . . . . . . . . . . . . . . . . 60Douching and Enemas . . . . . . . . . . . . . . . . . 60Spermicides and Microbicides . . . . . . . . . . . . 60Hormonal Contraceptives . . . . . . . . . . . . . . 61B. HIV Viral Load and Treatments . . . . . . . . . . 61Post-Exposure Prophylaxis . . . . . . . . . . . . . . 62Co-Infection with HIV and HCV . . . . . . . . 62Appendix 1: Suggestions for Further Reading . . 637. Increasing and Reducing Risk: Barrier Methodsfor Sexual Transmission of HIV2Condoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Quality Control . . . . . . . . . . . . . . . . . . . . . . 53Latex Condoms . . . . . . . . . . . . . . . . . . . . . . 53Lambskin Condoms . . . . . . . . . . . . . . . . . . . 53Synthetic Condoms . . . . . . . . . . . . . . . . . . . 53

HIV TRANSMISSION: Guidelines for Assessing RiskForeward and AcknowledgementsThe 5th edition of HIV Transmission: Guidelines for AssessingRisk marks a significant step forward in the evolution of theCanadian AIDS Society’s guidelines. For the first time, therevised guidelines incorporate hepatitis C (HCV) informationand a section on assessing the risk of HCV infection. Italso contains information included in the last edition, suchas that on injection drug use and maternal transmission.As well, this edition retains the range of biological factors,including mucosal immunity, and HIV viral load, highlightingthe complex factors that may increase or reduce anindividual’s risk of infection.HIV and HCV transmission do not occur in a biologicalvacuum. Research over the past few years has demonstrateda complex interplay among biological, sociological,psychological and economic factors that influences thevulnerability of individuals and specific groups of individualsto viral transmission. It has become clearer and clearerthat issues of class, power and socioeconomic status aremajor determinants of susceptibility to HIV infection. Themodel of attributing risk of HIV transmission to variousactivities has been retained, but an introductory section hasbeen included to place the scientific information presentedin later sections in context. Educators and health careproviders must realize that to prevent HIV transmissionsuccessfully they must incorporate prevention informationwithin the reality of an individual’s life. Using a condommay not be possible for everyone, for a variety of complexreasons. Similarly, abstaining from taking drugs or using anew and/or unshared needle and syringe every time a drugis injected may not be possible for everyone. All educatorsand health care providers should work towards developingstrategies that can help reduce an individual’s risk of HIVinfection, even if that risk is not eliminated. This may mean,for example, that assisting an individual to find stable housingmay be more effective at preventing transmission thanproviding the individual with a box of condoms.We hope that these guidelines offer a framework fromwhich to work with individuals from diverse communitiesand life experiences. These guidelines are by no means thefinal word. As information and circumstances change, so toowill the guidelines. The HIV and HCV epidemics are farfrom over. In fact, they are constantly growing and shifting.Treatment advances are enabling many people with HIV tolive longer and healthier than in the past. However, we area long way from a cure, for either HIV or HCV and thereare no vaccines in sight to prevent further infections. HIVand HCV prevention and education remains our strongestweapon in the fight against these diseases.In contrast to previous editions, these guidelines incorporatetransmission information and assessment of risk for HCV,a major concern for those people doing HIV work in thecommunity. HCV infection in Canada is rapidly on therise, especially among injection drug users, and many inpublic health and the medical community consider it tobe an epidemic on a grand scale. As a result, informationhas been included here about HCV and assessing its risk,acknowledging the many AIDS Service Organizations andfront-line workers who have taken on the role of deliveringHCV transmission information in the absence of an officialstrategy from Health Canada on coping with this secondepidemic.The Canadian AIDS Society continues to acknowledge theassistance of the organizations and individuals who contributedto the first, second and third editions of this documentin 1988, 1994 and 1999, respectively.We wish to express our gratitude to those who assisted usin developing the framework for this fourth edition. Inparticular, we are grateful for the time, energy and enthusiasmof the Review Committee, comprised of Daryn Bond,Claire Checkland, Darren Greer, Marc-André LeBlanc,Michael Mancinelli, Roger Procyk, Maxxine Rattner,Shaleena Theophilus, Kim Thomas, Sarah Tsiang, LynneBelle-Isle, Stéphanie Laporte, Christian Joubert, MichelMorin, Dominic Lévesque, Linda Truglia, Jean Dussaultand Jeremy Ries. The Canadian AIDS Society would alsolike to thank all those who worked on previous editions ofthe guidelines, including Health Hounds, and the consultantsand writers. This edition contains much that has gonebefore and could not have been completed without theircontributions.3

HIV TRANSMISSION: Guidelines for Assessing RiskThe consultation process for this edition involved educators,health care providers, researchers, people living withHIV/AIDS, people living with HCV and others from manyorganizations across Canada. Many of these individualsincluded their colleagues in the consultation, and we thankall those who devoted time and energy to the project.Canadian AIDS Society, June 20054

HIV TRANSMISSION: Guidelines for Assessing RiskQuick ReferenceCategories for Assessing HIV Risk1. No riskTo our knowledge, none of the practices in this categoryhave ever been demonstrated to lead to HIV infection.There is no potential for transmission since all of the basicconditions for viral transmission are not present.Potential for transmission . . . . . . . . . . . . . . . . . . . . . NoneEvidence of transmission . . . . . . . . . . . . . . . . . . . . . NoneExamples: Kissing (no blood); non-insertive masturbation;receiving unshared sex toys; contact with feces or urine(unbroken skin); injecting with unshared needles; usingdrugs with new pipe or straw; sadomasochistic activities(with universal precautions); tattooing, piercing, electrolysisand acupuncture with sterilized and new equipment;manicures or pedicures.2. Negligible riskAll of the practices assigned to this risk level present apotential for HIV transmission because they involvean exchange of body fluids, such as semen (includingprecum), vaginal fluid, blood or breast milk. However, theamounts, conditions and media of exchange are such thatthe efficiency of HIV transmission appears to be greatlydiminished. There are no confirmed reports of infectionfrom these activities.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . .YesEvidence of transmission: . . . . . . . . . . . . . . . . . . . . . NoneExamples: Receiving fellatio or cunnilingus; performingfellatio or cunnilingus with barrier; anilingus; fingering;fisting; using shared sex toys with a condom; using disinfectedsex toys; sadomasochistic activities; contact with fecesor urine (on broken skin); vulva-to-vulva rubbing; docking;taking breast milk into the mouth; using drugs with sharedpipe or straw; tattooing, piercing, electrolysis and acupuncturewith shared equipment; fighting; sharing toothbrushesand razors.3. Low riskAll of the practices assigned this risk level present a potentialfor HIV transmission because they involve an exchange ofbody fluids such as semen (including precum), vaginal fluid,blood or breast milk. There are also a few reports of infectionattributed to these activities (usually through individualcase studies or anecdotal reports, and usually under certainidentifiable conditions).Potential for transmission . . . . . . . . . . . . . . . . . . . . . . .YesEvidence of transmission: . . .Yes (under certain conditions)Examples: Kissing (with exchange of blood); performingfellatio or cunnilingus without barrier; intercourse (penileanalor penile-vaginal) with barrier; injecting with cleanedneedles; tattooing with non-professional equipment; takingblood in the mouth; occupational exposure.4. High riskAll of the practices assigned this risk level present a potentialfor HIV transmission because they involve an exchangeof body fluids, such as semen (including precum), vaginalfluid, blood or breast milk. In addition, a significantnumber of scientific studies have repeatedly associated theactivities with HIV infection. Even when the exact mechanismof transmission is not completely clear, the results ofsuch studies conclude that activities in this category are highrisk.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . .YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . .YesExamples: Penile-anal or penile-vaginal intercourse withoutcondom; receivng shared sex toys; injecting with sharedneedles.Quick Reference5

HIV TRANSMISSION: Guidelines for Assessing RiskQuick ReferenceCategories for Assessing Hepatitis C Risk1. No riskTo our knowledge, none of the practices in this categoryhave ever been demonstrated to lead to HCV infection.There is no potential for transmission since all of the basicconditions for viral transmission are not present.Potential for transmission . . . . . . . . . . . . . . . . . . . . . NoneEvidence of transmission . . . . . . . . . . . . . . . . . . . . . NoneExamples: Kissing without the exchange of blood; sadomasochisticactivities (with universal precautions); contactwith feces or urine (unbroken skin); injecting, smoking andsnorting drugs using new equipment; tattooing, piercing,branding, scarification, manicures, pedicures, electrolysisand acupuncture with sterilized and new equipment.2. Negligible riskAll of the practices assigned this risk level present a potentialfor HCV transmission because they involve an exchangeof blood. However, the amounts, conditions and media ofexchange are such that the efficiency of HCV transmissionappears to be greatly diminished. There are no confirmedreports of infection from these activities.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . .YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . NoneExamples: Fellatio; cunnilingus; anilingus; fingering;non-insertive masturbation; sadomasochistic activities withexchange of blood; contact with feces or urine (on brokenskin); vulva-to-vulva rubbing, docking, giving or receivingbreast milk into the mouth; fighting.3. Low riskAll of the practices assigned this risk level present a potentialfor HCV transmission because they involve an exchange ofblood. There are also a few reports of infection attributedto these activities (usually through individual case studiesor anecdotal reports, and usually under certain identifiableconditions).Potential for transmission . . . . . . . . . . . . . . . . . . . . . . .YesEvidence of transmission . . Yes (under certain conditions)Examples: penile-vaginal and penile-anal intercourse;fisting; snorting and smoking drugs using shared equipment;manicures and pedicures with uncleaned equipment;sharing toothbrushes and razors.4. High riskAll of the practices assigned this risk level present a potentialfor HCV transmission because they involve an exchange ofblood. In addition, a significant number of scientific studieshave repeatedly associated the activities with HCV infection.Even when the exact mechanism of transmission is notcompletely clear, the results of such studies conclude thatactivities in this category are high risk.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . .YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . .YesExamples: Injecting drugs using shared and cleaned needlesor mixing equipment; tattooing, piercing, electrolysis andacupuncture with shared equipment; occupational exposure.6 Quick Reference

HIV TRANSMISSION: Guidelines for Assessing RiskWho is this document for?This document:1. Guidelines Context• offers a framework for judging the levels of risk oftransmission of HIV and hepatitis C virus (HCV)through various activities;• summarizes the implications of the current medical andscientific evidence on HIV and HCV transmission; and• discusses risk reduction strategies and psychosocial factorswhich may affect a person’s ability to adopt them.These guidelines are intended as a resource for educators,counsellors, health care providers and others who provideinformation and support about safer sex, substance useand HIV and HCV transmission in various communitysettings. It is assumed that the reader will have a degree offamiliarity with scientific and technical language about HIVtransmission and risk reduction. The companion brochures,HIV Transmission – Things You Should Know and HepatitisC Transmission – Things You Should Know which contain aplain language summary of the information contained here,are intended for distribution to service users.Although these guidelines are not a complete “how to”guide for service providers, they offer a place from whichto start. Other sources need to be consulted to learn moreabout the means of equipping people with the understanding,motivation, skills, resources and social supportnecessary to make informed decisions about their sexual,substance-using and other life choices.Above all, this document is intended as a resource tool toassist in the delivery of consistent and coherent informationand support across a variety of settings. It is meant toprovide information that will assist individuals to makedecisions about the levels of risk they are willing to accept,and the types of activities that they are willing to do.Because many AIDS Service Organizations have assumedsome responsibility of providing HCV prevention informationand may be dealing with co-infection issues, thisedition also includes some information on assessing riskfor HCV. HCV risk assessment information is provided inseparate chapters.How the Document Was ProducedThe first edition of the guidelines originated in 1988 froma request by member organizations of the Canadian AIDSSociety (CAS). They were concerned by the confusionresulting from the distribution of inconsistent safer sex,drug use/safe injection, and vertical transmission informationacross the country.In response, CAS brought together a group of scientificexperts and educators to produce the approach thatappeared in the highly successful first edition of these guidelines.This fifth edition is the result of a three-part process:(1) an exhaustive review of the literature; (2) a nationalconsultation of medical, scientific and community-basedexperts to assess the continuing accuracy of the document,how it has been used and how it could be improved; and (3)review of a draft of the final document by a committee ofeducators, counsellors, heath care providers and health carepolicy analysts. The ultimate objective of regularly reviewingthese guidelines is to ensure that they reflect currentinformation and understanding about HIV transmission,and retain a reputation as one of the most authoritativepublications of its kind.Affirming Sexuality and the RiskReduction ApproachSince the beginning of the HIV and HCV epidemics, it hasbecome a truism that prevention education represents ourbest hope of controlling the effects of these viruses. Despitethe importance of prevention messages, the public has notalways been given basic, complete and easily understoodinformation that distinguishes between sexual and substanceuse practices that place individuals at risk of HIV and/orHCV infection and practices they can enjoy without worryof infection.Social disapproval and discomfort about sexuality and druguse have often led to either unhelpful coyness and innuendoor self-censorship and official silence. Too often the HIVand HCV epidemics have been used, either consciously orunconsciously, to reinforce notions of “good” and “bad”behaviour.Guidelines Context7

HIV TRANSMISSION: Guidelines for Assessing RiskThe CAS perspective concerning risk reduction has fourdimensions.1.2.3.4.Effective prevention and sexual pleasure are compatible.Research has shown that individuals will voluntarilypractise risk-reducing behaviour if they feel good aboutthemselves, about the preventive measures they aretaking and about their capacity to incorporate suchmeasures into their lives.HIV prevention messages should focus upon substanceuse as a health issue, rather than moral or criminalissues. Effective prevention measures need to acknowledgethat stopping alcohol and other substance use isnot possible for everyone. Risk reduction strategies offera variety of practical options aimed at decreasing thelikelihood of HIV and HCV transmission associatedwith substance use.All women have the right to make their own decisionsabout pregnancy and childbirth. They should beprovided with accurate information about their options,including alternatives for delivery, termination of thepregnancy and therapeutic options (for HIV) to reducethe risk of transmission to the fetus if they are HIVpositive or living with HCV.Information, education and counselling about HIVtransmission must take into account the wide varietyof psychological and social factors that can influencea person’s capacity to adopt or maintain risk-reducingbehaviour.To achieve and to reinforce positive behaviour change, itis important to affirm both sexuality and risk reduction,and acknowledge the key role they play in personal health.Healthy sexuality and choices about substance use will meandifferent things to different people, depending on theirexperiences, values and customs. Rather than attempting toget diverse groups of people to conform to a specific moralcode or lifestyle norm, we are more likely to bring aboutchanges by presenting risk reduction options most appropriateto the practices and desires of different individuals. Thatis why the emphasis of these guidelines is on informationthat can be applied to everyone and that respects individualchoice. This edition aims at providing information and supportto enable people to make informed choices rather thangiving advice. It also focusses on scenarios where informedchoice does not play the same role as it does in consensualsex or harm reduction, such as mother-to-child transmissionand sexual assault issues.Subject to the limitations imposed by anatomy, it is alsoassumed that no particular activity is confined to anyone group or class of people. Any or all of the activitiesdescribed here may be practised by gay men, lesbians,heterosexual and bisexual men and women, two-spiritedpeople 1 , transexual and transgendered people in all racial,linguistic and ethnocultural communities.It is hoped that the guidelines will encourage practices thatindividuals feel comfortable with, that bring them pleasure,and that promote their health and the health of others.The Challenge of Providing AccurateInformationThe safer sex strategy with which we are now familiar wasdeveloped before HIV was identified as the underlying causeof AIDS. The earliest AIDS-specific safer sex guidelines datefrom 1983 and were modelled on precautions to reduce thetransmission of hepatitis B, which then was prevalent incommunities becoming affected by AIDS. In the 20 yearssince those first prevention messages, a considerable amountof research has been conducted confirming much of theinitial information and clarifying different levels of risk fordifferent sexual practices.However, providing information about safer sex cannotremove all degrees of ambiguity from our messages. Theword “safer” implies that a level of safety can be achieved,but that absolute guarantees do not exist. This lack ofcertainty can lead to anxieties that inhibit some people’sability to adopt or maintain risk-reducing practices. Theseguidelines therefore now mainly refer to “risk reduction”or “HIV and HCV prevention” rather than “safer sex.”The guidelines also acknowledge that although total “riskelimination” may be the objective of the hyper-vigilant, it isnot necessarily achievable (or even desirable) in the contextof many individuals’ real lives.Lack of evidence has also led to a wide variation in riskreduction information offered by different sources. Thosewishing to educate themselves about HIV transmission haveoften been confused by conflicting information, differencesin emphasis and inconsistent terminology. For example, the1. Aboriginal lesbian, gay and bisexual people.8 Guidelines Context

HIV TRANSMISSION: Guidelines for Assessing Risksame act could be described in one pamphlet as “probablysafe” and in another as “possibly dangerous.”Providing basic information to injection drug users abouthow to avoid HIV and/or HCV transmission is no lesscomplex. The uneven availability of needle exchange anddisposal facilities, the frequency with which some usersinject, uncertainty about the efficacy of some equipmentcleaning techniques and the lack of access to informationabout other health risks associated with needle use, allpresent significant challenges to counsellors, educators andhealth care providers.The goal of this document is to offer a logical approachto the theory and evidence of HIV transmission, and toprovide a consistent framework for realistically assessing therisk represented by various activities.This edition also includes the risk of HCV infectionthrough the various activities discussed. Information aboutthe risk of transmission of this virus is becoming morewidely agreed upon and many ASOs are beginning toincorporate HCV risk information into their preventionstrategies.What Does Risk Mean?Because of the uncertainties about HIV transmission,educators and counsellors have chosen to use a qualitative“levels of risk” model. The model used in these guidelinesplaces sexual and drug using activities into categoriesaccording to their level of risk of HIV and/or HCV transmission.We negotiate risk in our lives every day and make decisions,both consciously and unconsciously, about the levels ofrisk taking with which we can cope. Every time we ridea bicycle, walk on city sidewalks, drive a car or take anairplane, we are taking a risk. We hear a great deal about thehealth risks of drinking coffee, smoking cigarettes or drinkingalcohol — risks that may eventually shorten our lives— and our actions show how we deal with that knowledge.The more we are aware of the risk, the better we are able tochoose our actions. Sexual, drug-taking and reproductivechoices should be placed in the context of other risks weface in our lives.Risk reduction information should acknowledge the optionsthat can be exercised by people who feel comfortable withsome risk, as well as validate the more cautious approachesof those who want greater assurances. There are “no-risk”options for engaging in sex and substance use and somewill choose them. However, for many people, some level ofrisk is probably either acceptable or unavoidable, making itnecessary to include a broad range of risk reduction choicesin HIV prevention education.Throughout the guidelines there is discussion of risk being‘slightly reduced’ by certain behaviours (e.g., giving fellatiowithout a condom and not swallowing semen being less ofa risk than swallowing.). However, mention of this reductionof risk does not necessarily mean a change from onecategory to another (e.g., from high to low risk) but ratherindicates different levels of risk within one category. For acategorized assessment of risk for all sexual, drug-taking andother activities, refer to sections 4 and 6.Criticisms of the Risk ModelThere have been some criticisms of the use of the risk modelin HIV prevention information. A recurring one is that riskcategories do not reflect people’s “real world” thinking aboutsexuality, nor do they reflect the “continuum” along whichsexual activity occurs (the flow and ebb of sex, with oneact stimulating or leading into another). Another criticismis that some groups of people who are deemed to be atincreased risk for HIV may take additional risks as part ofdaily life in order to survive (e.g. sex trade workers, streetinvolvedpeople, injection drug users).For the purposes of these guidelines, it must be made clearthat risk as it is defined here is based on the clinical evidenceof the likelihood of infection with HIV occurring duringthe performance of activities and behaviours described inSection 4. This clinical definition of risk does not take intoaccount other dangers or risks, such as other diseases, socialviolence or bodily damage due to drug use, that may beinherent in some situations where and when these activitiesare taking place. Whether a risk is good or bad, acceptableor unacceptable, is ultimately something individuals mustdecide for themselves. The role of these guidelines is not toeliminate or downplay risk, nor even to make individualchoice easier. It is to give a biologically accurate estimationof the likelihood of infection during certain behaviours andactivities so that a person may make up his or her own mindabout what constitutes an acceptable or non-acceptable risk.In addition, these guidelines provide a flexible frameworkupon which counsellors and front-line HIV workers maybase prevention education messages. As in the past, thisedition classifies activities according to degrees of risk bytaking into consideration the potential for transmission andGuidelines Context9

HIV TRANSMISSION: Guidelines for Assessing Riskactual scientific evidence that transmission has occurred.This model applies equally to HCV and HIV.Assessing Risk of HCV TransmissionIncluding risk assessment information for HCV in theseguidelines has been a real and ongoing challenge, partiallybecause of a lack of concrete evidence on how HCV istransmitted sexually in human beings. While the risk factorsfor transmission for HCV are similar to those for HIV inactivities involving the exchange of blood, they differ inactivities that involve the exchange of other body fluids.HCV transmission is addressed in sections 5 and 6.Risk ReductionFrom the broader perspective of public health strategy, thisdocument is guided by a commitment to risk reduction asthe most achievable goal in behaviour change. From thepoint of view of the individual, the document assumes thatit is better to provide information about options for bothreducing and eliminating risk. This way individuals candetermine which is appropriate for themselves.For example, individuals who are not comfortable withthe possibility of condom failure during vaginal or analintercourse can take further steps to protect themselves.In addition to using a condom, they can stop intercoursebefore ejaculation. If individuals want to reduce risk evenfurther, they can avoid vaginal or anal intercourse altogether.During oral sex, there is also a series of options thatindividuals can choose: they can avoid cunnilingus duringmenstruation, they can stop fellatio before ejaculationoccurs, they can use a condom or other latex barrier, or theycan avoid the practice altogether.To reduce the risk of maternal transmission of HIV tothe fetus in the uterus or during delivery, an HIV-positivewoman also has options. She may choose to terminate thepregnancy or she may choose to take prenatal anti-HIVtherapy. She may choose neither of those options and let thepregnancy run its course. After birth, she may refrain frombreast-feeding the child.Ultimately, it is up to individuals and their partners tochoose the options that are right for them. If they are givencomplete information and a chance to develop social skillsrelated to sex and substance use, individuals will usually actin their own best interests and those of their partners. Insome cases, information alone may not be enough. Both thewish to reduce or to eliminate risk and the capacity to do soare central to effective adoption of prevention measures. Thechallenge for educators and counsellors is to find ways tohelp people feel good about risk reduction strategies and toaddress issues that prevent them from being used.The Sexual and Drug TakingContinuumSexual and drug taking activities do not occur in discreetpackages of performance. Individual behaviours are oftendifficult to isolate when documenting cases of HIV infectionand their behavioural causes. Although the risk modelfor these guidelines isolates each activity and assesses riskbased on that activity or behaviour alone, it should bestressed that one activity often leads to another higher-riskactivity, making it difficult to pinpoint which activities arespecifically responsible for infection. This should be keptin mind when reviewing activities listed in these guidelineswhere “no evidence” of transmission is stated.When injecting drugs, the risk of HIV and HCV transmissioncan be eliminated by using a new needle and syringeevery time. Where sharing is unavoidable, risk of HIV transmissionis reduced by proper cleaning of the needle, cooker,syringe and other paraphernalia using bleach and water.The HCV virus is not eliminated by using these methods(see Section 5). To reduce the risk of HIV and other healthproblems associated with injection drug use, some drugsmay be swallowed or smoked but, because of the nature oftransmission of HCV and the longer life of the virus outsidethe human body, sharing of straws when snorting cocaineand other drugs is considered a higher-risk activity than forHIV (see Section 5).10 Guidelines Context

HIV TRANSMISSION: Guidelines for Assessing Risk2. Aspects of HIV TransmissionIf educators and counsellors focus on individual behaviourexclusively, without reference to social context, it will blindthem to a complete picture of how people do, or do not,adopt risk reduction practices. We now know that therisk of transmission of HIV is affected by a multiplicityof psychological and societal issues at both individual andsystemic levels. It seems essential to highlight some of theseissues in this edition of the guidelines. This section offers apsychosocial framework intended to provide context to therisk assessment model contained in Sections 3 and 4.Poverty and HealthThere is strong evidence that lower income and socioeconomicstatus is associated with poorer health in general,including lower standards of reproductive and sexualhealth 2 . Earlier initiation into sexual activity and riskiersexual practices are more common among youth with lowersocioeconomic status. Economic inequities often contributeto the continuing marginalization of certain social groups,including women, gay men, Aboriginal and ethnoculturalcommunities, sex trade workers, people with disabilities,substance users and youth. This marginalization is oftenmanifested in reduced access to education, housing andhealth care, low self-esteem, a diminished degree of controlover one’s life and environment, unequal power in relationshipsand a lower capacity to make positive choices abouthealth, including strategies aimed at reducing the risk ofHIV transmission.In addition to socioeconomic status, a range of other interrelatedclass, cultural and psychological factors can influencepeoples’ capacity to reduce their risk of HIV transmission.This section illustrates how some of these factors may bemanifested within certain marginalised groups. However,it must be emphasized that such factors are not alwaysparticular to any one group nor will members of any onegroup be similarly affected. (See Appendix 1 for suggestionsfor further reading.)2. Health Canada. Framework on Sexual and Reproductive Health, Health Canada. 1998.3. Neron, C. HIV and Sexual Violence Against Women, Health Canada. 1998.Power and NegotiationSome people lack the power or self-esteem necessary tonegotiate the use of risk reduction techniques in their sexualand drug-using relationships. For example, particularlyin relationships that involve sexual, emotional or physicalabuse, many people are at risk of HIV infection by partnerswho regard them as their “property,” who refuse to usecondoms or who consider unprotected intercourse to be “aright.” It is possible that some people with these attitudesare unaware of, or may deny, their HIV-positive status. Insuch relationships, a person’s lack of power or self-esteem islikely to affect his or her ability to decline sexual activity orto insist upon protection that will reduce risk. Peer pressure,desire to be wanted, touched or loved can all overpower aperson’s ability to negotiate for lower-risk behaviours. Theintoxicating effects of drugs and the adrenaline rush of sexcan cloud judgements when the negotiation of risk behavioursis taking place. In addition, countless other unforeseeableevents and situations may arise that will ultimatelydetermine how safe any one person is at any given time.Some men consider it unacceptable for a woman to refusesexual relations. By insisting upon condom use a womanmay be mistakenly viewed as promiscuous, disloyal, unfaithfulor a “bad” wife. The most extreme deprivation of awoman’s ability to practice risk-reducing behaviour occursin the case of rape or other sexual assault. Health Canadahas published guidelines for counsellors on HIV andsexual violence against women 3 . In addition, women fromAboriginal and ethnocultural communities, or women whoexperience isolation by virtue of geography or their designatedrole, may have limited access to appropriate forms ofinformation and support.Young people are prone to taking risks and experimentingwith drugs, alcohol and sexuality, highlighting theimportance of education and information about riskreduction for this group. Many young people also experiencemarginalization due to factors such as lack of access tohousing and education, unemployment, family breakdown,poverty and low self-esteem. Young people, particularlyAspects of HIV Transmission11

HIV TRANSMISSION: Guidelines for Assessing Riskthe homeless, are vulnerable to sexual exploitation. Onestudy found high levels of sexually transmitted infections(STIs), substance use and inconsistent condom use amongCanadian street youth 4 . Young people may be inclined toconsider themselves invulnerable or immortal, to think that“HIV and STIs only happen to other and/or older people”or to judge a person’s HIV status based on appearance (“Shelooks healthy.”). Without accurate information, they may besusceptible to misleading assurances that “there is no risk”or “don’t worry, I’m healthy.” Many young people who aresexually active and/or inject drugs do not have ready accessto condoms, clean needles, peer support or risk reductioninformation that is appropriate.Evidence suggests that experience of childhood abuseincreases an individual’s risk of HIV infection 5 . Any or all ofthese factors combined can render young people especiallyvulnerable to the risk of HIV infection.Potential vulnerability to abuses of sexual and emotionalpower and lack of access to risk reduction information alsoexist for people with intellectual, psychological or physicaldisabilities, or mental illness. Studies have shown a statisticallysignificant association between substance use, inconsistentcondom use and other risk behaviours among peoplewith severe mental illness and psychiatric disabilities 6 .The risk of HIV transmission for people in prison is particularlyhigh. Injection drug use, tattooing and sexual activity,including sexual assault and the trading of sex for favours,are known to be commonplace in prisons. The availabilityof condoms is limited and clean needles and syringes arenot available. Access to health care for prisoners may be lessfrequent or of a lower standard than for those outside theprison system.Stigma, Grief and LossFor many years in Canada and other developed countries,HIV infection rates have been highest among gay men. Theresulting misconception that HIV infection is a “gay disease”has led to a false sense of security among people whoare not gay, but who may practice activities that place themat risk of HIV infection. Such attitudes have contributed tothe fact that in the developed world, gay men have bornethe brunt of prejudice and discrimination associated withHIV disease, a factor that has compounded the substantialgrief, loss and depression among this group.This trend continues in other groups and in current timesas well. Reports and statistics about the seriousness of theepidemic among Canada’s injection drug users, prisoninmates, Aboriginal people and other groups lead manyto conveniently classify the disease as a risk only for thesesegments of society. Racism, objections on moral groundsto concepts of harm reduction, religious intolerances, socialmarginalization, poverty and other social ills cause many ofthese groups to face high levels of discrimination. This, inturn, contributes to growing rates of HIV and other illnessesamong these groups. In addition, this form of compartmentalizationincreases the risk of infection among those whodon’t see themselves as belonging to one of these groups.Society, in general, gradually falls prey to the “It won’thappen to me” cycle of denial that was partially responsiblefor the rapid spread of the disease at the beginning of theepidemic.Safer sex was coined in the mid-1980s as a short-termresponse to an immediate health crisis. Harm reduction andsafe injection techniques were similarly introduced in the1990s when the rates of infection began to increase amonginjection drug users. The failure to find a cure for or a vaccineagainst HIV disease means that many people have beenrequired to permanently incorporate risk reduction and thepossibility of infection into their daily lives. Many have beenable to do this successfully for many years. Others find thatsustaining risk-reducing behaviour in the face of continueddeath, illness and anxiety has not been easy. This is especiallytrue for those who have lost significant numbers of friendsand acquaintances to HIV/AIDS. Some have developed4. MacDonald NE, Fisher WA, Wells GA, Doherty JA, Bowie WR. Canadian street youth: correlates of sexual risk-taking activity, PediatricInfectious Disease Journal, 13(8): 690-7. Aug. 1994.5. Sterk, C.E. et al. Reducing Harm: The effects of childhood abuse on negotiating HIV risk reduction. 12th World AIDS ConferenceAbstract 238/33382. 1998.6. Thompson, S.C. et al. HIV risk behaviour and HIV testing of psychiatric patients in Melbourne, Australian & New Zealand Journal ofPsychiatry. Aug 1997. Menon A.S. et al. Substance use during sex and unsafe sexual behaviours among acute psychiatric patients.Psychiatric Services, Aug 1997.12 Aspects of HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskbecause failing to disclose would expose the sexual partnerto a “significant risk of serious bodily harm” without theirconsent. The decision therefore makes it clear that HIVpositivestatus must be disclosed before unprotected vaginal(and presumably anal) intercourse. But the decision did notoffer a clear answer to the question of whether disclosure isalso required when appropriate precautions are taken.For the purposes of these guidelines, practices have beenassessed for risk based on actual evidence of HIV transmission.That means the guidelines are consistent and valid foreveryone, including people who are living with HIV/AIDS.To put a different burden of responsibility on those whoare HIV positive would create a double standard in ourmessages: practise one set of guidelines with those who areinfected and practise another with those who are not. Infact, one-third of people who are HIV positive in Canadado not even know they are infected.Most people will find it desirable to share information abouttheir serostatus with their partners. The circumstances andtiming under which people living with HIV/AIDS willwant, and feel able, to tell others they are HIV positive willvary greatly. Some may want to tell all their sex partnersimmediately; others may find that revealing such informationcreates greater difficulties for them. For example, somepeople may perceive themselves to be in physical danger ifthey tell their sex partners. Issues of disclosure for peoplewho are HIV positive have proven to be complex, and thereis no easy solution. Questions of when and where and forwhat reasons to disclose will vary from person to person andfrom relationship to relationship.Consistency and coherency are the essential features of therisk model presented here. An expectation that people livingwith HIV/AIDS should have to exercise additional precautionsappears to remove the burden of responsibility fromthe other partner. It would send contradictory messagesabout the validity of the precautions recommended. Makingdecisions about behaviour based on any assessment of theprevalence of HIV in particular communities or groups ofpeople leads to false assumptions and is inappropriate forthe purpose of HIV prevention information.HIV and PrisonsThe HIV/AIDS epidemic has struck prisons, and otherplaces of detention with particular severity. Penal institutionsaround the world and in Canada have grossly disproportionaterates of HIV and HCV infection, and confirmedAIDS cases 11 . People entering prison tend to have a relativelyhigh incidence of HIV, and prisons provide a propitiousenvironment for transmission of the virus. High-riskbehaviours, such as injection drug use and unprotected sex,along with coerced sex, are common in prisons. Preventiontools such as condoms and new needles for drug use andtattooing practices are seldom available in Canadian prisons.Prisoners are often forced to “make do” with less effectivemeans of reducing risk. Assessing risk and providing meansfor changing risk behaviours in prisons requires a distinctand separate approach than for individuals who are notincarcerated. Knowledge of prison environments, high-riskpractices in the institutions and prison culture is required.Enhancing the Health of People Livingwith HIV/AIDSAlthough these guidelines apply equally to people who areliving with HIV/AIDS and those who are not infected,there are further considerations for the health of those whoare HIV positive. Making sex and substance use healthiercan be part of a broad-based health promotion approach forpeople living with HIV/AIDS. Just as they need to considera wide range of treatment and other options for improvingand maintaining mental and physical health, people livingwith HIV/AIDS should be aware of possible exposure toother infections.Other STIs are of primary concern. People living withHIV/AIDS should be aware that other STIs could affectthe immune system and potentially trigger the progressionof HIV from an asymptomatic seropositive state to illness.There is also some indication that STIs can have more pronouncedeffects, and be harder to treat, in men and womenliving with HIV/AIDS. HCV and other blood-borne infectionscontracted by sharing needles also pose a greater riskto people living with HIV/AIDS. They can act as catalystson each other, making each disease progress more quickly,and making treatment more difficult as well as reducing theoptions for treatment once a dual diagnosis is made.People living with HIV/AIDS also need to be aware of thepotential risks in having unprotected intercourse or sharingneedles with someone who is also HIV positive. It isgenerally considered that “exchanging” virus, especially onethat is drug-resistant, could possibly speed the progressionof the disease. Different strains of HIV may produce illness11. Canadian HIV/AIDS Legal Network. HIV/AIDS and Hepatitis C in Prisons: The Facts, Canadian HIV/AIDS Legal Network, 2004.Aspects of HIV Transmission15

HIV TRANSMISSION: Guidelines for Assessing Riskat varying rates or may affect different systems in the body.Infection with a new strain may cause new problems or mayresult in the development of premature resistance to someanti-HIV treatments. Becoming infected with STIs, HCVor other diseases, are serious considerations for the healthof some who is HIV positive. Variants of hepatitis such asA and B can hasten the progression of illness in someonewho is living with HIV by placing additional strain onthe liver. Given these possibilities, risk-reduction strategiesshould continue to be promoted between people living withHIV/AIDS.16 Aspects of HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Risk3. HIV TransmissionA Model for Assessing RiskEvolution of the ModelThe model of risk presented here has evolved from theearliest examples of safer sex advice. As discussed earlier,the notion of risk is qualitative; therefore, we do not have acompletely objective and quantifiable way to express degreesof likelihood of HIV transmission. However, bearing theselimitations in mind, the levels of risk of various activitiesare organized into four categories, based on the potentialfor transmission of HIV and the documented evidence thattransmission has actually occurred. These categories of HIVtransmission are no risk, negligible risk, low risk and highrisk.If these categories or levels were represented graphically ona continuous line, negligible and low risk would be muchcloser to the “no risk” end of the continuum. There is no“middle” level of risk. The graphic representation of therisk model appearing in this edition of the guidelines uses acurve to reflect the continuum along which risk levels occur.It is anticipated that future editions of the guidelines willcontinue to evolve as we learn more about HIV transmissionand its social consequences. This model is not intendedas a guide to risk levels for STIs other than HIV.Conditions for HIV TransmissionIt is well established within the field of HIV epidemiologythat certain conditions must exist for HIV transmission tooccur.1. There must be a source of infection.Relying on the identification of a person as a source ofinfection is not useful in developing prevention messages,since it is nearly impossible to tell if a person is infectedby looking at them. It is more appropriate to consider thesource of infection as the presence of HIV in certain bodyfluids, such as blood, semen, vaginal fluid or breast milk.2. There must be a means of transmission.The following routes of HIV transmission are well-established:• specific types of sexual activity (sexual transmission)• sharing used, uncleaned needles or syringes, and othersituations that involve piercing of the skin (subcutaneousand per cutaneous transmission)• mother-to-child transmission, in the uterus, duringchildbirth (vertical transmission) or through breastfeeding.• receiving transfusions of infected blood or bloodproducts, transplanted organs, or donated sperm (InCanada all donated blood, organs and semen are nowscreened for HIV antibodies).3. There must be a host susceptible toinfection.The virus is harmless until it finds a host or, more accurately,susceptible cells within the host’s body. Every human beingis considered to be a host susceptible to infection.4. There must be an appropriate route ofentry to the target cells of the body.Infected blood, semen, vaginal fluid or breast milk mustreach the HIV-susceptible cells in the blood, usuallythrough a break in the skin, absorption through mucosalmembranes (mucosa) or through some disruption to themucosa. Mucosa are the moist surfaces of the body whichline most of the body cavities and hollow internal organssuch as the vagina, rectum, mouth, urethra, nose andeyelids.5. There must be a sufficient level of virusdelivered to establish infection.Because of a higher concentration or quantity of virus, somebody fluids are efficient media for transmitting HIV, whileothers are not. Semen, vaginal fluid, blood and breast milkare of most concern in HIV transmission. Although HIVHIV Transmission17

HIV TRANSMISSION: Guidelines for Assessing RiskEVIDENCEPOTENTIALNONo RiskNOYES (under certaincircumstances)YES Negligible Risk Low Risk High RiskYEShas also been isolated in urine, saliva and tears, it is highlyunlikely that it will be present in sufficient concentrationsfor transmission to occur (even if all other four conditionswere fulfilled). Research has shown that an enzyme insaliva inhibits HIV. HIV does also not thrive in exposedenvironments outside the body or inside the body wherethere are high concentrations of acid, such as in the stomach(hydrochloric acid) or the bladder (uric acid).HIV has been isolated in pre-ejaculatory fluid (pre-cum).Though the concentration of HIV in pre-cum is likely to below, it cannot be discounted as a potential source of transmission.Viral load (the amount of HIV present in differentbody fluids and tissues) can also be a factor in transmissionof HIV. The higher the viral load, the higher the risk oftransmission through the exchange of these fluids.Factors Used to Determine the Levelof RiskA. Potential for TransmissionIn assessing potential for transmission, we consider whetherof not the 5 conditions for transmission explained above aremet. Because it is impossible to prove that an infection willnever happen, it is important to consider the potential fortransmission and weigh it against evidence of what is knownto have actually occurred. For the purposes of our model weconsider an activity to carry no risk only when there is nopotential for transmission to occur.B. Evidence of TransmissionIn creating these guidelines, a review of research was carriedout to examine the documented evidence of HIV transmissionthrough specific practices. Case reports, abstracts andresearch reports were considered, with the greatest weighton reports from cohort studies using multivariate analysistechniques (studying a specific group of individuals overtime and analysing the interaction of a number of variables).For the purpose of this model, greater emphasis is placedon what is known or proven to happen, than on what mayhappen in theory.To assess the risk of HIV transmission, the potentialfor transmission and the evidence that transmission hasoccurred are both considered. Activities are then placed intoone of four categories.Categories for Assessing Risk1. No riskTo our knowledge, none of the practices in this categoryhave ever been demonstrated to lead to HIV infection.There is no potential for transmission since all of the basicconditions for viral transmission are not present.Potential for transmission . . . . . . . . . . . . . . . . . . . . . NoneEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . None2. Negligible riskAll of the practices assigned to this risk level present apotential for HIV transmission because they involvean exchange of body fluids, such as semen (includingprecum), vaginal fluid, blood or breast milk. However, theamounts, conditions and media of exchange are such thatthe efficiency of HIV transmission appears to be greatlydiminished. There are no confirmed reports of infectionfrom these activities.Potential for transmission . . . . . . . . . . . . . . . . . . . . . YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . None3. Low riskAll of the practices assigned this risk level present a potentialfor HIV transmission because they involve an exchange of18 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskbody fluids such as semen (including precum), vaginal fluid,blood or breast milk. There are also a few reports of infectionattributed to these activities (usually through individualcase studies or anecdotal reports, and usually under certainidentifiable conditions).Potential for transmission . . . . . . . . . . . . . . . . . . . . . YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . Yes(under certain conditions)4. High riskAll of the practices assigned this risk level present a potentialfor HIV transmission because they involve an exchangeof body fluids, such as semen (including precum), vaginalfluid, blood or breast milk. In addition, a significantnumber of scientific studies have repeatedly associated theactivities with HIV infection. Even when the exact mechanismof transmission is not completely clear, the results ofsuch studies conclude that activities in this category are highrisk.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . YesHIV Transmission19

HIV TRANSMISSION: Guidelines for Assessing Risk20 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Risk4. Assessing Risk of HIVTransmissionThis model is not intended as a guide to risk levels for STIs other than HIV.Part 1. Sexual ActivitiesFor the purposes OF this model, we consider the risk ofa single episode of each particular sexual practice. In reallife, sexual activity is more complex. It is rarely confined toone episode or to one practice, nor is it always confined toone partner at one time. The order in which people engagein sexual practices also affects risk. If a combination orsequence of sexual activities is deemed to increase risk, thesefactors are addressed in the text.Kissing“Sucking face, necking, smooching”Potential for TransmissionThere is no potential for transmission in pressing dry lipstogether.In the absence of blood in the mouth, wet kissing can beclassified as no risk. Saliva that does not contain bloodpresents no potential for transmission. Research has shownthat an enzyme in saliva inhibits HIV 12 . In general, themouth and throat are well-defended against HIV; oralmucosal lining contains few cells that are susceptible toHIV. However, saliva should not be thought of as aneffective microbicide against HIV; it is not effective inpreventing transmission if it is used as a lubricant withoutbarrier protection.There is a very small potential for transmission in wetkissing where blood may be exchanged. The risk involved inwet kissing is increased when blood is present in the mouthof one or both partners. This could be caused by recentbrushing or flossing of the teeth, a sore in the mouth, gumdisease, a recent tooth extraction or biting or scratching oneanother (e.g. with the teeth or orthodontic alliances, suchas braces) during particularly vigorous kissing. Although itis likely that only a small amount of blood would ever bepresent in the mouth, the presence of a quantity sufficientfor transmission of HIV to occur cannot be discounted. Therisk of transmission is increased where blood is exchangedbetween mouths and where the mouth of the personreceiving the blood contains ulcers or sores, or where thereis evidence of dental recession. Accordingly, kissing in thepresence of blood in the mouth cannot be classified as norisk.Note: It is recommended that a period of approximately 30minutes to two hours be allowed to elapse after brushing orflossing teeth before sexual activity, due to the possibility ofblood in saliva.Evidence of TransmissionThere has never been a documented case of HIV transmissionthrough dry kissing. There are a few anecdotal reportsof HIV transmission through wet kissing where blood hasbeen exchanged.Assessment of Risk of HIV TransmissionWet or dry kissingNo exchange of blood . . . . . . . . . . . . . . . . . . . . . .No RiskWet kissingWith exchange of blood . . . . . . . . . . . . . . . . . . . Low RiskOral Sex: Fellatio“Giving or getting head, headjob, blowjob, sucking off,blowing, face-fucking, going down, cock-sucking”Potential for TransmissionIn fellatio, there is potential for transmission to the partnergiving fellatio (the person sucking or licking the penis)because pre-ejaculatory fluid (pre-cum) or semen can getinto the mouth. A healthy mouth is generally a hostile12. Reucroft, S, Swain, J. Saliva thwarts HIV. New Scientist, 17 January 1988.HIV Transmission21

HIV TRANSMISSION: Guidelines for Assessing Riskenvironment for HIV, because an enzyme in saliva has beenshown to inhibit HIV.The risk of transmission of HIV to the partner giving fellatiois increased if there is a disruption in the oral mucosasuch as bleeding gums, cuts, sores, lesions, ulcers or burnsin the mouth or by a recent tooth extraction. Risk can bereduced by using a protective barrier, such as a condom.Speculation that the risk of transmission is increased ifejaculate is swallowed now appears unfounded, sinceenzymes in the mouth, throat and the stomach are knownto inhibit HIV. The risk of transmission relates to takingejaculate or pre-ejaculatory fluid in an unhealthy orwounded mouth, not into the digestive system, which is ahostile environment for HIV.The risk in fellatio can be reduced by avoiding ejaculation ofsemen in the mouth and can be reduced further by using acondom. It is also recommended that the partner giving fellatiowait 30 minutes to two hours after brushing or flossingteeth before engaging in fellatio, since brushing and flossingteeth may cause temporary bleeding of the gums.In getting fellatio, risk is negligible. A small quantity ofblood from bleeding gums or sores in the mouth couldcome into contact with an abrasion on the head of thepenis, and/or with the mucosal lining of the penile opening.However, the small amount of blood that would be passedunder such conditions makes infection very unlikely.In the absence of some disruption to the oral cavity, the riskinvolved in either giving or getting head can be regarded asquite remote.Evidence of TransmissionTransmission of HIV is reported to have occurred throughgiving fellatio. It is only reported to have occurred veryrarely, usually in circumstances where there is a route ofentry resulting from a disruption to the oral mucosa causedby bleeding gums, cuts, sores, lesions, ulcers or burns in themouth.Much of the evidence of transmission during fellatio isbased on isolated case reports. Several of the earliest epidemiologicalstudies of men who have sex with men failed toshow that giving fellatio carried a significant risk. This mighthave been because one recognized act of a high risk activitywas considered the most likely route of transmission despitemultiple acts of lower-risk activities. Some later studies haveshown a risk but it is much smaller than for other activities,such as penile–anal intercourse without a barrier.Overall, the evidence indicates that transmission throughgiving fellatio is a relatively rare occurrence and thereforeit is classified as low risk. There have been no documentedcases of transmission through getting fellatio.Assessment of Risk of HIV TransmissionFellatio (performing)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom and taking semen and/orpre-ejaculate in the mouth . . . . . . . . . . . . . . . Low RiskFellatio (receiving)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom . . . . . . . . . . . . . . . . . . . Negligible Risk(The risk is increased if there is a disruption in the oralmucosa of the receiving partner, caused by bleeding gums,cuts, sores, lesions, ulcers or burns in the mouth or by arecent tooth extraction or other dental work.)* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Oral Sex: Cunnilingus“Licking out, eating out, going down, licking pussy, boxlunch, eating at the Y”Potential for TransmissionThere is a potential for transmission of HIV by performingcunnilingus (licking the clitoris and/or in or around thevulva) because vaginal fluid and blood can get in the mouth.However, the mouth generally is a hostile environment forHIV, because an enzyme in saliva has been shown to inhibitHIV.The potential for transmission to the performing partner isincreased if there is a disruption in the oral mucosa causedby bleeding gums, cuts, sores, lesions, ulcers or burns in themouth or by a recent tooth extraction, or other dental workthat causes trauma in the mouth. The risk in performingcunnilingus is also higher during menstruation because ofthe presence of blood. The risk can be reduced by avoidingcunnilingus during menses using a latex barrier over thevaginal opening, such as a dental dam or, as an alternative, anew and unlubricated condom carefully cut open and used22 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskas a barrier between the mouth and vulva or clitoris. It isalso recommended that the performing partner not engagein oral sex directly after brushing or flossing teeth beforeengaging in cunnilingus, since brushing and flossing maycause temporary bleeding of the gums. The amount of timeto wait varies from 30 minutes to two hours since theseactivities can produce cuts and tears along the gum, andthe amount and severity depends on how vigorously onebrushes or flosses their teeth.Receiving cunnilingus involves a small potential for transmissionbecause of the possibility of abrasions in the vagina;these could permit entry of small quantities of blood frombleeding gums or a sore in the mouth. However, the smallamount of blood likely to be involved in such contact makethis a remote possibility.Evidence of TransmissionThere are no well-designed studies offering evidence oftransmission through cunnilingus. However, the extremelysmall number of case reports in which transmission has beenattributed to performing cunnilingus supports the classificationof this activity as low risk.There have been no documented cases of transmissionthrough receiving cunnilingus.Assessment of Risk of HIV TransmissionCunnilingus (performing)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier and not during menses . . . . . . . Low RiskWithout barrier and during menses . . . . . . . . . . Low RiskCunnilingus (receiving)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Oral Sex: Anilingus“Rimming, licking out, eating out, licking or eating ass”Potential for TransmissionAnilingus is not an efficient means of HIV transmission.There is a potential for transmission in performing anilingusif blood is present in or around the anus. There is a potentialfor HIV transmission in receiving anilingus because of thepossibility of contact between blood in the mouth andthe rectal lining. The small amount of blood likely to beinvolved in such circumstances makes transmission highlyunlikely.It should be noted, however, that anilingus is an efficientroute of transmission for other STIs, such as syphilis, gonorrhea,hepatitis A and B, and intestinal parasites (includingCryptosporidium).Any risk from anilingus can be reduced by use of a latexbarrier, such as a dental dam or a new condom carefully cutopen and used as a barrier between the mouth and anus.Evidence of TransmissionThere have been no documented cases of HIV transmissionthrough receiving or performing anilingus.Assessment of Risk of HIV transmissionAnilingus (performing)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible RiskAnilingus (receiving)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Intercourse: Penile–Vaginal“Fucking, screwing, making love, getting or being laid”Potential for TransmissionThe earliest safer sex advice rightly categorized penile–vaginalintercourse without a barrier as high risk. All of theconditions for efficient viral transmission are in place duringthis activity.Penile-vaginal intercourse without a barrier is a high-riskactivity. The majority of documented cases of HIV transmissionthroughout the world are the result of unprotectedpenile–vaginal intercourse. The risk of transmission can bereduced through the proper use of male or female condomswith lubricant.HIV Transmission23

HIV TRANSMISSION: Guidelines for Assessing RiskReceptive penile–vaginal intercourse without a barrier isone of the most efficient means of HIV transmission. Whilethe male partner in penile–vaginal intercourse without abarrier is also at high risk for HIV infection, women shouldbe aware that as the receptive partners, they are at an evengreater risk because of the higher levels of virus present inmale seminal fluids, the greater exposed surface area in thefemale genital tract than in the male genital tract, the greateropportunity for trauma in the female and the high rates ofabsorption in the mucosal lining of the vagina.It is thought that transmission to the male partner duringunprotected penile-vaginal intercourse can occur in one oftwo ways. Minor or microscopic cuts or tears on the penismay allow entry of the virus and sores on the penis (e.g.genital ulcers) can pose even more risk by providing a pointof entry for the virus. There is also evidence that transmissioncan occur directly through the mucosal lining of theurethra (through the opening at the tip of the penis) or ofthe foreskin. There has been enough evidence to show thatit happens frequently enough for the insertive partner inunprotected penile–vaginal intercourse to be classified as ahigh-risk activity.Studies in sub-Saharan Africa show that uncircumcised menmay be at higher risk of HIV transmission than circumcisedmen in unprotected penile-vaginal or penile-anal intercourse13 . Foreskin contains large concentrations of the typesof cells that HIV targets – a finding that helps explain whyuncircumcised men may be more prone to HIV infectionthan circumcised men 14 . In addition, the foreskin mayprovide an environment for survival of bacteria and viruses,and may be susceptible to tears, scratches and abrasions,suggesting that its presence may increase the likelihood ofcontracting HIV.A widespread misconception is that the risk for the receptivepartner will be reduced if unprotected penile–vaginalintercourse is stopped before ejaculation occurs (coitusinterruptus). This action carries a significant potential fortransmission, given the efficiency of transmission throughpenile–vaginal intercourse and the impossibility of determininghow much pre-ejaculatory fluid may be depositedin the vagina before ejaculation. Interrupted penile–vaginalintercourse without a condom, therefore, is still high risk.Evidence of TransmissionThere is ample documented evidence of HIV transmissionthrough unprotected insertive and receptive penile–vaginalintercourse.The proper use of the male or female condom has beenshown to greatly reduce incidence of HIV transmissionduring penile-vaginal intercourse (see diagram pg. 55).However, there is evidence of occasional condom failure sopenile-vaginal intercourse with a condom is considered to below risk for the both partners. To reduce potential trauma tothe vagina, it is important to always use plenty of lubricant,especially if a condom cannot be used for some reason.Some evidence shows that there is a higher risk of transmissionfor the male partner during unprotected penile-vaginalintercourse when the female partner is menstruating.However, there is sufficient evidence of infection outsidemenses to prevent any useful distinction in risk based uponabsence of menstrual blood.Assessment of Risk of HIV TransmissionInsertive penile-vaginal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . High RiskReceptive penile-vaginal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . High Risk*Condoms are not 100% reliable. There is enough evidence oftransmission due to condom breakage or improper use to classifythis activity as low rather than negligible risk.Intercourse: Penile–Anal“Butt-, bum- or ass-fucking, screwing, making love, gettingor being laid, anal sex”Potential for TransmissionThe earliest safer sex advice rightly classified penile–analintercourse without using a condom as high risk. All of theconditions for efficient viral transmission are in place duringthis activity. The risk can be reduced through the proper useof condoms with lubricant. Any notion that the insertive13. Johannes van Dam, M.D. MPH and Marie-Christine Anastasi, M.A. Male Circumcision and HIV Prevention: Directions for FutureResearch, 200214. Crabb, Charlene. Circumcision and HIV Susceptibility, AIDS: 17(2) p. N3. January 2003.24 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskpartner in penile–anal intercourse has a low risk of infectionis untrue. Although more cases of transmission have beenattributed to receptive penile–anal intercourse, the numberof infections among insertive partners is significant enoughto make this a high-risk activity.From the perspective of public health education strategies,and particularly from the perspective of individuals engagingin sex, being the insertive partner offers no reliableprotection. The mistaken belief that the performing partneris at low risk can foster a false sense of security, makingit more difficult for receptive partners (whether male orfemale) to insist that precautions be used.It is thought that transmission to the male partner duringunprotected penile-anal intercourse can occur in one oftwo ways. Minor or microscopic cuts or tears on the penismay allow entry of the virus and sores on the penis (e.g.genital ulcers) can pose even more risk by providing a pointof entry for the virus. There is also evidence that transmissioncan occur directly through the mucosal lining of theurethra (through the opening at the tip of the penis) or ofthe foreskin. There has been enough evidence to show thatit happens frequently enough for the insertive partner inunprotected penile–anal intercourse to be classified as ahigh-risk activity.Recent evidence suggests that uncircumcised men may beat higher risk of HIV transmission than circumcised menas the insertive partner in penile–vaginal or penile–analintercourse (see Intercourse: Penile–Vaginal) 15 .Another widespread misconception is that the risk for theunprotected receptive partner is considerably reduced if analintercourse is stopped before ejaculation occurs. However,given the efficiency of transmission through penile–analintercourse and the impossibility of determining how muchpre-ejaculatory fluid has been deposited in the rectum, thisis a high-risk activity. To reduce potential trauma to theanus and rectum, it is important to always use plenty oflubricant, especially if a condom cannot be used for somereason.Evidence of TransmissionThere is ample documented evidence of HIV transmissionthrough unprotected insertive and receptive penile–analintercourse.The proper use of condoms with lubricant has been shownto greatly reduce incidence of transmission during analintercourse. There is evidence of transmission due to condomfailure, however, so receptive penile–anal intercoursewith a condom is considered to be low risk.Female condoms have not been studied specifically foruse in anal intercourse, nor have they been designed orapproved for that purpose. However, anecdotal evidencesuggests that they may provide another alternative for reducingrisk of HIV transmission from penile–anal intercourse(see Section 7).Assessment of Risk of HIV TransmissionInsertive penile–anal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . High RiskReceptive penile–anal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . .Low risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . High risk*Condoms are not 100% reliable. There is enough evidence oftransmission due to condom breakage or improper use to classifythis activity as low rather than negligible risk.Fingering (Anal and Vaginal)“Finger job, finger-fucking”Potential for TransmissionFingering the clitoris, labia, vagina or anus carries negligiblerisk unless the inserted finger has an open cut, sore, lesion,burn or rash. However, it is possible that the vaginal orrectal lining can suffer trauma; fingernails can easily tearthese membranes. This would increase the potential fortransmission through other higher-risk activities that mayfollow (e.g. unprotected penile intercourse). Masturbatingoneself and then fingering one’s partner may insert semen orvaginal fluid and increase the potential for transmission.The primary risk for the performing partner (person doingthe fingering) comes from contact with small amountsof blood or vaginal fluid that could find a route of entrythrough a cut finger or hangnail. The risk for transmissionvia this method is increased during periods of menstruation.15. Crabb, Charlene. Circumcision and HIV Susceptibility, AIDS: 17(2) p. N3. January 2003.HIV Transmission25

HIV TRANSMISSION: Guidelines for Assessing RiskThe risk can be reduced by using a latex glove, whichperforms a similar function to a condom during penileintercourse. However, a gloved finger might still cause somestress to the mucosal linings of the receiving partner, whichcould increase the risk to the receiving partner if other riskyactivities follow.Evidence of TransmissionThere are no documented cases of HIV transmissionthrough performing or receiving digital–vaginal or digital–analintercourse.Assessment of Risk of HIV TransmissionVaginal or Anal Fingering (performing)With latex glove . . . . . . . . . . . . . . . . . . . Negligible Risk*Without latex glove . . . . . . . . . . . . . . . . . . Negligible riskVaginal or Anal Fingering (receiving)With latex glove . . . . . . . . . . . . . . . . . . . Negligible Risk*Without latex glove . . . . . . . . . . . . . . . . . Negligible Risk*The latex glove could be defective or improperly used, makingit impossible to classify these activities as no risk. However,using a glove will reduce risk, particularly if open cuts, sores,lesions, burns or rashes are present.Fisting (Anal and Vaginal)Potential for TransmissionThe practice of inserting the hand into the rectum or vaginais not by itself an efficient means of HIV transmission.However, studies indicate that receiving fisting is linkedclosely with HIV infection. This is due to the extensivetrauma that fisting may cause to the anal or vaginal canalproducing a very favourable environment for HIV transmission—iffollowed by unprotected penile intercourse or theinsertion of shared sex toys. Even after a single episode, thetrauma to the mucosal lining may last for several weeksafter the event and the person is vulnerable during thistime as well. Masturbating oneself and then fisting one’spartner may insert semen or vaginal fluid and increase therisk of transmission. For this reason, the risk is greater forthe receiving partner. The performing partner may havecuts or abrasions (including hangnails) which may beexposed to blood or vaginal fluid during fisting. This riskcan be reduced by using a latex glove and by using plenty oflubricant.Evidence of TransmissionSeveral studies have identified fisting as a co-factor in HIVtransmission, suggesting that other higher-risk activitiesoften precede or follow this activity. However, there is noevidence that fisting alone has resulted in HIV transmission.Assessment of Risk of HIV TransmissionFisting (performing)With glove . . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without glove . . . . . . . . . . . . . . . . . . . . . Negligible RiskFisting (receiving)With glove . . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without glove . . . . . . . . . . . . . . . . . . . . . Negligible Risk*The latex glove could be defective or improperly used,making it impossible to classify these activities as no risk.However, using a glove will reduce risk, particularly if opencuts, sores, lesions, burns or rashes are present.Masturbation by Partner“Jerking or jacking off, J/O, giving or getting a hand-job,getting someone off, making someone cum”Potential for TransmissionThe practice of masturbating a man through manualstimulation of the erect penis, or of masturbating a womanby manual stimulation of the clitoris, carries no risk forthe person holding the penis or fingering the clitoris unlessthere are cuts, burns, abrasions or rashes on the fingers orhands that come into contact with pre-cum, semen, vaginalfluid or blood. This risk can be greatly reduced by using alatex glove.If a man uses his own semen (including pre-cum) or awoman uses her own vaginal fluid as a lubricant on thepenis of a male partner, there is a risk of HIV infectionthrough an abrasion on the penis or the mucosal lining ofthe penile opening or foreskin of the man being masturbated.If a woman uses her vaginal fluid or a man uses hissemen or pre-cum as a lubricant to masturbate a woman,there is a similar possibility of infection through contactwith cuts or inflammation of the clitoris, labia or vaginallining. This risk can be eliminated by avoiding the exchangeof semen, pre-cum and vaginal fluids between partners andby using a water-based lubricant.Care should also be taken during and after ejaculation toensure that no semen or vaginal fluid comes into contact26 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskwith the other partner’s rectum, vagina, mucosal lining ofthe penis or with any open cuts, sores, lesions, ulcers, burnsor rashes (in the mouth or on the body). . . . . . . . . . . . . .Evidence of TransmissionThere are no documented cases of transmission throughmasturbation of a male or female partner.Assessment of Risk of HIV TransmissionNon-insertive Masturbation* (performing)With glove . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskWithout glove . . . . . . . . . . . . . . . . . . . . . . . . . No Risk**Non-insertive Masturbation* (receiving)With glove . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskWithout glove . . . . . . . . . . . . . . . . . . . . . . . . . No Risk*** For insertive masturbation (fingering) please see Fingering,page 25.**Providing there are no open cuts, sores, lesions, burns orrashes on the hand or fingers which come into contact with thepartner’s pre-ejaculate, semen or vaginal fluid.Using Insertive Sex ToysPotential for TransmissionUsing sex toys (e.g. dildos, vibrators, Chinese balls, buttplugs, anal beads) and other objects can cause trauma tothe mucosal lining of the rectum or vagina. The extent oftrauma varies depending on the size of the device and theway it is used. Even if properly cleaned and therefore notdirectly transmitting HIV, trauma and resulting inflammationcan promote the possibility of later transmissionby opening a route of entry for HIV to the blood and toHIV-susceptible cells through the cuts or tears in the rectalor vaginal mucosa, and thereby increase the risk for otheractivities that might follow.Transferring a sex toy directly from one partner to anotherallows for sharing of infected fluids that can result in directHIV transmission.The risk of HIV transmission can be reduced by cleaning sextoys after use. They should be washed with soap and water,and rinsed. When using instruments and toys for sex play,universal precautions, such as is found in hospitals for materialssuch as metal, wood, rubber, etc., should be followed.For more information on universal precautions consultInfection Control Guidelines: Preventing the transmissionof bloodborne pathogens in health care and public servicessettings (Health Canada). The cleaning method will dependon the toy—for example, a rubber dildo can be soaked but avibrator with electrical parts cannot.Placing a condom on the toy will make cleaning mucheasier. In the immediacy of a sexual situation, some peoplemay use a condom as a substitute for cleaning. After using acondom with one person, replace it with a new one beforethe toy is transferred to another person. There is some riskinvolved with this method because of the possibility thatthe condom can break, slip off or not completely cover thesurface of the toy.Other non-insertive sex toys are discussed under SadomasochisticActivities.Evidence of TransmissionThere is evidence of HIV transmission to the receivingpartner from the sharing of insertive sex toys 16 .Assessment of Risk of HIV TransmissionUsing Sex Toys*Receiving, shared, no condom . . . . . . . . . . . . . . High riskReceiving, shared, with condom . . . . . . . Negligible risk**Receiving, unshared . . . . . . . . . . . . . . . . . . . . . . . No riskReceiving, disinfected . . . . . . . . . . . . . . .Negligible risk***Giving, shared, no condom . . . . . . . . . . . . Negligible riskGiving, shared, with condom . . . . . . . . . Negligible risk**Giving, unshared . . . . . . . . . . . . . . . . . . . . Negligible riskGiving, disinfected . . . . . . . . . . . . . . . . . . . Negligible risk*This activity may cause trauma to the vaginal or rectal lining,making it easier for HIV transmission to occur later withunprotected penile intercourse.**The condom could be defective or improperly used, making itimpossible to classify these activities as no risk.***There is a possibility that the toy may not be cleanedproperly.16. Kwakwa, H A et al. Female-to-female transmission of human immunodeficiency virus, Clinical Infectious Diseases, 36 (1): February2003.HIV Transmission27

HIV TRANSMISSION: Guidelines for Assessing RiskSadomasochistic Activities“S/M, S & M”Potential for TransmissionMany sadomasochistic activities pose no risk of HIVtransmission. These include the use of whips, chains,clamps, masks, weights, gags, ties and other restraints andnon-insertive devices.As with other sexual activities, the general principles ofHIV transmission apply: infection can occur when infectedsemen, vaginal fluid, blood or breast milk comes intocontact with a receiving site, such as the mucosal linings ofthe rectum, penis or vagina, or a route of entry to the bloodsystem via an open cut, sore, lesion, ulcer, burn or rash.Some activities may lead to the incidental or intentionaldrawing of blood (e.g. whips, nipple-clamps, restraints,severe spanking, tattooing, skin piercing). When anysadomasochistic activity involves the potential drawing ofblood, universal precautions similar to those set in hospitalsshould be taken 17 . Anything used to draw blood should notbe used on more than one person without disinfecting it(see Using Sex Toys).Evidence of TransmissionNo studies have ever examined HIV transmission by meansof various sadomasochistic activities.Assessment of Risk of HIV TransmissionSadomasochistic activities(using universal precautions) . . . . . . . . . . . . . .No RiskSadomasochistic activities . . . . . . . . . . . . . Negligible RiskContact with Feces“Scat, shit play, brown”Potential for TransmissionThere have been no reports of isolation of HIV from feces,but blood can occasionally be present. This means that thereis a small potential for HIV transmission through receivingdefecation where the feces come into contact with mucosaor with open cuts, sores, lesions, ulcers, burns or rashes.Defecation on unbroken skin does not pose a risk.Evidence of TransmissionThere is no evidence that transmission of HIV has occurredfrom contact with feces.Assessment of Risk of HIV TransmissionContact with fecesOn unbroken skin . . . . . . . . . . . . . . . . . . . . . . . .No RiskWith mucosa or with open cuts, sores, lesions, ulcers, burnsor rashes . . . . . . . . . . . . . . . . . . . . . . . . Negligible Risk**Due to the potential of blood, if present in the feces, enteringan open cut, sore, lesion, burn, ulcer, rashes or mucosaUrination“Watersports, golden showers, pissing, yellow”Potential for TransmissionUrine is not an efficient medium for viral growth andcontains few of the lymphocytes that host HIV. Externalurination on unbroken skin poses no possibility of transmission.Ingesting or otherwise allowing urine inside the bodyinvolves a small potential for HIV transmission. Ingestingurine poses the possibility of infection by other organisms,particularly hepatitis A and B, herpes and other diseases ofparticular concern for people living with HIV.There is some evidence that small amounts of blood ispresent in urine, and HIV could be passed on to a receptivepartner. Bloody urine coming into contact with an opencut, sore, lesion, burn or bleeding gums in the mouth ofthe recipient partner would be classified as negligible ratherthan no risk.Evidence of TransmissionThere is no evidence that transmission of HIV has occurredthrough contact with urine.Assessment of Risk of HIV TransmissionReceiving urineOn the body . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskInto the body . . . . . . . . . . . . . . . . . . . . . Negligible Risk*17. Health Canada. Infection Control Guidelines: Preventing the transmission of bloodborne pathogens in health care and publicservices settings, Health Canada. May 199728 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Risk* As blood may be present in the urine, there is a potential oftransmission through an open cut, sore, lesion, burn or bleedinggums in the mouth of the receiving partner.Vulva-to-vulva rubbing“pussy, beaver, cat fight”Potential for TransmissionVulva-to-vulva rubbing poses the potential for transmissionbecause there is a possibility that vaginal fluid may beexchanged between partners. During menstruation, the riskis increased by the potential exchange of blood.Evidence of TransmissionThere is no evidence of transmission of HIV by vulva-tovulvarubbing. The very few reported cases of female-tofemalesexual transmission of HIV have most likely been theresult either of mouth–vagina contact or sharing of sex toys.Assessment of Risk of HIV TransmissionVulva-to-vulva rubbing . . . . . . . . . . . . . . . Negligible RiskVulva-to-vulva rubbing during menses . . Negligible RiskDockingPotential for TransmissionDocking is placing the foreskin of one partner over thepenis of another partner followed by masturbation of bothpenises simultaneously. There is a small potential for transmissionby the entry of semen into the urethra, especiallyif the foreskin is sealed tight enough to prevent the escapeof semen. There is also a possibility that pre-cum or semenwill be retained under the foreskin of an uncircumcisedpartner, resulting in a risk of transmission into or throughits mucosa. The risk of HIV transmission for uncircumcisedmen is higher than for circumcised men 18 . (See Chapter 7.)Evidence of TransmissionAlthough the theoretical risk for transmission is high, nodocumented cases of HIV infection have been attributedto docking. However, it should be stressed that althoughit may be difficult to isolate cases of infection, this doesnot rule out the possibility of cases occurring, consideringthe continuum of sexual activities in which partnersmay participate, including where one low-risk activityleads to another higher-risk activity. The lack of literaturementioning this specific mode of transmission may not beconclusive.Assessment of Risk of HIV TransmissionDocking . . . . . . . . . . . . . . . . . . . . . . . . . . Negligible RiskDocking with exchange of semen and/orpre-cum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A**According to our model, the lack of documented cases in relationto the high potential of risk would lead this activity to becategorized as Negligible Risk. In this case though, the potentialfor risk associated with the activity and the lack of mentionin research literature precludes making a risk assignment.Breast milkPotential for TransmissionTaking breast milk into to mouth can occur during sexualactivity. There is a potential for transmission because HIVhas been isolated in breast milk in sufficient quantities toenable transmission to occur. The potential is increasedif bleeding gums, cuts, sores, ulcers, lesions or burns arepresent in the mouth of the recipient. Also, lactating motherswho are actively feeding infants may experience crackednipples which may bleed and transfer the HIV virus tothose taking breast milk into the mouth from the source.Evidence of TransmissionThere are no documented cases of HIV transmission fromtaking breast milk in the mouth during sexual activity.Assessment of Risk of HIV TransmissionTaking breast milk into the mouth . . . . . . Negligible RiskCultural PracticesPotential for TransmissionCultural practices, such as clitorectomy, vaginal sewing andapplying herbal drying agents to the mucosal lining of thevagina to tighten the vaginal cavity, may cause initial andrecurring trauma that induces bleeding and increases therisk of HIV.The potential for bleeding, developing open sores andopen wounds exists with all of these activities. There is an18. Crabb, Charlene. Circumcision and HIV Susceptibility, AIDS: 17(2) p. N3. January 2003.HIV Transmission29

HIV TRANSMISSION: Guidelines for Assessing Riskincreased potential for HIV transmission because of theincreased likelihood of an exchange of blood, semen orvaginal fluid between partners.disease and complicateor reduce treatmentoptions.Evidence of TransmissionAlthough there are no documented cases of HIV that canbe directly attributed to these cultural practices, there havebeen studies which have shown that the rates of HIV arehigher in those regions which practice these activities 19 .Assessment of Risk of HIV TransmissionAccording to our model, the lack of documented cases inrelation to the high potential of risk would lead this activityto be categorized as Negligible Risk. In this case though,the potential for risk associated with the activity and thelack of mention in research literature precludes making arisk assignment.Part 2. Drug UseDrugs can be consumed many different ways. For thepurposes of HIV transmission the methods of consumptionthat we will examine include snorting, smoking and injection.Injection Drug Use“Shooting up, hitting up, jacking up, mainlining, cranking”Injection drug use may involve either street drugs (e.g.cocaine, heroin), prescription drugs (e.g. insulin, anabolicsteroids), hormones or vitamin supplements (e.g. intramuscularvitamin B12).Potential for TransmissionSharing needles or syringes has a very high potential fortransmission of HIV due to the presence of blood in theshaft of the used needle and in the tube of the used syringe.Whether it is visible or not, blood will almost certainly bepresent in a used needle or syringe in sufficient quantitiesfor transmission to occur. Infective HIV may remain presentin the blood in a used needle or syringe for up to 24 to 72hours 20 . Sharing needles and syringes can also transmit otherblood-borne viruses, such as hepatitis B and hepatitis C.These are of particular concern to people living with HIV(and vice-versa), as they can hasten the progression of theTo reduce the risk,a new needle andsyringe should beused every time. Ifsharing a needle orsyringe is absolutelyunavoidable, it isessential that they arecleaned using bleachand water to reducethe risk of contractingHIV. Any brand ofhousehold bleach willdo, although the mostconcentrated bleach(5% or more) is best.If undiluted bleach is not available, then diluted bleach isa less but still somewhat effective cleaning agent. Liquiddishwashing detergent can also help eliminate HIV. If nothingelse is available, hydrogen peroxide, rubbing alcoholor strong drinking alcohol might be tried, although theseagents are considered less effective and are no guaranteeof killing any virus present. Tunnel wash—a mix of soap,diluted bleach, vinegar and water—is widely used in prisonswhere undiluted bleach is not readily available. Sterile water(available from some needle exchanges) is preferable for rinsing,but water which has been recently boiled can be used ifsterile water is not available.Even when injection drug use does not involve sharedneedles or syringes, a number of infections other than HIVmay be acquired by injecting drugs. Avoiding these illnessesis particularly important for people living with HIV/AIDS.These illnesses include skin abscesses and infections at thesite of injection, blood clots, heart infections and bacterialpneumonia.Evidence of TransmissionIt is well established that sharing needles and syringes posesa high risk of transmission of HIV.19. Baleta, A. Concern voiced over “dry sex” practices in South Africa, The Lancet: 352:1292. 1998.20. Masters, B. et al. Recovery of HIV from syringes. 12th World AIDS Conference Abstract 23222, 1998.30 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing RiskAssessment of Risk of HIV TransmissionInjection using shared and/or uncleaned needle, syringeand/or mixing equipment . . . . . . . . . . . . . . . . . High RiskInjection using shared and cleaned needle, syringe and/ormixing equipment . . . . . . . . . . . . . . . . . . . . . . .Low risk*Injection using new and/or unshared needle, syringe andmixing equipment . . . . . . . . . . . . . . . . . . . . . . . .No Risk*There is evidence of transmission due to improperly cleanedneedles and/or syringes.Non-Injection Drug UseSharing straws, crack pipesPotential for TransmissionThere is a potential of transmission of HIV through thesharing of straws or pipes for snorting or smoking drugs.This is because of the likelihood of blood being present onthe straw or pipe due to a disruption of nasal membranes orcuts and sores on the lips.The likelihood of transmission of HIV is lessened by theamount of time that the pipe or straw is exposed to the airbefore being used by a second person. HIV does not survivewell outside of the body.Evidence of TransmissionThere is no published evidence of HIV transmission specificallythrough the sharing of crack pipes. There are severalstudies indicating HIV transmission through crack usersperforming oral sex. In these cases transmission the cuts,sores and burns on the lips of the crack user are thought tohave served as the route of entry for the disease 21 .There are no published cases of transmission of HIVthrough the sharing of straws or other devices for snorting.Assessment of Risk of HIV TransmissionSnorting or smoking drugs using new and/or unsharedstraws or pipes . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskSnorting or smoking drugs using shared straws orpipes . . . . . . . . . . . . . . . . . . . . . . . . . . . . Negligible Risk**Risk is associated with the potential presence of blood on thesematerials due to the rupture of nasal membranes and/or thepresence of sores or cuts on the lips.Part 3. Other Activities InvolvingNeedlesTattooing, Piercing, Electrolysis and AcupuntureOther than for injection drug use, needles can be used fortattooing, piercing, electrolysis and acupuncture.Potential for TransmissionAll tattooing, piercing, electrolysis and acupuncture practitionersshould follow universal precautions similar to thoseused in hospitals 22 . It is required by law that all needles usedin such procedures be used only once and disposed of afteruse. However, situations occur where these precautionsmay not be adhered to or strictly enforced. In such cases,individuals will have to negotiate their own level of acceptablerisk. Appropriate queries should be made about theprecautions observed in any particular clinic or studio priorto such procedures being performed. (See Section 2, HIVand Prisons).There is also an opportunity for genital piercing potentiallyto puncture a condom. An extra-large condom or condomwith a larger resevoir may provide added protection forpiercings on the head of the penis.Evidence of transmissionThere is a potential for blood to be present on tools usedfor piercing, tattooing and electrolysis, however there havebeen no reported cases of transmission through this method.Ensuring that the tattoo, piercing or electrolysis is carriedout using sterilized equipment (using universal precautions)and new needles will eliminate the risk of exposure.Evidence of transmission using non-professional, handmade equipment (for example, the equipment used by peo-21. Faruque S, Edlin BR, McCoy CB, Word CO, Larsen SA, Schmid DS, Von Bargen JC, Serrano Y. Crack cocaine smoking and oral soresin three inner-city neighborhoods. J Acquir Immune Defic Syndr Hum Retrovirol., 13(1): 87-92.22. 1996 Sept. Masters, B. et al. Recovery ofHIV from syringes. 12th World AIDS Conference Abstract 23222, 1998.22. Health Canada. Infection Control Guidelines: Preventing the transmission of bloodborne pathogens in health care and publicservices settings, Health Canada. May 1997.HIV Transmission31

HIV TRANSMISSION: Guidelines for Assessing Riskple in prisons for unsanctioned tattooing) has been difficultto obtain. One study 23 , along with anecdotal evidence, doesindicate that tattooing while in prison was an independentfactor in HIV transmission.Assessment Of RiskTattooing, piercing, electrolysis and acupuncture usinguniversal precautions . . . . . . . . . . . . . . . . . . . . . .No RiskTattooing, piercing, electrolysis and acupuncture usingshared, uncleaned equipment . . . . . . . . . . Negligible RiskTattooing using non-professionalequipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Low RiskPart 4. Mother-to-Child TransmissionBecause of the complexity of issues relating to maternal transmission,no category to assess the risk of transmission is assignedhere. The statistical probabilities are taken from recent scientificstudies.Breast FeedingPotential for transmissionHIV is present in the breast milk of lactating HIV-positivewomen. Infants may be at risk of HIV infection throughbreast-feeding, as the mucosal immunity in their mouths isnot fully developed. In North America, it is recommendedthat HIV-positive mothers do not breast-feed infants. Thisis not always the recommendation in developing countries.In such countries, breast milk may be the only availablesource of nutrients necessary for the child’s developmentand provide the only means of protecting the infant withantibodies against other potentially life-threatening infections.However, studies are being done on longer-term useof Zidovudine (AZT) to prevent the transmission of HIVthrough breast-feeding 24 .Vertical TransmissionPotential for transmissionA woman’s choice to have a child when she is HIV positiveis a complex and emotional one. Studies have shown that ifno anti-HIV treatments are taken during pregnancy, thereis between 20%-30% chance of HIV transmission fromthe mother to the fetus. This is often referred to as verticaltransmission. Recent studies also suggest that a numberof other factors are associated with vertical transmission,including maternal viral load, clinical stage of disease,nutritional status, low infant birth weight, cigarette smokingduring pregnancy and intrapartum (during birth) factors,such as prolonged rupture of membranes that may exposethe fetus to maternal fluids.In recent years, it has been shown that the risk of verticaltransmission is reduced to 2% - 3% by treatment with theanti-HIV drugs Zidovudine or Nevirapine, administeredorally during the second and third trimesters of pregnancy,intravenously during labour, and to the baby just afterbirth 25 . Combination antiretroviral therapy may reduce thisrisk even further, although studies examining this have notyet been completed. Delivery via caesarian section may alsodecrease the risk of maternal HIV transmission 26 .A woman’s right to reproduce is not diminished, nor shouldit be discouraged, because she is HIV positive. Womenliving with HIV/AIDS who are pregnant, or who areconsidering pregnancy, should be encouraged to discusstheir situation with an obstetrician or reproductive healthspecialist who is experienced in the issues surroundingmaternal transmission of HIV.Part 5. Artificial Insemination, BloodTransfusion and Organ TransplantsIn Canada, all donated blood, organs and semen are nowscreened for HIV antibodies. There is a very small potentialfor transmission due to the possibility that blood or semen23. Estebanez Estebanez, P., Colomo Gomez, C., Zunzunegui Pastor, M.V., Rua Figueroa, M., Perez, M., Ortiz, C., Heras, P., Babin, F. Jailsand AIDS. Risk factors for HIV infection in the prisons of Madrid. Gaceta sanitaria, 4(18):100-5. 1990 May-June.24. Manigart O, et al. Effect of Perinatal Zidovudine Prophylaxis on the Evolution of Cell-Free HIV-1 RNA in Breast Milk and PostnatalTransmission, Journal of Infectious Diseases, 190:1422-1428. 2004.25. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ, et al. Reduction of maternal infant transmission of HIV-1 withzidovudine treatment, New England Journal of Medicine. 331:1173-80. 1994.26. Read, J. Mode of delivery and vertical transmission of HIV-1: A meta-analysis from fifteen prospective cohort studies (The InternationalPerinatal HIV Group). 12th World AIDS Conference Abstract 23275, 1998.32 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskmay have been donated in the four-to-six-week windowperiod prior to the donor developing HIV antibodies.However, it cannot realistically be assigned a risk categoryunder this model. To further reduce this small risk, new andmore sensitive screening tests are being developed.Part 6. OtherBranding and ScarificationBranding and scarification are practices that can occur indifferent contexts, including in S/M activities or as part ofcultural practices, such as healing scarification.Potential for TransmissionHeat-branding does not meet the conditions for HIV transmissionbecause of the high temperatures involved (heatkills HIV). Knife-branding should only be done with asterile scalpel with a disposable blade (scalpels can be boughtat medical supply stores). It should only be used once, thenplaced in a strong narrow-necked plastic container with alid, and thrown in the garbage. If using a new scalpel is notpossible, the knife should be soaked in bleach for twentyminutes and then rinsed with water.Likewise, scarification should be performed using newneedles, knives or razors. If using a new equipment is notpossible, the equipment should be soaked in bleach fortwenty minutes and then rinsed with water.Evidence of TransmissionThere is a risk of HIV transmission from sharing unsterilizedbranding or scarification equipment under certaincircumstances, although there is little documented researchexploring the role of branding or scarification in HIV transmission27 , and none that demonstrate documented cases ofHIV transmission occurring through these practices. Thelack of literature mentioning this specific mode of transmissionmay not be conclusive.lack of mention in research literature precludes making arisk assignment.EstheticsPotential for TransmisisonEven without sterilization, it is unlikely that HIV wouldbe transmitted via manicures or pedicures as HIV does notsurvive long when exposed to the environment.Evidence of TransmissionThere is no evidence to support transmission occurringthrough receiving a manicure, pedicure, haircut, massage,etc.Assessment of Risk of HIV TransmissionManicures or pedicures with uncleanedequipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskManicures or pedicures with sterilizedequipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskFightingPotential for TransmissionMost of the conditions for transmission of HIV are presentin the case of a fight where both people have open cutsor wounds. However, due to the short life of HIV whenexposed to the open air, there is a question as to whether ornot there would be a sufficient level of the virus to transmitHIV.Evidence of TransmissionThere are no documented cases of transmission of HIV inthis manner.Assessment of Risk of HIV TransmissionFighting . . . . . . . . . . . . . . . . . . . . . . . . . Negligible RiskAssessment of Risk of HIV TransmissionAccording to our model, the lack of documented cases inrelation to the high potential of risk would lead this activityto be categorized as Negligible Risk. In this case though,the potential for risk associated with the activity and the27. Orubuloye, I. O. and Caldwell, Pat and Caldwell, John. A note on suspect practices during the AIDS epidemic: vaginal drying andscarification in southwest Nigeria. Health Transition Review, 5(suppl.):161-165. c. 1995.HIV Transmission33

Risk MHIV TRANSMISSION: Guidelines for Assessing RiskEVIDENCEPOTENTIALNONo RiskNOYES (under certaincircumstances)YES Negligible Risk Low Risk High RiskYESHepatitis C No Risk: Kissingwithout the exchange of blood;sadomasochistic activities (withuniversal precautions); contactwith feces or urine (unbroken skin);injecting, smoking and snorting drugsusing new equipment; tattooing,piercing, branding, scarification,manicures, pedicures, electrolysisand acupuncture with sterilized andnew equipment.Hepatitis C Negligible Risk: Fellatio;cunnilingus; anilingus; fingering; non-insertivemasturbation; sadomasochistic activities withexchange of blood; contact with feces or urine(on broken skin); vulva-to-vulva rubbing, docking,giving or receiving breast milk into the mouth;fighting.HIV No Risk: Kissing (no blood); non-insertive masturbation; receiving unshared sex toys;contact with feces or urine (unbroken skin); injecting with unshared needles; using drugs withnew pipe or straw; sadomasochistic activities (with universal precautions); tattooing, piercing,electrolysis and acupuncture with sterilized and new equipment; manicures or pedicures.34

HIV TRANSMISSION: Guidelines for Assessing RiskodelHepatitis C High Risk: Injecting drugsusing shared and cleaned needles ormixing equipment; tattooing, piercing,electrolysis and acupuncture with sharedequipment; occupational exposure.HIV High Risk: Penileanalor penile-vaginalintercourse withoutcondom; receivngshared sex toys;injecting with sharedneedles.Hepatitis C Low Risk: penile-vaginaland penile-anal intercourse; fisting; snortingand smoking drugs using shared equipment;manicures and pedicures with uncleanedequipment; sharing toothbrushes andrazors.HIV Negligible Risk: Receiving fellatio or cunnilingus;performing fellatio or cunnilingus with barrier; anilingus;fingering; fisting; using shared sex toys with a condom; usingdisinfected sex toys; sadomasochistic activities; contactwith feces or urine (on broken skin); vulva-to-vulva rubbing;docking; taking breast milk into the mouth; using drugswith shared pipe or straw; tattooing, piercing, electrolysisand acupuncture with shared equipment; fighting; sharingtoothbrushes and razors.HIV Low Risk: Kissing(with exchange of blood);performing fellatio orcunnilingus without barrier;intercourse (penile-anal orpenile-vaginal) with barrier;injecting with cleaned needles;tattooing with non-professionalequipment; taking blood in themouth; occupational exposure.35

HIV TRANSMISSION: Guidelines for Assessing RiskIntentional Blood Exchange“Vampirism”, “Blood Brother/Sisterhood”Potential for TransmissionDrinking, sucking or licking the blood of a person who isinfected with HIV poses a potential for transmission. Thisrisk of transmission is increased depending on the amountof blood that is taken into the mouth, and the frequency ofthe activity and the presence of cuts or sores in the mouth.Likewise, customs like “blood brothers” or “blood sisters”(where blood can be exchanged between people by rubbingopen cuts together to show trust and friendship with oneanother) can also put a person at risk for contracting HIV.Customs like this can allow one persons’ blood to get intothe bloodstream of another person, allowing transmission ofHIV to occur.Evidence of TransmissionThere are a few anecdotal reports of HIV transmissionthrough taking blood into the mouth.There are no documented cases of HIV transmissionthrough blood Brother/Sisterhood pacts. It should bestressed however, that blood Brother/Sisterhood pacts carrya very high assessment of theoretical risk as the likelihood ofsomeone else’s blood directly entering your bloodstream ishigh.Assessment of Risk of HIV TransmissionTaking blood into the mouth . . . . . . . . . . . . . . . Low RiskBlood Brother/Sisterhood pacts: According to our model,the lack of documented cases in relation to the highpotential of risk would lead this activity to be categorizedas Negligible Risk. In this case though, the potential forrisk associated with the activity and the lack of mention inresearch literature precludes making a risk assignment.if universal precautions are not followed. For exampleexposure through needle-stick injuries happen and in suchcases there have been three factors associated with transmissionof HIV: the volume of blood injected, the illness ofthe source patient and the administering of post-exposureprophylaxis 28 . Safe handling of needles, wearing gloveswhen administering punctures to draw blood and access topost-exposure prophylaxis (in the case of exposure) can allhelp reduce the potential for transmission.Evidence of TransmissionIn Canada there have been few (three cases as of 2002)recorded cases of HIV transmission due to occupationalexposure.Assessment of Risk of HIV TransmissionOccupational Exposure . . . . . . . . . . . . . . . . . . . Low RiskSharing toothbrushes, razors etc.Potential for TransmissionSharing personal use items such as razors and toothbrushesgenerally do not present an effective means or route for HIVtransmission. In addition, the short life of HIV outside thebody reduces the likelihood of transmission. However, itis preferable to avoid sharing such items, as contact withthe first user’s blood is possible as a result of nicks, cuts andbleeding gums in both users.Evidence of TransmissionThere are no documented cases of HIV transmissionattributed to sharing personal use items such as razors ortoothbrushes.Assessment of Risk of HIV TransmissionSharing toothbrushes, razors etc. . . . . . . . Negligible RiskOccupational ExposurePotential for transmissionExposure to semen, vaginal fluids, blood and breast milk inan occupational setting (for example in emergency responseand medical staff) does carry a potential for transmission28. CDC. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood --- France,United Kingdom, and United States, January 1988-August 1994. MMWR 44:929-33. 1995.36 HIV Transmission

HIV TRANSMISSION: Guidelines for Assessing Risk5. Hepatitis C Transmission:A Model for Assessing RiskHepatitis C (HCV) is a blood-borne virus that can destroythe liver. The major causes of HCV infection worldwideare unscreened blood transfusions, and re-use of needles,syringes, tattooing and piercing equipment. In Canada, alldonated blood and organs are now screened for HCV.There is currently no vaccine to prevent HCV. PegylatedInterferon combined with Ribavirin is used in the treatmentof persons with chronic HCV infection.Differences between HIV and HCVHCV has been shown to live much longer outside the bodyand in a dormant state, even on dried surfaces, than HIV.Activities that would be negligible risks for HIV, such assharing toothbrushes or straws to snort cocaine, are muchhigher for HCV. This is because they often involve exchangingsmall amounts of blood and the external exposure (toair, temperature and light) that kills HIV may not kill HCV.In addition, cleaning techniques for needles that considerablyreduce the risk of HIV do not necessarily have the samerisk reduction effects for HCV. This also suggests that HCVis much hardier than HIV.The risk of contracting HCV through sexual contact is notas well-established. Recent studies show that there is littleto no HCV present in vaginal fluids and semen. However,it must be stressed that this area is still being researched andno final conclusions have been made on the assessment ofrisk for transmission through sexual activities that do notinvolve the presence of bloodConditions for Transmission of HCVThe same five conditions as for HIV must be present forHCV transmission to occur. There are however some differencesbetween HIV and HCV within each category becauseof the fact that blood is the main concern for transmissionof HCV.1. There must be a source of infection.Relying on the identification of a person as a source ofinfection is not useful in developing prevention messages,since it is nearly impossible to tell if a person is infectedby looking at them. It is more appropriate to consider thesource of infection as the presence of HCV in the blood.2. There must be a means of transmission.The following routes of HCV transmission are well-established:• sharing used needles or syringes or other drug usingequipment, and other situations that involve piercing ofthe skin (such as tattooing or piercing)• specific types of sexual activity (when blood may beexchanged)• receiving transfusions of infected blood or bloodproducts or transplanted organs (in Canada all donatedblood and organs are screened for HCV).• mother-to-child transmission, in the uterus, duringchildbirth (vertical transmission) or through breastfeeding (when nipples are bleeding).3. There must be a host susceptible toinfection.The virus is harmless until it finds a host or, more accurately,susceptible cells within the host’s body. Every human beingis considered to be a host susceptible to infection.4. There must be an appropriate route ofentry to the target cells of the body.Infected blood reach the HCV-susceptible cells in the blood,usually through a break in the skin. Unlike HIV, transmissionof the virus purely through the mucosal membranes(mucosa) exposed during sexual contact has not been found.Mucosa are the moist surfaces of the body which line mostof the body cavities and hollow internal organs such as thevagina, rectum, mouth, urethra, nose and eyelids.Hepatitis C Transmission37

HIV TRANSMISSION: Guidelines for Assessing RiskEVIDENCEPOTENTIALNONo RiskNOYES (under certaincircumstances)YES Negligible Risk Low Risk High RiskYES5. There must be a sufficient level of virusdelivered to establish infection.Because of a higher concentration or quantity of virus, somebody fluids are efficient media for transmitting HCV, whileothers are not. Blood is of most concern in HCV transmission.Factors Used to Determine the Levelof RiskA. Potential for TransmissionIn assessing potential for transmission, we consider the 5conditions for transmission. Because it is impossible toprove that an infection will never happen, it is important toconsider the potential for transmission and weigh it againstevidence of what is known to have actually occurred.B. Evidence of TransmissionIn creating these guidelines, a review of research was carriedout to examine the documented evidence of HCV transmissionthrough specific practices. Case reports, abstracts andresearch reports were considered, with the greatest weighton reports from cohort studies using multivariate analysistechniques (studying a specific group of individuals overtime and analysing the interaction of a number of variables).For the purpose of this model, greater emphasis is placedon what is known or proven to happen, than on what mayhappen in theory.To assess the risk of HCV transmission, the potentialfor transmission and the evidence that transmission hasoccurred are both considered. Activities are then placed intoone of four categories.Categories for Assessing Risk1. No riskTo our knowledge, none of the practices in this categoryhave ever been demonstrated to lead to HCV infection.There is no potential for transmission since all of the basicconditions for viral transmission are not present.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . NoneEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . None2. Negligible riskAll of the practices assigned this risk level present a potentialfor HCV transmission because they involve an exchangeof blood. However, the amounts, conditions and media ofexchange are such that the efficiency of HCV transmissionappears to be greatly diminished. There are no confirmedreports of infection from these activities.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . . . YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . None3. Low riskAll of the practices assigned this risk level present a potentialfor HCV transmission because they involve an exchange ofblood. There are also a few reports of infection attributedto these activities (usually through individual case studiesor anecdotal reports, and usually under certain identifiableconditions).Potential for transmission . . . . . . . . . . . . . . . . . . . . . . . . YesEvidence of transmission . . . Yes (under certain conditions)4. High riskAll of the practices assigned this risk level present a potentialfor HCV transmission because they involve an exchange of38 Hepatitis C Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskblood. In addition, a significant number of scientific studieshave repeatedly associated the activities with HCV infection.Even when the exact mechanism of transmission is notcompletely clear, the results of such studies conclude thatactivities in this category are high risk.Potential for transmission . . . . . . . . . . . . . . . . . . . . . . . . YesEvidence of transmission . . . . . . . . . . . . . . . . . . . . . . . . YesChallenges of Assessing Risk for HCVA. Lack of Consistent Information andResearch on Sexual TransmissionResearch on sexual transmission of HCV shows somediscrepancy between male to male transmission and femaleto male/male to female transmission. There is frequentmention of certain activities (for example: penile-analintercourse, anilingus, using insertive sex toys and sadomasochisticactivities) in the male to male research indicatingthat these activities are consistent with sexual transmission.In female to male/male to female these activities are notmentioned and there is little evidence of sexual transmissionof HCV between men and women. For the purposes ofassessing risk, where there is potential and evidence for atleast one group, the assessment assumes that the conditionsfor transmission have been met for all groups unless thereare physiological differences that warrant a different riskassessment.B. Difficulty Assessing the Risk of a SingleActivity in the Presence of Multiple ActivitiesFor the purposes this model, we consider the risk of a singleepisode of each particular practice. In real life, activityis rarely confined to one episode or to one practice. If acombination or sequence of activities is deemed to increaserisk, these factors are addressed in the text.Hepatitis C Transmission39

40HIV TRANSMISSION: Guidelines for Assessing Risk

HIV TRANSMISSION: Guidelines for Assessing Risk6. Assessing Risk of Hepatitis CTransmissionPart 1. Sexual ActivitiesThe risk of contracting hepatitis C through sexual contact isnot well-established. Recent studies show that there is littleto no hepatitis C virus present in vaginal fluids or semen.However, transmission can occur if blood is present, eithervisibly or through microscopic cuts or tears in the skinand/or mucosa.It must be stressed that this area is still being researched andno final conclusions have been made on the assessment ofrisk for transmission through sexual activities that do notinvolve the presence of blood.Kissing“Sucking face, necking, smooching”Potential for TransmissionThere is no potential for HCV transmission in pressing drylips together.In the absence of blood in the mouth, wet kissing can beclassified as no risk. Saliva that does not contain bloodpresents no potential for transmission.There is a small potential for transmission in wet kissingwhere blood may be exchanged. The presence of blood inthe mouth could be caused by recent brushing or flossing ofthe teeth, a sore in the mouth, gum disease, a recent toothextraction or biting or scratching one another (e.g. withthe teeth or orthodontic alliances, such as braces) duringkissing. Although it is likely that only a small amount ofblood would ever be present, the presence of a quantitysufficient for transmission of HCV to occur cannot bediscounted. The risk of transmission is increased whereblood is exchanged between mouths and where the mouthof the person receiving the blood contains ulcers or sores, orwhere there is evidence of dental recession.Note: It is recommended that a period of 30 minutes totwo hours be allowed to elapse after brushing or flossingteeth before sexual activity, due to the possibility of blood insaliva.Evidence of TransmissionThere is no evidence of transmission of HCV throughkissing alone.Assessment of Risk of HCV TransmissionWet or dry kissingNo exchange of blood . . . . . . . . . . . . . . . . . . . . . .No RiskWet kissingWith exchange of blood . . . . . . . . . . . . . . . . . . . . . . N/A** According to our model, the lack of documented cases in relationto the high potential of risk would lead this activity to becategorized as Negligible Risk. In this case though, the potentialfor risk associated with the activity and the lack of mentionin research literature precludes making a risk assignment.Oral Sex: Fellatio“Giving or getting head, headjob, blowjob, sucking off,blowing, face-fucking, going down, cock-sucking”Potential for TransmissionThere is a potential risk of transmission of HCV to thepartner giving fellatio if there is a disruption in the oralmucosa such as bleeding gums, cuts, sores, lesions, ulcers orburns in the mouth or by a recent tooth extraction and thepresence of blood from an abrasion or cut on the penis.It is recommended that the partner giving fellatio wait 30minutes to two hours after brushing or flossing teeth beforeengaging in fellatio, since brushing and flossing teeth maycause temporary bleeding of the gums.There is a similarly small risk of contracting HCV in gettingfellatio if blood from bleeding gums or sores in the mouthcould come into contact with an abrasion on the penis.Although it is likely that only a small amount of bloodHepatitis C Transmission41

HIV TRANSMISSION: Guidelines for Assessing Riskwould ever be present, the presence of a quantity sufficientfor transmission of HCV to occur cannot be discounted.Evidence of TransmissionSome studies show small amounts of HCV in saliva wherepoor dental health is apparent, indicating that trauma in themouth (bleeding gums) is likely responsible for the presenceof HCV in these cases. It is not known if the enzyme insaliva that inhibits HIV also inhibits HCV. To date, there isno evidence of HCV being transmitted through fellatio.Assessment of Risk of HCV TransmissionFellatio (giving)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom . . . . . . . . . . . . . . . . . . . Negligible RiskFellatio (getting)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Oral Sex: Cunnilingus“Licking out, eating out, going down, licking pussy, boxlunch, eating at the Y”Potential for TransmissionThere is a potential for transmission of HCV by performingcunnilingus (licking the clitoris and/or in or around thevulva) because of the possible exchange of bloodThere is a potential for transmission to the partner performingcunnilingus if there is a disruption in the oral mucosacaused by bleeding gums, cuts, sores, lesions, ulcers or burnsin the mouth or by a recent tooth extraction, or other dentalwork that causes trauma in the mouth and the presence ofblood from an abrasion or cut on the clitoris or vulva. Therisk in performing cunnilingus is also higher during menstruationbecause of the presence of blood.It is recommended that the performing partner wait 30minutes to two hours after brushing or flossing teeth beforeengaging in cunnilingus, since brushing and flossing maycause temporary bleeding of the gums.Receiving cunnilingus involves a small potential for transmissionbecause of the possibility of abrasions on the vagina,clitoris or vulva; these could permit entry of small quantitiesof blood from bleeding gums or a sore in the mouth.Although it is likely that only a small amount of bloodwould ever be present, the presence of a quantity sufficientfor transmission of HCV to occur cannot be discounted.The risk can be reduced by using a latex barrier over thevulva, such as a dental dam or, as an alternative, a newand unlubricated condom carefully cut open and used as abarrier between the mouth and vulva or clitoris.Evidence of TransmissionSome studies show a small amount of HCV in saliva wherepoor dental health is apparent, indicating that trauma in themouth (bleeding gums) is likely responsible for the presenceof HCV in these cases. To date, there is no evidence ofHCV transmission as a result of cunnilingus.Some reports suggest that in people living with HIV/AIDSthere is an increased possibility of transmitting HCV.Assessment of Risk of HCV TransmissionCunnilingus (performing)With barrier and during menses . . . . . . . Negligible Risk*With barrier and not during menses . . . . . Negligible RiskWithout barrier and not during menses . . Negligible RiskWithout barrier and during menses . . . . . Negligible RiskCunnilingus (receiving)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Oral Sex: Anilingus“Rimming, licking out, eating out, licking or eating ass”Potential for TransmissionAnilingus is not an efficient means of HCV transmission.There is a potential for transmission in performing anilingusif blood is present in or around the anus and there is a disruptionto the oral mucosa caused by bleeding gums, cuts,sores, lesions, ulcers or burns or by a recent tooth extraction,or other dental work. Although it is likely that only a smallamount of blood would ever be present, the presence of aquantity sufficient for transmission of HCV to occur cannot42 Hepatitis C Transmission

HIV TRANSMISSION: Guidelines for Assessing Riskbe discounted. Any risk from anilingus can be reduced byuse of a latex barrier, such as a dental dam or a new condomcarefully cut open and used as a barrier between the mouthand anus.Receiving anilingus involves a small potential for transmissionbecause of the possibility of abrasions in or around theanus; these could permit entry of small quantities of bloodfrom bleeding gums or a sore in the mouth. Although itis likely that only a small amount of blood would ever bepresent, the presence of a quantity sufficient for transmissionof HCV to occur cannot be discounted.It is recommended that the performing partner wait 30minutes to two hours after brushing or flossing teeth beforeengaging in anilingus, since brushing and flossing may causetemporary bleeding of the gums.Evidence of TransmissionThere is no evidence of transmission for HCV in thisactivity.Assessment of Risk of HCV TransmissionAnilingus (performing)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible RiskAnilingus (receiving)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Intercourse: Penile–Vaginal“Fucking, screwing, making love, getting or being laid”Potential for TransmissionThere is potential for transmission in the presence of bloodfrom cuts, abrasions or sores on the penis and vaginal area.The presence of menstrual blood also increases the risk fortransmission. Minor or microscopic cuts or tears and soreson the penis (e.g. genital ulcers) can provide a point of entryfor the virus. The foreskin may be particularly susceptible totears, scratches and abrasions, suggesting that its presencemay increase the likelihood of contracting HCV.Evidence of TransmissionSome studies have indicated that transmission of HCV hasoccurred during penile-vaginal sex, when blood is present.As mentioned above, studies show that there is little to novirus present in vaginal fluids and semen, so the evidencepresented to date is under certain circumstances only,resulting in a low risk category for HCV transmission withor without a condom.Some studies indicate that people living with HIV are atgreater risk of sexual transmission of HCV.Assessment of Risk of HCV TransmissionInsertive penile-vaginal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . Low RiskReceptive penile-vaginal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . Low Risk* There is enough evidence of breakage or improper use of barriermethods to classify this activity as low rather than negligiblerisk.Intercourse: Penile–Anal“Butt-, bum- or ass-fucking, screwing, making love, gettingor being laid, anal sex”Potential for transmissionThere is potential for transmission in the presence of bloodfrom cuts, abrasions or sores on both the penis and the anusor rectum. Minor or microscopic cuts, tears or sores on thepenis (e.g. genital ulcers) can provide a point of entry forthe virus. The foreskin may be particularly susceptible totears, scratches and abrasions, suggesting that its presencemay increase the likelihood of contracting HCV.The potential for transmission of HCV through penile-analsex is the same for men or women who have anal sex.Evidence of TransmissionStudies examining the risk of sexual transmission of HCVidentify several activities as risky. These include fisting andanal sex.The specific condition of one or both partners having HIVmay increase the likelihood of transmission of HCV.Hepatitis C Transmission43

HIV TRANSMISSION: Guidelines for Assessing RiskAssessment of Risk of HCV TransmissionInsertive penile–anal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . Low RiskReceptive penile–anal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*There is enough evidence of breakage or improper use of barriermethods to classify this activity as low rather than negligiblerisk.Fingering (Anal and Vaginal)“Finger job, finger-fucking”Potential for TransmissionThere is a risk of transmission of HCV through fingeringthe clitoris, labia, vagina or anus if the finger has an opencut, sore, lesion, burn, rash or hangnail and there is bloodpresent in or on the clitoris, labia, vagina or anus. Thelikelihood of the vaginal or rectal lining suffering trauma isincreased as fingernails can easily tear these membranes.The risk for transmission via this method is increased withthe presence of menstrual blood.The risk can be reduced by using a latex glove, whichperforms a similar function to a condom during penileintercourse. However, a finger (gloved or not) might stillcause some stress to the mucosal lining of the receivingpartner, which could increase the risk to the receivingpartner if other activities (such as penile-vaginal or penileanalintercourse without a condom) follow.Evidence of TransmissionThere are no documented cases of HCV transmissionthrough performing or receiving digital-vaginal or digitalanalintercourse.Assessment of Risk of HCV TransmissionVaginal or Anal Fingering (performing)With latex glove . . . . . . . . . . . . . . . . . . . Negligible Risk*Without latex glove . . . . . . . . . . . . . . . . . Negligible RiskVaginal or Anal Fingering (receiving)With latex glove . . . . . . . . . . . . . . . . . . . Negligible Risk*Without latex glove . . . . . . . . . . . . . . . . . Negligible Risk*The latex glove could break or be defective or improperlyused, making it impossible to classify these activities as no risk.However, using a glove will reduce risk, particularly if opencuts, sores, lesions, burns or rashes are present.Fisting (Anal and Vaginal)Potential for TransmissionThe practice of inserting the hand into the rectum or vaginais not by itself an efficient means of HCV transmission.Tearing may occur due to forceful insertion or scratchesfrom finger-nails. The performing partner may have cutsor abrasions (including hangnails) which may be exposedto blood during fisting. There might also be a presence ofmenstrual blood.Risk can be reduced by using a latex glove. However, a handand or fingers (gloved or not) might still cause some stressto the mucosal lining of the receiving partner, which couldincrease the risk to the receiving partner if other activities(such as penile-vaginal or penile-anal intercourse without acondom) follow.Evidence of TransmissionStudies examining the risk of sexual transmission of HCVidentify several activities as risky. These include fisting andanal sex. As mentioned above, the specific condition of oneor both partners having HIV may increase the likelihood oftransmission of HCV.Assessment of Risk of HCV TransmissionFisting (performing)With glove . . . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without glove . . . . . . . . . . . . . . . . . . . . . . . . . . Low RiskFisting (receiving)With glove . . . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without glove . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*The latex glove could break or be defective or improperly used,making it impossible to classify these activities as negligible risk.However, using a glove will reduce risk, particularly if opencuts, sores, lesions, burns or rashes are present.44 Hepatitis C Transmission

HIV TRANSMISSION: Guidelines for Assessing RiskMasturbation by Partner“Jerking or jacking off, J/O, giving or getting a hand-job,getting someone off, making someone cum”Potential for TransmissionThe practice of masturbating a man through manualstimulation of the erect penis, or of masturbating a womanby manual stimulation of the clitoris, carries no risk forthe person holding the penis or fingering the clitoris unlessthere are cuts, burns, abrasions or rashes on the fingers orhands that come into contact with the partners’ blood. Thisrisk can be reduced by using a latex glove.Evidence of TransmissionThere are no documented cases of transmission throughmasturbation of a male or female partner.Assessment of Risk of HCV TransmissionNon-insertive Masturbation* (performing)With glove . . . . . . . . . . . . . . . . . . . . . . .Negligible Risk**Without glove . . . . . . . . . . . . . . . . . . . . . Negligible RiskNon-insertive Masturbation* (receiving)With glove . . . . . . . . . . . . . . . . . . . . . . .Negligible Risk**Without glove . . . . . . . . . . . . . . . . . . . . . Negligible Risk* For insertive masturbation, see Fingering.**The latex glove could break or be defective or improperlyused, making it impossible to classify these activities as no risk.However, using a glove will reduce risk, particularly if opencuts, sores, lesions, burns or rashes are present.Using Insertive Sex ToysPotential for transmissionUsing sex toys (e.g. dildos, vibrators, Chinese balls, buttplugs, anal beads etc.) can cause trauma resulting inbleeding to the rectum or vagina. The extent of potentialtransmission varies depending on the size of the device andthe way it is used.Trauma and resulting bleeding can promote the possibilityof later transmission by providing a route of entry for HCVto the blood and to HCV-susceptible cells through the cutsor tears in the rectum or vagina, and thereby increase therisk for HCV transmission through other activities thatmight follow (such as penile-vaginal or penile-anal intercourse).Transferring a sex toy directly from one partner to anotherallows for sharing of infected blood that can result in directHCV transmission. When using instruments and toys forsex play, universal precautions, such as is found in hospitalsfor materials such as metal, wood, rubber, etc., should befollowed. For more information on universal precautionsconsult Infection Control Guidelines: Preventing thetransmission of bloodborne pathogens in health care andpublic services settings (Health Canada).Placing a condom on the toy can make cleaning mucheasier. In the immediacy of a sexual situation, some peoplemay use a condom as a substitute for cleaning. After using acondom with one person, replace it with a new one beforethe toy is transferred to another person. There is some riskinvolved with this method because of the possibility thatthe condom can break, slip off or not completely cover thesurface of the toy.Evidence of TransmissionThere are no documented cases of transmission throughusing insertive sex toys, however the risk of exposure toblood, and the lack of literature mentioning this specificmode of transmission may not be conclusive.Assessment of Risk of HCV TransmissionAccording to our model, the lack of documented cases inrelation to the high potential of risk would lead this activityto be categorized as Negligible Risk. In this case though,the potential for risk associated with the activity and thelack of mention in research literature precludes making arisk assignment.Sadomasochistic Activities“S/M, S & M”Potential for TransmissionInfection can occur when infected blood comes into contactwith a route of entry to the blood system via an open cut,sore, lesion, ulcer, burn or rash.Some activities may lead to the incidental or intentionaldrawing of blood (e.g. whips, nipple-clamps, restraints,severe spanking). When any sadomasochistic activityinvolves the potential drawing of blood, sterile precautionsHepatitis C Transmission45

HIV TRANSMISSION: Guidelines for Assessing Risksimilar to those set in hospitals should be taken 29 . Anythingused to draw blood should not be used on more than oneperson.Any open cuts, sores, lesions, ulcers, burns or rashes shouldalso be protected from exposure to blood. Any body part,device or item that has blood on it should not come intocontact with another person’s vagina, rectum, penis or eyes,or with an open cut, sore, lesion, ulcer, burn or rash in themouth or on the body.Even when sadomasochistic activities are very rough – ifthey do not draw blood that comes into contact withsomeone else and are not followed by any other sexualactivities that involve contact with blood – they are not arisk for HCV transmission.Evidence of TransmissionThere are no documented cases of transmission throughsadomasochistic activities, however the risk of exposure toblood, and the lack of literature mentioning this specificmode of transmission may not be conclusive.Assessment of Risk of HCV TransmissionSadomasochistic activities (with universalprecautions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskSadomasochistic activities . . . . . . . . . . . . . Negligible RiskContact with Feces“Scat, shit play, brown”Potential for TransmissionBlood can occasionally be present in feces which means thatthere is a small potential for HCV transmission throughreceiving defecation onto open cuts, sores, lesions, ulcers,burns or rashes. Defecation on unbroken skin does not posea risk.Evidence of TransmissionThere is no evidence of HCV transmission through contactwith feces.Assessment of risk of HCV transmissionContact with fecesOn unbroken skin . . . . . . . . . . . . . . . . . . . . . . . .No RiskOn broken skin . . . . . . . . . . . . . . . . . . . Negligible Risk**Due to the potential of blood, if present in the feces, enteringan open cut, sore, lesion, burn on the body.Urination“Watersports, golden showers, pissing, yellow”Potential for TransmissionBlood can occasionally be present in urine which means thatthere is a small potential for HCV transmission throughreceiving another person’s urine onto open cuts, sores,lesions, ulcers, burns or rashes.Evidence of TransmissionThere is no evidence that transmission of HCV has occurredthrough contact with urine. There is some evidence thatsmall amounts of HCV virus are present in blood in theurine, and could be passed on to a receptive partner if thaturine is ingested. In this case, ingesting the urine would beclassified as negligible rather than no risk.Assessment of risk of HCV transmissionReceiving urineOn the body . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskInto the body . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Onto broken skin . . . . . . . . . . . . . . . . . Negligible Risk** As blood may be present in the urine, there is a possibility oftransmission through an open cut, sore, lesion, burn or bleedinggums in the mouth of the receiving partner.Vulva-to-vulva rubbing“pussy, beaver, cat fight”Potential for TransmissionDuring menstruation, the risk is increased by the potentialexchange of blood into open cuts, sores, lesions, ulcers,burns or rashes on the vulva or clitoris.Evidence of TransmissionThere have been no studies to demonstrate transmission ofHCV in this manner.29. Health Canada. Infection Control Guidelines: Preventing the transmission of bloodborne pathogens in health care and publicservices settings, Health Canada. May 1997.46 Hepatitis C Transmission

HIV TRANSMISSION: Guidelines for Assessing RiskAssessment of Risk of HCV TransmissionVulva-to-vulva rubbing . . . . . . . . . . . . . . . Negligible RiskDockingPotential for TransmissionThe potential for transmission requires the presence ofblood and an open sore or cut on the penis of both partners.If both partners have no bleeding or open sores, there is nopotential for transmission.Evidence of TransmissionThere is no evidence of transmission.Assessment of Risk of HCV TransmissionDocking . . . . . . . . . . . . . . . . . . . . . . . . . . Neglibible RiskBreast milkPotential for TransmissionThe presence of HCV virus in breast milk is negligible. Thepotential is present if bleeding gums, cuts, sores, ulcers,lesions or burns are present in the mouth of the recipientand the lactating woman is experiencing cracked nippleswhich may bleed and transfer the virus to those takingbreast milk into the mouth.Evidence of TransmissionThere is no evidence of transmission.Assessment of Risk of HCV TransmissionGiving or receiving breast milk into themouth . . . . . . . . . . . . . . . . . . . . . . . . . Negligible RiskCultural PracticesCultural practices, such as clitorectomy, vaginal sewing, andapplying herbal drying agents to the mucosal lining of thevagina to tighten the vaginal cavity, may cause initial andrecurring trauma that induces bleeding and increases therisk of transmission of HCV.Potential for TransmissionThe potential for bleeding, developing open sores and openwounds exists with all of these activities. The opportunityfor transmission of HCV in the presence of bleeding soresor wounds has been observed.Evidence of TransmissionWhile there are no documented cases of HCV transmissiondirectly attributed to these practices, the theoretical riskremains high.Assessment of Risk of HCV TransmissionAccording to our model, the lack of documented cases inrelation to the high potential of risk would lead this activityto be categorized as Negligible Risk. In this case though,the potential for risk associated with the activity and thelack of mention in research literature precludes making arisk assignment.Part 2. Drug UseIInjection Drug Use“Shooting up, hitting up, jacking up, mainlining, cranking”Injection drug use may involve either street drugs (e.gcocaine, heroin), prescription drugs (e.g. insulin, anabolicsteroids), hormones or vitamin supplements (e.g. intramuscularvitamin B12).Potential for TransmissionThe sharing of needles or syringes involves a very highpotential for transmission of HCV due to the presence ofblood in the shaft of the used needle and in the tube of theused syringe. Whether it is visible or not, blood will almostcertainly be present in a used needle or syringe in sufficientquantities for transmission to occur. Infective HCV mayremain present in the blood in a used needle or syringe forseveral days, or even weeks.There is also a risk of HCV transmission through the sharingof other injecting equipment can such as spoons, filters,water, tourniquets and swabs.Evidence of TransmissionIt is well established that sharing needles and syringes posesa high risk of transmission of HCV. To eliminate the risk, anew needle, syringe and mixing equipment should be usedevery time.It is very important to note that there are serious doubts asto whether cleaning methods are adequate for the purposeof killing HCV. To completely avoid the risk of infectionwith HCV, needles should never be shared. All needlesshould be capped and disposed of as soon as possible afterHepatitis C Transmission47

HIV TRANSMISSION: Guidelines for Assessing Riskuse. A needle should never be recapped by anyone otherthan the person who used it. It is also important not toshare vials or spoons of liquid, because blood from oneperson’s needle can get into the liquid and be drawn intoanother person’s needle. Needles can be marked by burningor breaking pieces of the plastic to identify which needlebelongs to whom.Assessment of Risk of HCV TransmissionInjection using new needle and syringe and unshared mixingequipment . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskInjection using shared, uncleaned needle and/or syringeand/or mixing equipment . . . . . . . . . . . . . . . . . High RiskInjection using shared, cleaned needle and/or syringe and/ormixing equipment . . . . . . . . . . . . . . . . . . . . . . High RiskNon-Injection Drug UseSharing straws, crack pipesPotential for TransmissionSharing straws and crack pipes when snorting or smokingcocaine or other drugs contains a real potential for the transmissionof HCV. Snorting can rupture mucosal linings inthe nose causing bleeding, and small amounts of blood canremain on the straw when it is used by another person. Thepotential for HCV to be transmitted in blood on the strawand then find a route of entry through mucosal rupturesin another user’s nose is classified as low risk. Sharing crackpipes also poses a risk of HCV infection because hot pipescan potentially burn or blister the lips of a user and causethem to bleed. As with straws, blood on the pipe could alsotransmit HCV.Evidence of TransmissionIt is well established that sharing pipes to smoke drugs orstraws to snort drugs can lead to HCV infection.Assessment of risk of HCV transmissionSnorting or smoking cocaine or other drugs using new orunshared straws and/or pipes . . . . . . . . . . . . . . . .No RiskSnorting or smoking cocaine or other drugs using sharedstraws and/or shared pipes . . . . . . . . . . . . . . . . . Low RiskPart 3. Other Activities InvolvingNeedlesTattooing, Piercing, Electrolysis and AcupuncturePotential for TtransmissionAll tattooing, piercing, electrolysis and acupuncture practitionersshould follow universal precautions similar to thoseused in hospitals 30 . It is required by law that all needles usedin such procedures be used only once and disposed of afteruse. However, situations occur where these precautionsmay not be adhered to or strictly enforced. In such cases,individuals will have to negotiate their own level of acceptablerisk. Appropriate queries should be made about theprecautions observed in any particular clinic or studio priorto such procedures being performed. (See Section 2, HIVand Prisons).Evidence of TransmissionHCV is much hardier than HIV when exposed to air. Thismeans that some percutaneous activities, such as piercingand tattooing with shared equipment (including ink) have amuch higher risk for HCV transmission than for HIV.There is a potential for blood to be present on tools used forpiercing, tattooing, electrolysis and acupunture and therehave been several studies linking tattooing and piercingwith HCV transmission. Ensuring that the tattoo, piercing,electrolysis or acupuncture is carried out using sterilizedequipment (using universal precautions) and new needleswill eliminate the risk of exposure. It is important to notethat cleaning with soap or bleach is not an adequate methodof destroying the HCV virus.Blood may also be present in ink pots, deposited during theuptake of ink and present on other paraphernalia used intattooing, piercing, electrolysis or acupunture. Check withyour service provider to ensure that all equipment is eithersterilized or unused.Evidence of transmission using non-professional equipment(for example, the equipment used by people in prisonsfor unsanctioned tattooing) has been cited in a number ofstudies.30. Health Canada. Infection Control Guidelines: Preventing the transmission of bloodborne pathogens in health care and publicservices settings, Health Canada. May 1997.48 Hepatitis C Transmission

HIV TRANSMISSION: Guidelines for Assessing RiskAssessment of Risk of HCV TransmissionPiercing, tattooing, acupuncture or electrolysis withshared equipment with or without cleaning . . . High RiskTattooing with shared ink . . . . . . . . . . . . . . . . . High RiskPiercing, tattooing acupuncture or electrolysis with sterilizedequipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskPiercing, tattooing acupuncture or electrolysis withunshared equipment (including ink) . . . . . . . . . .No RiskPart 4. Maternal TransmissionBecause of the complexity of issues relating to maternal transmission,no category to assess the risk of transmission is assignedhere. The statistical probabilities are taken from recent scientificstudies.Breast FeedingPotential for transmissionThe presence of HCV virus in breast milk is negligible.Studies have shown that for infants born to women withHCV, the average rate of infection was the same for infantswho were breastfed as those who were bottle-fed 31 . Thepotential is present if the mother is experiencing crackednipples which may bleed and transfer the virus to her child.Vertical TransmissionPotential for transmissionA woman’s right to reproduce is not diminished, nor shouldit be discouraged, because she is living with HCV. Womenliving with HCV who are pregnant, or who are consideringpregnancy, should be encouraged to discuss their situationwith an obstetrician or reproductive health specialist who isexperienced in the issues surrounding maternal transmissionof HCV.The rates of vertical transmission (from mother to fetus)ranges from 0% to 20%, with an average of 5%. The a highviral load the time of birth is a key factor associated with thetransmission of the virus. It should be noted that a womanwho is co-infected with HIV and HCV is 3.8 times morelikely to transmit HCV 32 .Part 5. Artificial Insemination, BloodTransfusion and Organ TransplantsIn Canada, all donated blood, organs and semen are nowscreened for HCV. Due to the possibility that blood mayhave been donated in the window prior to the donordeveloping HCV antibodies, there is a very small potentialfor transmission. However, it cannot realistically be assigneda risk category under this model. To further reduce thissmall risk, new and more sensitive screening tests are beingdeveloped.Part 6. OtherBranding and ScarificationBranding and scarification are practices that can occur indifferent contexts, including in S/M activities or as part ofcultural practices, such as healing scarification.Potential for TransmissionKnife-branding should only be done with a sterile scalpelwith a disposable blade (scalpels can be bought at medicalsupply stores). It should only be used once, then placed ina strong narrow-necked plastic container with a lid, andthrown in the garbage. Likewise, scarification should beperformed using new needles, knives or razors. Bleach isnot known to kill the HCV virus effectively. Therefore,cleaning branding and scarification equipment can onlypartially reduce, and not eliminate, the risk of transmission.However, if using a new equipment is not possible,the equipment should still be soaked in bleach for twentyminutes and then rinsed with water to reduce the risk oftransmission.Evidence of TransmissionThere is a risk of HCV transmission from sharing unsterilizedbranding or scarification equipment, although there islittle documented research exploring the role of branding orscarification in HCV transmission.Assessment of Risk of HCV TransmissionBranding and scarification, new or unsharedequipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No Risk31. CDC Viral Hepatitis; Perinatal Transmission Modes viewed on the Internet at.32. Yen T, Keeffe EB, Ahmed A. The Epidemiology of Hepatitis C Virus Infection. Journal of Clinical Gastroenterology. 36(1):47-53, 2003.Hepatitis C Transmission49

HIV TRANSMISSION: Guidelines for Assessing RiskBranding and scarification, sharedequipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N/A** According to our model, the lack of documented cases in relationto the high potential of risk would lead this activity to becategorized as Negligible Risk. In this case though, the potentialfor risk associated with the activity and the lack of mentionin research literature precludes making a risk assignment.EstheticsPotential for TransmisisonSome of the services that estheticians provide for theirclients, for example manicures and pedicures, could pose arisk of HCV transmission. Estheticians’ tools pose the samerisk for the transmission of HCV as personal hygiene itemslike razors and toothbrushes.Evidence of TransmissionSome studies show that HCV transmission may occurthrough esthetical procedures, although the exact means oftransmission in these cases remains unclear.Assessment of Risk of HCV TransmissionManicures or pedicures with uncleanedequipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Low RiskManicures or pedicures with sterilized, new or unsharedequipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .No RiskFightingPotential for TransmissionThe conditions for transmission of HCV are present in thecase of a fight where both people have open cuts or wounds.Evidence of TransmissionThere are no documented cases of transmission of HCV inthis manner.Assessment of Risk of HCV TransmissionFighting . . . . . . . . . . . . . . . . . . . . . . . . . . Negligible RiskIntentional Exposure to Blood“Vampirism”, “Blood Brother/Sisterhood”Potential for TransmissionDrinking, sucking or licking the blood of a person who isinfected with HCV poses a potential for transmission. Thisrisk of transmission is increased depending on the amountof blood that is taken into the mouth and the presence ofcuts in the mouth. The presence of blood in the mouthcould be caused by recent brushing or flossing of the teeth,a sore in the mouth, gum disease, a recent tooth extractionor biting or scratching one another (e.g. with the teeth ororthodontic alliances, such as braces) during kissing.Likewise, customs like “blood brothers” or “blood sisters”(where blood can be exchanged between people by rubbingopen cuts together to show trust and friendship with oneanother) can also put a person at risk for contracting HCV.Customs like this provide a direct route of one persons’blood into the bloodstream of another person and meets allfive conditions for transmission of HCV.Evidence of TransmissionThere are no reported cases of vampirism as being a methodof HCV transmission.There are no documented cases of HCV transmissionthrough blood Brother/Sisterhood pacts. It should bestressed however, that blood Brother/Sisterhood pacts carrya very high assessment of theoretical risk as the likelihood ofsomeone else’s blood directly entering your bloodstream ishigh.Assessment of Risk of HCV TransmissionAccording to our model, the lack of documented cases inrelation to the high potential of risk would lead this activityto be categorized as Negligible Risk. In this case though,the potential for risk associated with the activity and thelack of mention in research literature precludes making arisk assignment.Occupational ExposurePotential for transmissionExposure to blood in an occupational setting (for examplein emergency response and medical staff) does carry apotential for transmission if universal precautions are notfollowed.50 Hepatitis C Transmission

HIV TRANSMISSION: Guidelines for Assessing RiskSafe handling of needles and wearing gloves when administeringpunctures to draw blood or for other activities whereexposure to blood is possible can help reduce the potentialfor transmission.Evidence of TransmissionAccidental needle-stick injuries has been documented asa form of transmission for HCV and the seroconversionrate from one exposure is estimated to be between 3% and10% 33 .Assessment of Risk of HCV TransmissionOccupational Exposure . . . . . . . . . . . . . . . . . . High RiskSharing toothbrushes, razors etc.Potential for TransmissionSharing personal use items such as razors, toothbrushes andnail care equipment meet the conditions for HCV transmission,given that these items may come in contact withblood, and that the HCV virus can live for extended periodsof time outside the human body.Evidence of TransmissionSome studies show that HCV transmission may occurthrough “household exposure” in households where someindividuals are living with HCV, although the exact meansof transmission in these cases remains unclear. The studiesdid exclude sexual exposure and injection drug use as riskfactors.Assessment of Risk of HCV Transmission“Household exposure”. . . . . . . . . . . . . . . . . . . . Low Risk** Studies do not specify whether transmission occurred throughsharing of toothbrushes, razors, etc, or through other means. Thestudies did exclude sexual exposure and injection drug use asrisk factors.33. Op. Cit.Hepatitis C Transmission51

52HIV TRANSMISSION: Guidelines for Assessing Risk

HIV TRANSMISSION: Guidelines for Assessing Risk7. Increasing and ReducingRisk: Barrier Methods for SexualTransmission of HIVCondomsMale and female condoms made of latex or polyurethane arean effective barrier and one of the most important tools inpreventing HIV transmission.Quality ControlIn Canada, condoms as contraceptive devices are classifiedas medical devices, and are subject to regulatory controlunder the Food and Drugs Act and Medical DevicesRegulations. The Regulations are administered by theHealth Protection Branch of Health Canada, and theyoutline standards and conditions of sale with which condommanufacturers and importers must comply. The Regulationsapply to all types of condoms available for distributionand sale in Canada, including those sold through vendingmachines and by mail order.Some requirements apply to all condoms, regardless of theirmaterial of manufacture. For example, all condoms must beproperly packaged and labelled, and all manufacturers mustnotify the Branch of the sale of condoms. Other regulatorycontrols are specific to the different kinds of condoms,depending on what they are made of.Latex CondomsLatex condoms must meet design, length and width requirementsas well as specific tests for water leakage, burstingvolume and bursting pressure as described in the Regulations.The Health Protection Branch maintains a nationalprogram of sampling and analysis to monitor latex condomssold in Canada to ensure that they comply with theserequirements. Periodically, one lot from each brand of latexcondoms available on the Canadian market is sampled andtested. Unsatisfactory lots are removed from retail sale andfollow-up testing is performed to ensure product efficacy.Imported condoms must be accompanied by documentationdemonstrating they meet Canada’s standards.Health Canada does not have the resources to inspect allcondoms distributed in the country. There is no visible wayfor the public to know that Health Canada has spot-testedany particular product. However, complaints or concernsabout a particular product can be reported to the MedicalDevices Hotline at 1 (800) 267-9675. The Medical DevicesBureau is also able to provide further information aboutCanada’s condom standards and test results from its periodiccompliance surveys.Lambskin CondomsNatural membrane condoms are not required to meet theabove requirements for latex condoms because of theirdifferent material characteristics. Lambskin condoms usedalone are not considered effective in the prevention of HIV,because the virus is easily able to pass through the membrane.However, lambskin membrane condoms are madeavailable for people who have an allergy to latex and “double-bag”—thatis a latex or polyurethane condom is placedover a lambskin membrane condom if the allergic person isthe insertive partner, or placed under it if the allergic personis the receptive partner.Synthetic CondomsManufacturers of condoms made from synthetic materials,such as the polyurethane female condom, must submit dataconcerning their safety and effectiveness to the Health ProtectionBranch. The manufacturer must demonstrate thatthe condoms provide an effective barrier to micro-organismsand sperm, and must have acceptable test methods sothat the quality of the condom sold on the market can bemonitored.Reducing Risk53

HIV TRANSMISSION: Guidelines for Assessing RiskPolyurethane CondomsPolyurethane has been shown to be an effective barrieragainst HIV. Polyurethane condoms have different characteristicsthan latex condoms, which users should consider.Female condoms are currently made of polyurethane, andmale condoms are also available in polyurethane, althoughthey may be more difficult to find.Polyurethane is stronger than latex, but the female condomand the male polyurethane condom are considerablymore expensive than the latex male condom. In addition,polyurethane does not stretch like latex, which may make itmore difficult to ensure a proper fit on the penis, in the caseof a male condom made of polyurethane.However, unlike latex condoms, polyurethane does notbreak down when exposed to heat and light, so they maybe stored for up to five years. Also, polyurethane conductsheat better than latex, providing users with a more “natural”feel. Male condoms made of polyurethane are easier toput on, since they can be pulled on, rather than rolled onthe penis. Finally, people who are allergic to latex can usepolyurethane.Male Condom UseCondoms require getting used to. Men who are first-timecondom users should practise using them by themselvesbefore they use one with a partner. To ensure that theirmale partners are using condoms properly and to be morecomfortable about their role in making condoms a regularpart of intercourse, women can also practise condom-use byputting the condom on a penis substitute.There is some evidence that condoms break or slip morefrequently when used in anal sex, although this may be dueto higher levels of improper use. Thicker latex condomshave been designed specifically for anal sex; however, there islittle available evidence to date to suggest that they are moreeffective than regular condoms.If condoms are used properly, they have been shown tosubstantially reduce risk of HIV transmission. However,sometimes condoms may fail, usually because they are notused properly and consistently. Because of evidence of HIVtransmission due to broken or improperly used condoms,vaginal and anal intercourse with a condom are deemed tobe low rather than negligible, risk.The key to reducing risk is proper condom use. Therefore, itis important to follow the guidelines included here.Buying and StoringThere are many different brands of condoms and preferencesare personal. Try several brands to find the most comfortable.When using condoms, follow these guidelines:••••••••Always use before the expiry date on the package. If indoubt, get a fresh supply.Store condoms in a cool, dry place Exposure to heatcan break down latex. Polyurethane condoms are notaffected by heat or light and may be stored for up to fiveyears.Carefully open the condom package; teeth or fingernailscan tear the condom.Use a new condom for each act of sexual intercourse.Hold the condom over an erect penis.If a penis is uncircumcised, pull back the foreskin beforeputting on the condom.Put the condom on by pinching the reservoir tip andunrolling it all the way down the shaft of the penis fromhead to base.If the condom does not have a reservoir tip, pinch itto leave a half-inch space at the head of the penis forsemen to collect after ejaculation.54 Reducing Risk

HIV TRANSMISSION: Guidelines for Assessing Risk• In the event that the condom breaks, withdraw thepenis and put on a new condom before resumingintercourse.• Use only water-based lubrication (oil-based lubricants,such as cooking or vegetable oil, baby oil, hand lotionor petroleum jelly will cause the condom to deteriorateand break).• Withdraw the penis after ejaculation while still erect,grasp the rim of the condom between the fingers andslowly withdraw the penis (with the condom still on) sothat no semen is spilled.• Remove the condom, making certain that no semen isspilled.• Carefully dispose of the condom. Do not reuse it.Female Condom UseThe female condom is now approved and available forsale in Canada (availability may vary). Laboratory studieshave shown that polyurethane, the material used in themanufacture of the female condom, does not permit thetransmission of HIV. The female condom is the first generationof HIV-specific vaginal barrier methods. It is a sheaththat lines the vagina, with two flexible plastic rings at eitherend. The closed end is inserted in the vagina and the openend hangs outside the body against the outer lips of thevagina. The condom comes with a water-based lubricant tomake insertion easier and to allow comfortable movementduring sex. It may be inserted into the vagina up to eighthours before intercourse.Testing of the female condom indicates that semen leakageafter sex is less frequentthan with a male condom,and that the risk of semengetting into the vagina dueto dislodgment is one-thirdlower. Other tests haveinvestigated the femalecondom’s risk of causingirritation or encouragingbacteria and other healthproblems in the vagina. Insome tests, female condomswere used in sex and thenleft in the vagina overnight(a much longer period than normal). The results showed nocomplications, indicating that even women with very sensitiveskin can use the female condom. Studies have also beenconducted to ascertain how women and their partners feelabout the female condom. While many women and theirpartners find it acceptable, some people are concerned thatthe part of the condom which stays outside the vagina isaesthetically unappealing, while other women have reporteddiscomfort with the rings. These problems have tended to bereduced as people become more familiar with the device. 34Because it is made of polyurethane rather than latex, thefemale condom 35 is both sturdier than the male condomand more expensive to manufacture. Several studies havebeen conducted to determine the safety and acceptabilityof reusing the female condom in an effort to make it moreaffordable and accessible. WHO convened two expertconsultations to review the various studies and formrecommendations to the field. The resulting statementwas released at the XIV International AIDS Conference inBarcelona, July 2002.Based on these consultations, WHO does not recommendor promote reuse of female condoms. However, recognizingthe urgent need for risk-reduction strategies for women whocannot or do not access new condoms, the consultationdeveloped a draft protocol for safe handling and preparationof female condoms intended for reuse. This protocolis based on the best available evidence, including studiesconfirming the structural integrity of female condoms afterrepeated cleaning and re-use. The protocol has not beenextensively studied for safety and has not been evaluated forefficacy in human use. The WHO protocol, as well as otherresources relating to the reuse of the female condom, can befound at ‹www.reusefemalecondom.org›.The female condom offers the welcome potential of givingwomen the chance of more control over their own protection.Like the male condom, proper use is crucial to itseffectiveness. The following guidelines are recommended:••••Do not use damaged, discoloured, brittle, or stickycondoms.Check the expiration date.Carefully open the condom package; teeth or fingernailscan tear the condom.First, inspect the condom and make certain it is completelylubricated on the outside and the inside.34. Family Planning Perspectives Digest, 33(4). July/August 2001.35. Note that the studies have been conducted only on the Reality TM female condom, and the WHO guidelines apply exclusively to thatproduct.Reducing Risk55

HIV TRANSMISSION: Guidelines for Assessing RiskThe female condom is inserted into the vagina with fingers,much like a tampon that has no applicator. To do so:• Hold the condom at the closed end and squeeze theflexible inner ring with thumb and middle finger soit becomes long and narrow. With the other hand,separate the outer lips of the vulva.• Gently insert the inner ring end as far into the vaginaas possible, using the index finger to push up the innerring until the finger reaches the cervix (similar to how adiaphragm would be inserted).• Before intercourse, make certain the condom is in place.When in place, it will cover the opening of the cervixand line the vaginal walls. A general indicator of correctinsertion is that the individual will no longer feel thering. The open end of the condom must always remainoutside the vaginal opening. Before intercourse, makecertain that the condom is straight and not twisted.• Add water-based lubricant onto the penis and/or theinside of the female condom to increase comfort anddecrease noise. It is important to use enough lubricantso that the condom stays in place during sex. If thecondom is pulled out or pushed in, that is an indicatorthat there is not enough lubricant.• Be sure that the penis is not entering the vaginal canaloutside of the condom before intercourse.• To remove the condom, twist the outer ring and gentlypull the condom out to avoid any spillage. Carefullydispose of the condom.• Do not use a male condom along with a femalecondom. If the two condoms rub together, the frictionbetween them can cause the male condom to be pulledoff or the female condom to be pushed in.The Female Condom for Anal Intercourse?The female condom has not been designed or approved foruse during anal intercourse. However, it is being used bymany people for this purpose. One study that examined theuse of the female condom by MSM found that 57% of themen reported problems that included rectal bleeding by thereceptive partner 36 . The use of lubricant inside, removingthe inner ring and placing the condom on an erect penis canhelp eliminate some trauma and discomfort.Dental DamsDental dams are relatively thick sheets of latex squaresdeveloped by dentists to isolate a tooth for infection controlpurposes. Although cunnilingus and anilingus carry anegligible to low risk of HIV transmission, dental damshave been recommended for people who wish to reduce riskfurther.The following steps are recommended when using a dentaldam:• Rinse off with water to get rid of powder coating.• Put some water-based lubricant on the partner’s vaginaor anus and place a new latex square so that it completelycovers the vaginal or anal opening.• Hold the dam firmly in place with both hands, andapply mouth and tongue to the unlubricated side of thedam only.• When done, safely dispose of the dental dam.Many people find that dental dams are small, difficult touse and greatly reduce sensation. Dams are often availableonly from medical supply stores. An alternative that somepeople find more accessible and easier to use is to cut openan unused, unlubricated condom or latex glove and placeit over the vagina or anus following the method describedabove.Plastic WrapPlastic wrap has also been advocated by some AIDS educatorsas a risk-reduction tool for cunnilingus and anilingus.Only one brand, Glad®, has been tested in the laboratory. Itwas found to be effective for preventing transmission of theherpes simplex virus. It has not been tested as a barrier forHIV. Plastic wrap is not subject to the quality control testingfor filtering viruses and micro-organisms that condomsrequire. It is not as elastic as latex, but it is cheap, accessibleand easy to use. However, plastic wrap marketed as “microwavable”is more porous than the conventional plastic wrap;it is not recommended for use during sexual activity.Latex Gloves and Finger CotsLatex gloves and finger cots (latex covers that go overindividual fingers, rather than a full glove) reduce the riskof HIV transmission via open cuts, sores, lesions, burns or36. Gross M, Buchbinder SP, Holte S, Celum CL, Koblin BA, Douglas JM. Use of reality “female condoms” for anal sex by US men whohave sex with men. HIVNET Vaccine Preparedness Study Protocol Team. Am J Public Health, 89(11):1739-41. 1999 Nov.56 Reducing Risk

HIV TRANSMISSION: Guidelines for Assessing Riskrashes on the hands or fingers. In certain circumstances,they are recommended for use during fingering and fisting.However, some people are allergic to latex or to the powderinside latex gloves. Care should also be taken to preventholes being made in the glove by fingernails during vigorousactivity (e.g. fisting) and rings should removed beforeputting on the glove.Cervical BariersCervical barriers (diaphragms and cervical caps) are softlatex or silicone cups that fit at the upper end of the vagina,covering the cervix. They are currently used to preventpregnancy, but research is underway to see if their use mayalso reduce the transmission of HIV and other STIs.alone or with a microbicide, could protect women fromthese devastating diseases 38 .Cervical barrier contraceptives are labelled for use withnonxynol-9 (N-9) spermicide. Frequent use (more thanonce a day) of N-9 products can cause vaginal irritation,which may increase the risk of getting HIV or other STIsfrom infected partners. Research on cervical barriers forHIV prevention involves non-spermicidal lubricants, andthe use of N-9 products is not recommended for those athigh risk of HIV infection.Women are physically more vulnerable to sexual transmissionof HIV than men, probably due in part to the natureof the cervix. Unlike the vaginal epithelium (surface), whichconsists of approximately 30-50 layers of flat, sturdy cells,parts of the surface of the cervix are made up of a singlelayer of fragile cells, which are more easily damaged.In younger women, these fragile cervical cells are even moreexposed than in adult women, probably a major factor inadolescent girls’ higher risk. In addition, several target cellsfor HIV, including CD-4 cells, are found more frequentlyon the cervix than throughout the rest of the vagina. Thepassage of infectious fluids into the upper genital tract (alsohighly susceptible) via the cervix may be another factor inwomen’s HIV acquisition.Though the cervix is not the only site of vaginal transmissionof HIV or STIs, it is possible that a woman couldreduce her risk of infection by protecting her cervix witha barrier 37 . Developers are working on new cervical barriermethods that would be easier to use for contraception, andin addition, some researchers are exploring their potentialutility for disease prevention.No rigorous research has yet been completed that showswhether cervical barrier methods can reduce the risk ofHIV transmission but observational studies have alreadydemonstrated an association between cervical barrier useand reduced risk of other STIs. More research is needed todetermine whether cervical barrier methods, used either37. Moench T, Chipato T, Padian N. Preventing disease by protecting the cervix: the unexplored promise of internal vaginal barrierdevices. AIDS, 15(13):1595-1602. 2001.38. Cervical barriers viewed on the Internet at .Reducing Risk57

58HIV TRANSMISSION: Guidelines for Assessing Risk

HIV TRANSMISSION: Guidelines for Assessing Risk8. Increasing and Reducing Risk ofHIV: Biological FactorsA. Mucosal Immunity and HIVBody cavities and canals that are open to the air, includingthe mouth, nose, eyes, urethra, vagina and rectum, are linedwith thin layers of tissue that secrete a protective liquid.These tissues are mucous membranes (mucosa) and theyprevent germs from infecting the body from outside. Theprotective effect of mucous membranes is called mucosalimmunity.In recent years, much has been learned about the way inwhich the body’s immune system functions. Many factorsinfluence mucosal immunity, making it either harder oreasier for germs (e.g. HIV) to enter the body. This sectionexamines different biological factors known to influencemucosal immunity and therefore affect the risk of HIVtransmission.Sexually Transmitted InfectionsActive STIs, such as syphilis, gonorrhea, herpes simplex,Human Papilloma Virus (genital warts) and Chlamydia,are known to increase the risk of HIV transmission. Thereare three reasons for this. Firstly, any STI-related sores orlesions provide an open route of entry for HIV to enterthe bloodstream and infect cells. Secondly, STIs weakenmucosal immunity, enabling HIV to enter the body directlythrough mucous membranes. Evidence suggests thatrepeated infection with STIs, even if each infection has beentreated, can weaken mucosal immunity so that the body’smucous membranes no longer protect it as well from HIVinfection 39 . Third, cells in the immune system that targetHIV are prone to be present in greater numbers at the siteof an infection.This information is important for a number of reasons. Itmeans that people with recurrent STI infections may be atincreased risk of HIV infection, and they should considerextra precautions for low-risk activities (e.g. oral sex). It alsomeans that taking precautions against STIs may preventincreased risk of HIV infection. And, it means that peoplewho are at risk for STIs should visit their doctor or STIclinic regularly (at least every six months) for STI testing.Any infections that are found should be treated promptly.There is also evidence that the additional impact of recurrentSTIs on the immune system can hasten the progressionof HIV disease 40 . For this reason, it is important that peopleliving with HIV/AIDS also take precautions to avoidinfection with STIs and have them treated promptly if theyoccur. In addition, vaccinations against infections, such ashepatitis A and hepatitis B, are also recommended to thoseliving with HIV/AIDS.Untreated STIs can increase a person’s susceptibility toHIV infection. STIs are also of particular concern to peopleliving with HIV/AIDS because they may affect the immunesystem and contribute to the progression of HIV.Common Vaginal InfectionsCommon vaginal infections (e.g. yeast) can weaken mucosalimmunity, increasing the risk of HIV transmission. Womenshould treat common vaginal infections promptly and ifpossible avoid any unprotected sexual activity in the areaaffected while the infection persists.Open Cuts, Sores, Lesions, Ulcers, Burns andRashesThe conditions of transmission make it clear that it is possiblefor HIV to gain access to the body through open cuts,sores, lesions, ulcers, burns or rashes. Scrapes, incisions,skin rashes, cold sores or genital sores (e.g. herpes) should39. Wasserheit JN. Heterogeneity of heterosexual transmission: the role of other STIs. [Abstract We.C.453] 11th International conferenceon AIDS. July 1996.40. Dyer JR, Eron JJ, Hoffman IF, Kazembe P, Vernazza PL, Nkata E, Daly CC, Fiscus SA, Cohen MS. Association of CD4 cell depletion andelevated blood and seminal plasma human immunodeficiency type 1 RNA concentrations with genital ulcer disease in HIV-1 infectedmen in Malawi. Journal of Infectious Disease 177:224-7. 1998.Reducing Risk59

HIV TRANSMISSION: Guidelines for Assessing Riskbe protected from contact with blood, semen, vaginal fluidand with another person’s mucous membranes. Any sexualactivity that could bring blood, semen, vaginal fluid orbreast milk into contact with skin or mucous membranesthat are inflamed or damaged creates a greater risk of HIVtransmission.Vaginal DryingIn some cultures women use various herbal mixtures to drythe lining of the vagina before intercourse. This practicetightens the vagina, which may increase pleasure for themale partner. Any substance that dries out the vaginalmucosa reduces its immunity and increases the risk of HIVtransmission. A well-lubricated vagina reduces the risk ofHIV transmission.Women may experience vaginal drying as natural phenomenaof aging. Along with condom use, increasing artificiallubrication with water-soluble products can reduce the riskof HIV, as well as ease discomfort associated with vaginaldrying during and after sex.CircumcisionStudies in sub-Saharan Africa show that uncircumcised menmay be at higher risk of HIV transmission than circumcisedmen in unprotected penile-vaginal or penile-anal intercourse41 . Foreskin contains large concentrations of the typesof cells that HIV targets – a finding that helps explain whyuncircumcised men may be more prone to HIV infectionthan circumcised men 42 . In addition, the foreskin mayprovide an environment for survival of bacteria and viruses,and may be susceptible to tears, scratches and abrasions,suggesting that its presence may increase the likelihood ofcontracting HIV.SalivaHIV can be found in saliva, but in much lower concentrationsthan in semen, blood, vaginal fluid and breast milk.Furthermore, an enzyme in saliva has been found to inhibitthe capacity of HIV to enter white blood cells and thereforeto infect the body. For this reason, the exchange of salivadoes not pose a risk of HIV transmission. However, theremay be a risk of transmission if HIV-infected blood ispresent in saliva.EyesContact with eyes is often overlooked as a potential routefor transmission. Care should be taken to ensure no blood,semen, vaginal fluid or breast-milk comes in contact with apartner’s eyes. Although there is no documented evidenceof HIV transmission through the lenses of the eye, themucosal linings around the eye could provide a theoretical(negligible) risk of infection. As well, other viruses suchas adenovirus and the herpes virus have been transmittedthrough this means 43 .Crack CocaineThe regular use of crack cocaine may lead to a weakeningof mucosal immunity. Smoking crack cocaine can lead toburns and inflammation in the mouth, which significantlyincreases the risk of viral transmission via oral sex or sharingpipes (especially in the case of HCV) 44 . Crack cocaine userscan reduce this risk through the use of condoms during oralsex and, in the case of HCV, by not sharing pipes.Douching and EnemasStudies show that douches and enemas make the mucosallining in the rectum and vagina more vulnerable to inflammationby removing the protective top layer of tissue andchanging its micro bacterial surroundings. This reducesmucosal immunity and can increase the risk of HIV transmissionduring sex.Spermicides and MicrobicidesSpermicides are chemical substances that kill sperm. Microbicidesare chemical substances that kill viruses and othermicrobes. Scientists are currently testing many spermicidesand microbicides to see if they can help prevent transmis-41. Johannes van Dam, M.D., MPH and Marie-Christine Anastasi, M.A. Male Circumcision and HIV Prevention: Directions for FutureResearch. 2002.42. Crabb, Charlene. Circumcision and HIV Susceptibility, AIDS: 17(2) p. N3. January 2003.43. Minimizing Transmission of Bloodborne Pathogens and Surface Infectious Agents in Ophthalmic Offices and Operating Rooms.American Academy of Ophthalmology, 2003.44. Faruque S, Edlin BR, McCoy CB, Word CO, Larsen SA, Schmid DS, Von Bargen JC, Serrano Y. Crack cocaine smoking and oral sores inthree inner-city neighbourhoods. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 13:87-92, 1996.60 Reducing Risk

HIV TRANSMISSION: Guidelines for Assessing Risksion of STIs, including HIV. As of yet, no safe and effectivemicrobicide is currently available to the public.One of the most common spermacides is nonoxynol-9, achemical which functions mainly as a back-up in helpingto prevent pregnancy. Until recently, scientists believedthat vaginal use of nonoxynol-9 offered limited protectionagainst bacterial STIs (e.g. gonorrhea, Chlamydia). However,recent evidence has refuted this. Three randomizedcontrolled trials failed to detect any statistically significanteffect of N-9 against common bacterial STIs 45 . As a result,the World Health Organization has concluded that productscontaining N-9 should not be promoted for STI protection46 .Early evidence (mainly in test tubes) that N-9 would beeffective against HIV in humans have also turned out to bemisleading. After a long and complicated history of testing,scientists have concluded that products containing N-9 donot offer protection against HIV. It appears that when usedfrequently, products (e.g. lubricants, vaginal foams, jellies,etc.) containing N-9 may increase risk of HIV transmissionby causing small disruptions in the vaginal epithelium.Scientists are concerned that these disruptions may increasea woman’s risk of acquiring HIV 47 . In addition, N-9 shouldnever be used rectally, as even single use at low doses causesdisruption in rectal mucosa.However, the failure of N-9 clinical trials as an effectivemicrobicide against HIV and other STIs have not curbedhopes that some agents may yet be helpful, when combinedwith other methods of protection (e.g. condoms) in reducingrisk of HIV infection.Microbicides are still being tested for effectiveness againstHIV transmission.Hormonal ContraceptivesHormonal contraceptives, in pill, patch or injection form,have been linked to reduced mucosal immunity of thevagina 48 . It has been observed that oral contraceptivescontaining the hormone progesterone can reduce the thicknessof the vaginal epithelium, which in turn reduces themucosal immunity of the vagina, and that they can increasethe presence of target cells for HIV infection in cervicalepithelium 49 .However, other studies have since shown that while thereis biological reasoning that would suggest a connectionbetween hormonal contraceptives and increased risk ofHIV/STI acquisition, the only method for which thisassociation held up was between Depo-provera use andchlamydial and gonococcal infections 50 . Further, a 2003population-based study in Uganda shows that hormonalswere not associated with HIV after accounting for behavioralfactors 51 .B. HIV Viral Load and TreatmentsViral load is the amount of HIV present in different bodyfluids and tissues at a given time. A test to measure viralload in blood plasma has been widely available in Canadasince 1997.People with a high viral load are more infectious than thosewith a low viral load. In the normal course of untreatedHIV disease, viral load will be very high shortly after infectionduring the “seroconversion” period, before the bodyhas begun to make antibodies to HIV. After seroconversion,the viral load decreases. Gradually, as the disease progresses,viral load will increase (at different rates depending on theindividual). In the later stages of HIV disease, viral load isvery high. Other factors (e.g. nutrition, STIs, local infec-45. Roddy et al. 1998; Van Damme 2000; Roddy et al. 2002.46. WHO/CONRAD Technical Consultation on Nonoxynol-9. Geneva: World Health Organization. 2002.47. Ibid.48. Progesterone and SIV transmission in monkeys. Joint WHO/UNAIDS statement. May 9 1996.49. Prakash, M. et al. Oral Contraceptive Use Induces Upregulation of the CCR5 Chemokine Receptors on CD4+ T cells in the CervicalEpithelium of Healthy Women. Journal of Reproductive Immunology. 54: 117-131. 2002.50. Morrison, C. et al. Hormonal Contraceptive Use, Cervical Ectopy, and the Acquisition of Cervical Infection. Sexually TransmittedDiseases. 31(9): 561-567. September 2004.51. Kiddugavu, M. et al. Hormonal Contraceptive Use and HIV-1 Infection in a Population-Based Cohort in Rakai, Uganda. AIDS, 17:233-240. 2003.Reducing Risk61

HIV TRANSMISSION: Guidelines for Assessing Risktions, other illnesses) may also affect a person’s viral load atany given time.The use of combination antiretroviral drugs (combinationtherapy) can reduce HIV viral load, sometimes below thelimit of detection of the available viral load tests. This doesnot mean that no HIV is present, merely that it is reducedsubstantially.Studies have shown that when viral load is reduced inblood it may also be reduced in semen 52 vaginal fluid 53and the anorectal mucosa 54 . This may reduce the risk ofHIV transmission. However, it does not eliminate the risk.High-risk activities remain high-risk activities. No oneshould assume that a low HIV viral load makes unprotectedintercourse a low-risk activity. A person’s viral load levelmay fluctuate considerably between tests, and it is possiblethat higher concentrations of virus may be present at thesite of a local infection, such as a sore caused by an STI.Unprotected anal and vaginal intercourse remain high-riskactivities. Furthermore, when HIV is transmitted from aperson taking combination therapy, it is possible that thenewly infected person may acquire a drug-resistant strain ofthe virus, making treatment of HIV disease in the newlyinfectedperson potentially more difficult.Post-Exposure Prophylaxislifestyle and safer drug use practices (e.g vein care, use ofnew needles) are necessary to avoid other infections thatcould complicate treatment and worsen progression of theprimary diseases.It is known that treatment for co-infected patients is morecomplex than for those singly infected with either virus.Studies indicate that people can be successfully treated forHCV when they are co-infected with HIV. However, theyalso have more side-effects, discontinue treatment more andalso have lower rates of virus suppression than people whoare not co-infected with HIV.One of the key challenges in the treatment of co-infectedpatients is the well-established higher risk of toxicity associatedwith interferon therapy for HCV among those alreadyundergoing highly active antiretroviral therapy for HIV.Both therapies include medications that can cause anaemia(low red blood cell count). HCV treatment can lower CD4cells and be harmful to the immune system. HCV treatmentmay also change the amount of anti-HIV drugs in theblood, potentially causing resistance to these drugs. The riskof developing side effects from HIV drugs, especially Videx(ddI, didanosine), is greater in people taking HCV medications.Due to these concerns, liver and HIV doctors oftenprefer to treat HCV first, when someone has well above 500CD4 cells.Taking combination therapy after exposure to HIV (calledpost-exposure prophylaxis, or PEP) may be an option forsome people to prevent seroconversion in some instanceswhere it is likely that exposure to HIV has occurred andaccess to the drugs is immediate, such as in a hospital aftersexual assault, or an occupational exposure to HIV (e.g. aneedle stick injury in a health care setting 55 ). The existenceof (and access to) PEP should never be used as a substitutefor HIV prevention practices.Co-Infection with HIV and HCVPractising risk reduction is especially important in patientsinfected with both HIV and HCV. Safer sex, healthy52. Vernazza, PL, et al. Effect of antiviral treatment on the shedding of HIV-1 in semen. AIDS 11 (10): 1249-1254, Aug 1997.53. Dalmore M, Ellerbrock T, Lennox JL, Hart C, Schnell C, Bush T, Evans-Strickfaden T, Conley L, Clancy K. Does Antiretroviral TherapyReduce the Amount of HIV in Vaginal Secretions of HIV-Infected Women? [Abstract 111.3] 3rd National Conference on Women and HIVMay 1997.54. Lampinen, T. , et al. Antiretroviral therapy and HIV-1 shedding from anorectal mucosa. 12th World AIDS Conference Abstract 23393,1998.55. Carbo, DM, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. New EnglandJournal of Medicine, 337:1485-90. 1997.62 Reducing Risk

HIV TRANSMISSION: Guidelines for Assessing RiskAppendix 1Suggestions for Further ReadingAnderson, D. Mechanisms of HIV transmission via semen,Journal of NIH Research, 1992, 4(7):104-107.Bureau of HIV/AIDS, STD and TB, Centre for InfectiousDisease Prevention and Control, Health Canada. HIV/AIDSEpi Updates: Ethnicity Reporting for AIDS and HIV inCanada, Health Canada, 2001c:27.Brackbill, R.M., R.J. MacGowan and D. Rugg. HIV infectionrisks, behaviors and methadone treatment: client-reportedHIV infection in a follow-up study of injection drug usersin New England, American Journal of Drug and AlcoholAbuse, 1997, 23(3): 397-411.Canadian Aboriginal AIDS Network. UnderstandingHIV/AIDS epidemiology: HIV/AIDS surveillance amongCanada’s Aboriginal peoples. Ottawa: Canadian AboriginalAIDS Network, 2001.Canadian HIV/AIDS Legal Network. HIV/AIDS andHepatitis C in Prisons: The Facts, Canadian HIV/AIDS LegalNetwork, 2004.Canadian Journal of Infectious Diseases Society. Hepatitis Cand HIV Management Guidelines; 2001, Available on line at.Carey, R., W. Herman, S. Retta, J. Rinaldi, B. Herman andT. Athe. Effectiveness of Latex condoms as a barrier to humanimmunodeficiency virus-sized particles under conditions ofsimulated use, Sexually Transmitted Diseases, 1992, 19(4):230-234.Centers for Disease Control. Update: barrier protectionagainst HIV infection and other sexually transmitted diseases,Morbidity and Mortality Weekly Report, 1993, 42(30):589-591.Center for Community-Based Health Strategies. Prioritysetting guide: glossary. 2001. Available on line at: .Clemetson, D., G. Moss, D. Willerford et al. Detection ofHIV DNA in cervical and vaginal secretions, Journal of theAmerican Medical Association, 1993, 269(22): 2860-2864Connor, EM., R.S. Sperling, R. Gelber, P. Kiselev, G. Scott,M.J. O’Sullivan et al. Reduction of maternal infant transmissionof HIV-1 with zidovudine treatment, New EnglandJournal of Medicine, 1994, 331: 1173-1180.Crabb, Charlene. Circumcision and HIV Susceptibility,AIDS: 17(2) p. N3. January 2003.Craib, K.J., D.R. Meddings, S.A. Strathdee, R.S. Hogg, J.S.Montaner, M.V. O’Shaughnessy and M.T. Schechter. Rectalgonorrhoea as an independent risk factor for HIV infection ina cohort of homosexual men, Genitourinary Medicine, 1995,71(3): 150-154.De Vincenzi, I. et al. (European Study Group on HeterosexualTransmission of HIV). Comparison of female to maleand male to female transmission of HIV in 563 stable couples,British Medical Journal, 1992, 304(6830): 809-813.Duerr A., Y. Mundee, L. Flowers, J. Xia, N. Kamtorn et al.Risk of HIV transmission during the seroconversion versus thepost-seroconversion period, XIth International Conference onAIDS, 1996, (Abstract Mo.C.571).European Study Group on Heterosexual Transmission ofHIV. Risk factors for male to female transmission of HIV,British Medical Journal, 1989, 298: 411-415.Fiore, J.R., Y.J. Zhang, A. Bjoundal, M. Di Stefano, G.Angarano, G. Pastore and E.M. Fenyo. Biological correlatesof HIV-1 heterosexual transmission, AIDS, 1997, 11(9):1089-1094.Fox, Philip C., A. Wolff, Chih-Ko Yeh, Jane C. Atkinsonand Bruce J. Baum. Salivary inhibition of Hiv-1 infectivity:functional properties and distribution in men, women andchildren, Journal of the American Dental Association, 1989,118 (june): 709-711.63

HIV TRANSMISSION: Guidelines for Assessing RiskGarfein RS, Doherty MC, Monterroso ER et al. Prevalenceand incidence of hepatitis C virus infection among young adultinjection drug users. Journal of Acquired Immune DeficiencySyndromes and Human Retrovirology 1998;18 Suppl 1:S11-19.Gu, Z., Q. Gao, E.A. Faust and M.A. Wainberg. Possibleinvolvement of cell fusion and viral recombination in generationof human immunodeficiency virus variants that displaydual resistance to AZT and 3TC, 1995, Journal of GenVirology, 76: 2601-2605.Hankins, C. and J. Roy. The Sexual Transmission of theHuman Immunodeficiency Virus: An Annotated Bibliographyand Overview of the Literature, Montréal, Centre d’étudessur le sida/Centre for AIDS Studies, 1990.Health Canada, Framework on Sexual & ReproductiveHealth: Directions from a National Discussion Process, HealthCanada, 1998.Health Canada. Infection Control Guidelines: Preventing thetransmission of bloodborne pathogens in health care and publicservices settings, Health Canada. May 1997.HIV Prevention and Women, Journal of the American MedicalAssociation, 1995, 273: 979.Keet, I., N. Albrecht van Lent, T. Sandfort, R. Coutinhoand G. Van Griensven. Orogenital sex and the transmission ofHIV among homosexual men, AIDS, 1992, 6(2): 223-226.Laga, M., A. Manoka, M. Kivuvu et al. Non-ulcerativesexually transmitted diseases as risk factors for HIV-1 transmissionin women: results from a cohort study, AIDS, 1993, 7(1):95-102.Liskin, Laurie L. and Chuanchom Sakondhavit. The femalecondom: a new option for women.dans Mann, Jonathan, Daniel J.M. Tarantola et Thomas W.Netter (dir.), AIDS in the World: A Global Report, Cambridge,MA: Harvard University Press, 1992, p. 700-707.MacDonald, N.E., W.A. Fisher, G.A. Wells, J.A. Dohertyand W.R. Bowie. Canadian Street Youth: correlates of sexualrisk-taking activity, Pediatric Infectious Disease Journal,1994, 13(8): 690-7.Moench T, Chipato T, Padian N. Preventing disease by protectingthe cervix: the unexplored promise of internal vaginalbarrier devices. AIDS, 15(13):1595-1602. 2001.Myers, T., S.L. Bullock, L.M. Calzavara, P. Cockerill andV.W. Marshall. Differences in sexual risk-taking behaviourwith state of inebriation in an aboriginal population onOntario, Canada, Journal of Studies on Alcohol, 1997,58(3): 312-22.Neron, Carole. HIV and Sexual Violence Against Women - Aguide for counsellors working with women who are survivors ofsexual violence, Health Canada, Ottawa, 1998.O’Donnell, Darryl. Orogenital Sex Between Men, AustralianFederation of AIDS Organizations, 1994.Osmond, D.H. and N. Padian. Sexual transmission of HIV,The AIDS Knowledge Base, 1994.Piazza, M., A. Chirianni, L. Picciotto et al. Blood in Salivaof Patients with Acquired Immunodeficiency Syndrome: PossibleImplication in Sexual Transmission of the Disease, Journalof Medical Virology, 1994, 42(1): 38-41.Post-Exposure Prophylaxis, AIDS Weekly Plus, 29 july 1996:13.Public Health Agency of Canada. Division of HIV/AIDSEpidemiology and Surveillance, Bureau of HIV/AIDS,STD and TB, Centre for Infectious Disease Prevention andControl. HIV and AIDS in Canada: surveillance report toDecember 31, 2004. Public Health Agency of Canada 2004.Remien, R.H., A. Carballo-Dieguez, G. Wagner. Intimacyand sexual risk behaviour in serodiscordant male couples, AIDSCare, 1995, 7(4):429-38.Reucroft, S. and J. Swain. Saliva protein reduces infectivity ofHIV, New Scientist, 17 February 1998.Roper, W., H. Peterson and J. Curran. Commentary:condoms and HIV/STI prevention - clarifying the message,American Journal of Pubic Health, 1992, 83(4): 501-503.Rosenberg, M., K. Holmes and World Health Organization.Virucides in prevention of HIV infection: research priorities,Sexually Transmitted Diseases, 1993, 20(1): 41-44.Royce, Rachel. “Does male circumcision prevent HIVinfection?”, in Mann, Jonathan, Daniel J.M. Tarantola andThomas W. Netter (ed.), AIDS in the World: A GlobalReport, Cambridge, MA: Harvard University Press, 1992.Royce, R.A., A. Sena, W. Cates, M.S Cohen. Sexual transmissionof HIV, New England Journal of Medicine, 1997,336(15): 1072-8.64

HIV TRANSMISSION: Guidelines for Assessing RiskRunganga, A.O. and J. Kasule. The vaginal use of herbs/substances:an HIV transmission facilitatory factor? AIDS Care,1995,7(5):639-45.Samuel, M., N. Hessol, S. Shiboski et al. Factors associatedwith human immunodeficiency virus seroconversion in Homosexualmen in three San Francisco cohort studies, 1984-1989,Journal of Acquired Immune Deficiency Syndromes, 1993,6(3): 303-312.Saracco, A. et al. Man-to-woman sexual transmission of HIV:longitudinal study of 343 steady partners of infected men,Journal of Acquired Immune Deficiency Syndromes, 1993,6(5): 497-502.Stein, Zena. HIV prevention: an update on the status ofmethods women can use, American Journal of Public health,1993, (83), 10:1379-1382.Women’s Addiction Foundation. Substance use, HIV andhepatitis C. 2001. Available on-line at:.Yeh, Chih-ko, Beverly Handelman, Philip C. Fox and BruceJ. Baum. Further studies of salivary inhibition of HIV-1 infectivity,Journal of Acquired Immune Deficiency Syndromes,1992, 5(9): 898-903.Young, Hugh. Safe Sex Guidelines: Defining Risk for GayMen and Other Men Who Have Sex with Men, The NewZealand AIDS Foundation, 1995.Zhu, T., N. Wang, A. Carr, S. Wolinsky and D.D. Ho.Evidence of coinfection by multiple strains of human immunodeficiencyvirus type 1 subtype B in an acute seroconvertor,Journal of Virology, 1995, 69: 1324-7.Stone, K. and H. Peterson. Spermicides, HIV and the vaginalsponge. Journal of the American Medical Association, 1992,268(4): 521-523.Turner, B.J., W.W. Hauck, T.R. Fanning, L.E. Markson.Cigarette smoking and maternal-child HIV transmission,Journal of Acquired Immune Deficiency Syndromes &Human Retrovirology, 1997, 14(4): 327-37.United Nations Joint Program on AIDS. UNAIDS BestPractice Collection: The Female Condom, Geneva, UNAIDS,1997.Vernazza, P.L., B.L. Gilliam, M. Flepp, J.R. Dyer, A.C.Frank, S.A. Fiscus, M.S. Cohen, J.J. Eron and A.C. Frank.Effect of antiviral treatment on the shedding of HIV-1 insemen, AIDS, 1997, 11:987-993.Voeller, B. et al. Mineral oil lubricants cause rapid deteriorationof latex condoms, Contraception, 1989, 39(1): 95-102.Warren, D., R.S. Klein, W. Brown, J. Sobel, P. Schuman,J. Anderson, S. Cu-Cuvin, K. Mayer, S. Holmberg andA. Duerr. High prevalence of abnormal vaginal flora andbacterial vaginosis in women with or at risk for HIV infection,Xlth International Conference on AIDS, 1996, (abrégéTh.B.114).Wasserheit, J. Epidemiological synergy: interrelationshipsbetween HIV infection and other sexually transmitted diseases,Sexually Transmitted Diseases, 1992, 19(2): 61-77.65

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