What is Safer Sex Now?

Safer sex is now a combination of preventative methods, which for many years focused on condom use only. In many countries condoms, PrEP, TasP (U=U) and PEP are considered equally effective interventions against onward transmission of the virus.

HIV

The following are the recommended responses from the ECDC 2015 Guidance: HIV and STI Prevention among men who have sex with men. Information on TasP (U=U) has been taken from the National Centre for HIV/AIDS, viral hepatitis, STI and TB Prevention. USA – December 2018. It is recommended that you check online at ECDC and other sources such as PrEP In Europe to see if more up to date guidance has been published recently.

Condoms and condom-compatible lubricant use

“Condom use when having anal sex with a partner of unknown viral burden or infection status is a core component of HIV and STI prevention. Condoms prevent contact between semen and rectal mucosa, as well as between rectal fluid and the penile mucosa, thereby preventing the transmission of HIV

“Operational research also emphasises the importance of condom-compatible lubricant use (water- or silicon-based) during anal sex. Lubricant use facilitates entry and prevents micro-tears in the rectum during anal sex as well as decreasing rates of condom breakage. Oil-based lubricants increase the risk of latex condom breakage and are not recommended in combination with condoms for anal sex. The importance of condom-compatible lubricant use needs to be taken into account as a part of condom promotion interventions for MSM, and preferably distributed through the same programmes. Sub-optimal lubricant use is common among MSM, and correct use of lubricant should be included in prevention messages.”

HIV testing

“Provide voluntary and confidential HIV counselling and testing through a variety of ways that are easy to access for the target group, including outreach to the community, and routine offering of tests in clinics and community-based settings.

“It is suggested that individual counselling and mapping of risk behaviour should be used for individual recommendations around frequency of testing for HIV (and other STIs), but that annual testing for sexually active MSM would be a minimum suggested interval for testing.”

Community-based testing

“Rapid HIV testing and counselling in community settings delivered by trained staff or peers can increase the uptake of HIV testing among MSM and can reach populations of men that have previously not accessed HIV testing. MSM have also expressed preference for rapid testing over conventional testing in some European settings. Testing done in community settings such as testing centres located in easily accessible areas and at easily accessible times of day, or through outreach or mobile services, can allow easier access to and uptake of HIV testing services. Community-based testing services provide testing that is free or low-cost in an environment that is comfortable for difficult-to-reach groups. Community based testing services can be delivered by trained peers, which can improve the uptake and acceptability of services for some MSM.”

HIV self-sampling and self-testing

“HIV self-sampling consists of a kit that allows a user to take a blood or saliva sample from themselves, post it to a testing lab and receive the result by phone, text or email. HIV self-testing implies that the patient would obtain a sample at his own convenience, such as an oral fluid swab, self administer the test and then interpret the result. Some countries have approved or are in the process of approving the sale of self-testing kits for HIV. The United Kingdom became the first country to initiate sale of tests for home testing in April 2015. These kits will permit the individual to produce their own sample and run the test in their own home, with a result in 15 to 40 minutes. Self-testing might increase testing frequency due to test availability and easy access, but it requires careful quality assurance to minimise false negative and false positive results as well as well-defined pathways for accessing confirmatory testing and counselling in order to ensure linkage to care, and access to prevention and support.”

Pre-exposure prophylaxis (PrEP)

“PrEP is a method to reduce the risk of HIV infection in HIV-negative adults who are at high risk of HIV exposure. The treatment includes the use of oral antiretrovirals in order to prevent the virus from establishing a permanent infection. Detectable drug levels in the blood strongly correlated with the prophylactic effect, emphasising the importance of adherence to PrEP.

“While it was expected that open-label, non-trial use of PrEP might result in lower efficacy, the UK PROUD trial of 545 MSM randomised to immediate or deferred daily PrEP arms, found an 86% reduction among men in the immediate PrEP arm, and equal rates of rectal STIs and high condom use in both groups throughout the course of the trial, indicating that men had incorporated PrEP into existing risk reduction strategies [100]. The French Ipergay study carried out on 400 MSM, also demonstrated an 86% reduction in HIV infection among MSM taking intermittent PrEP (two tablets 2–24 hours before sex, one tablet 24 hours later, and one tablet 48 hours subsequent to the first dose) as compared to the placebo arm. High efficacy was achieved despite the fact that only 43% of MSM reported taking PrEP optimally during their last intercourse.

“These studies provide strong evidence on the efficacy of PrEP and indicate that serious consideration should be given to its inclusion in the ‘HIV prevention toolbox’, especially for those MSM most at risk of acquiring infection.”

Post-exposure prophylaxis (PEP)

“Post-exposure ARV-based prophylaxis is approved for use in Europe and should be started as soon as possible after HIV risk exposure, but always within 48–72 hours. Treatment should be continued for 28 days, unless the source individual is determined to be HIV negative.

“PEP has consistently been shown to reduce HIV transmission in animal studies and was originally introduced to reduce transmission following needle stick injuries. For ethical reasons no RCT has been conducted. Observational studies show consistent protection, but of various degrees. Apart from occupational PEP and PEP in situations of sexual assault, in most countries PEP is also recommended to individuals having had anal intercourse without a condom with partner of unknown HIV serostatus, seeking care within 48–72 hours. The most common use of non-occupational PEP is in discordant couples (where the index partner is not on ART) due to condom breakage or failure. United States and most European guidelines also specifically include individuals having had unprotected receptive anal intercourse with a homosexual or bisexual man of unknown HIV-status as eligible for PEP. Since antiretroviral medication also carries a risk of adverse events, individual benefit of PEP needs to be weighed against risks, and in countries where PEP is available, it is a clinical decision based on individual benefit, rather than a strict guideline-based measure.

“PEP has not been associated with an increase in high-risk sexual behaviour among MSM, and has rarely been promoted as a main prevention method to the MSM population. Awareness of PEP and perceived access to PEP is low among MSM in most European countries, indicating that PEP is not a first-line prevention intervention.

“In EMIS 2010, less than 2% of respondents in 26 of the 38 countries included reported ever having accessed PEP; the remaining countries reported slightly higher use, with respondents in France reporting the highest use, still only 9%. The low use of PEP in most European settings could be explained by low awareness or low perceived needs. Access is also an important issue and in the 2010 EMIS survey, about one-third of European countries reported that PEP could not be accessed for free.”

Treatment as prevention (TasP)

“HIV treatment has been shown to be beneficial both to individual health and in decreasing the risk of transmission to the individual’s partner(s). The sexual transmission of HIV from an HIV-positive person to their partner is correlated with concentrations of HIV in the genital tract and genital fluids, which is the mechanism for how combination antiretroviral treatment (ART) reduces sexual transmission of HIV.

“Studies evaluating HIV transmission were carried out mostly on heterosexual HIV-discordant couples and have shown that treatment of persons with HIV can reduce the risk of sexual transmission of HIV to their partner by over 90%.

“The results of the PARTNER study, which included MSM discordant couples, have confirmed these findings for the MSM population by not detecting any episodes of linked HIV transmission from men infected with HIV and a viral load below the limit of detection. It has been estimated that the majority of HIV transmissions among MSM in UK settings occur before the positive partner is diagnosed. Therefore, the main efforts for effective HIV prevention and care programmes in EU/EEA settings will be focused on achieving high and regular testing frequency for those MSM most at-risk and facilitating treatment access and adherence to treatment among those who are tested positive.

“New data from the Partner II study, which concentrated on sero-discordant MSM couples support the findings of the orginal Partner study. Neither of these studies observed any genetically linked infections while the HIV positive partner was virally suppressed and the couples were engaging in condomless sex and not using pre-exposure prophylaxis (PrEP). In these studies, viral suppression was defined as less than 200 copies of HIV RNA per millilitre of blood; most HIV positive participants had less than 50 copies of HIV RNA per millilitre of blood. Couples in both studies engaged in over 100,000 sex acts without a condom or PrEP – and the transmission risk estimates and their corresponding 95% confidence levels are reported as a 0.00 risk (0.00-0.24) per 100 couple years. This is why we can now say with confidence that Undetectable equals Untransmissable and that HIV positive partners on effective treatment cannot pass on their HIV.”

(taken from the National Centre for HIV/AIDS, viral hepatitis, STI and TB Prevention. USA – December 2018)

STIs

The following are the recommended responses from the ECDC 2015 Guidance on HIV and MSM

Comprehensive screening for STIs

“Regular comprehensive screening offered to asymptomatic MSM includes anal/penile inspection and sampling of the urethra, pharynx, rectum and blood for syphilis, gonorrhoea, chlamydia (and LGV if positive for chlamydia).

“Testing for Herpes simplex virus type 2 (HSV-2) should also be performed if clinically indicated. These tests should preferably be performed in combination with HIV testing for men not yet diagnosed. MSM living with HIV should be offered voluntary screening for hepatitis C and other STIs annually or more often if clinically indicated.

“Routine STI screening of asymptomatic individuals will reduce the period in which infected individuals might remain both untreated and unknowingly able to transmit the infection to others. Screening frequency for STIs should be decided according to individual risk assessment and local epidemiological circumstances. The use of rapid tests, which are progressively becoming widely available for some infections can increase test uptake, including among MSM, but quality standards for their use must be ensured. Adequate treatment according to national, regional or WHO guidelines should be offered to persons testing positive.”

Treatment for STIs

“Bacterial STIs should be treated with targeted antibiotic treatment in accordance with national clinical guidelines. Due to widespread availability of diagnostic tools including rapid tests and in order to reduce drug resistance, syndromic management is not recommended for STI treatment. National treatment guidelines, particularly for gonorrhoea, should be reviewed regularly due to changing resistance patterns. The IUSTI treatment guidelines are regularly updated based on the latest epidemiological and microbiological data.

“Topical lotions for treatment of infections such as pubic lice (crabs) or Scabies are available via pharmacies.”

Viral Hepatitis (A, B & C)

Testing

“Testing protocol for viral hepatitis should follow the suggestions made for STI testing, so regular comprehensive screening offered to asymptomatic MSM includes anal/penile inspection and sampling of the urethra, pharynx, rectum and blood for syphilis, gonorrhoea, chlamydia (and LGV if positive for chlamydia). Hepatitis B (for unvaccinated men) and C screening is performed as indicated by the individual risk or local epidemiological circumstances.”

Vaccination/s

Hepatitis A and B vaccination

“A three-dose course of hepatitis B vaccination (at 0, 1 and 6 months) provides 95% long-term protection against hepatitis B and is recommended by WHO to be part of child vaccination programmes. According to self-reported data from EMIS 2010, 40% of MSM in Europe are in need of hepatitis B vaccination, largely irrespective of age. In many countries the proportion is substantially higher. Therefore, better access to hepatitis B vaccination is a crucial prevention measure for MSM in Europe.

“Outbreaks of hepatitis A have occurred among MSM within the EU, associated with faecal-oral contact during sex and also with sex at saunas. Given this, a combination vaccine for both hepatitis A and B is suggested for adults as a catch-up vaccination for MSM in need. Vaccination against both hepatitis A and B has been shown to be safe and have a high efficacy. Information on vaccine availability should be included in health promotion programmes targeting MSM.”

Treatment

“Antiviral treatment for hepatitis C or herpes simplex virus should also be provided as per national or regional (EASL and IUSTI) clinical guidelines. There is good evidence that early treatment of hepatitis C is more desirable, and new direct-acting antiviral treatment regimens are highly effective.

“Timely provision of antiviral treatment of HIV, hepatitis B and C according to individual needs and national or international clinical guidelines should be ensured.”

Provide targeted antibiotic treatment for other STIs

The preventive benefits of treatment are significant. STI, HIV and hepatitis treatment should be offered following a positive diagnosis based on an appropriate test, and in relation to clinical guidelines. In the absence of national guidelines, regional guidelines produced by IUSTI, the European Association on the Study of the Liver (EASL), and the European AIDS Clinical Society (EACS) [54] or global guidelines could be useful. Correct and specific treatment is crucial to benefit the health of the individual and to hinder further transmission.”

Interventions reviewed which were not included due to strength of evidence and expert opinion

Intervention	Outcome	Strength of Evidence	Expert Opinion
Voluntary medical male circumcision	HIV Incidence	Possible (2b) *evidence of reduced incidence for MSM who are only or mostly insertive during intercourse	Not recommended due to lack of evidence for efficacy for receptive anal sex; perceived unacceptability to the target group.
Avoid semen in the mouth/unprotected oral sex	HIV Incidence	Insufficient (3)	Not recommended
Avoiding nitrate inhalants/poppers during intercourse	No studies retrieved	Insufficient (3)	No recommendation made due to insufficient evidence for reduction of HIV transmission. Members of the expert group noted that use of stimulants affect individuals decision making capacity with regard to sexual risk taking.
Serosorting	HIV Incidence	Insufficient (3)	Not recommended
Interventions to reduce alcohol binge drinking	UAI	Insufficient (3)	No recommendation made due to insufficient evidence for reduced HIV/STI transmission; members of the expert group noted that alcohol affects individuals decision making capacity with regard to sexual risk taking.
Female condom for anal sex	Condom failure	Pending (2c)	While biologically possible, it was deemed that the product needed to be adjusted for anal sex in order to be used by MSM. It was the opinion of the expert group that this intervention is rarely used among MSM.

Next module: Understanding the epidemiological dynamics of HIV infection in MSM in Europe