Presented to the International Rectal Microbicide Advocates, 14 May 2009

1. Use of Saliva as a Lubricant inSexual Practices Among Homosexual Men:Clues to the Route of KSHV Transmission Presented to the International Rectal Microbicide Advocates, 14 May 2009 Butler, L.M., Osmond, D., Graves Jones, A., & Martin, J. (2008) Use of saliva as a lubricant in anal sexual practices among homosexual men. Journal of Acquired Immunodeficiency Syndromes, Journal of Acquired Immunodeficiency Syndromes, 50 (2): 162-167.

2. KSHV Transmission in Homosexual Men • KSHV seroprevalence: • HIV- homosexual men: 15-30% • HIV+ homosexual men: 40-60% • Other populations: < 10% • Spread by intimate contact • Exact route of transmission unknown • Saliva harbors KSHV most commonly

3. Objective Examine prevalence and determinants of saliva use among homosexual men as a lubricant during insertive and receptive: • penile-anal intercourse • fisting/fingering

4. San Francisco Young Men’s Health Study • Began in 1992 • Household probability sample • Homosexual & Bisexual men • Ages 18-29 • 21 census tracts with highest AIDS incidence

5. Methods Serial 6 month follow up • Self-administered questionnaire • No. of partners: insertive & receptive sexual practices • HIV-serostatus of partners • Saliva use in insertive & receptive practices • e.g.,Thinking about the times when you have put your penis into another man’s rectum (you were the “top”), how often have you used your saliva as a lubricant (“lube”)? • e.g., Thinking about the times when another man has put his finger or fist into your rectum, how often do you think the other man used his own saliva (spit) as a lubricant (“lube”)?

6. Characteristics of 283 Participants

7. Lifetime Saliva Use in Insertive and Receptive Sexual Acts

8. Saliva Use in Receptive Penile-Anal Intercourse: Lifetime % of Participants Never Once Sometimes Most Times Always Frequency of Saliva Use

9. Saliva Use in Receptive Sexual Acts: Prior 6 Months Penile-Anal Intercourse Fisting/Fingering % of Participants No. of Partners No. of Partners

10. Prevalence and magnitude of saliva use as a lubricant in insertive and receptive anal sexual acts in the prior 6 months among homosexual men reporting any participation (with or without saliva use) in these acts during the reporting period. * denotes interquartile range

11. Proportion of Participants who Used Saliva During Penile-Anal Intercourse:Prior 6 months By Partner Serostatus

12. Proportion of Participants who Used Saliva During Penile-Anal Intercourse:Prior 6 months By Participant and Partner Serostatus

13. Consistency of Saliva Use in Receptive Anal Intercourse Over Time (1 year) Concordance = 79%

14. Determinants of Saliva Use in Insertive Anal Intercourse

15. Determinants of Saliva Use in Receptive Anal Intercourse

16. Saliva Use Despite Otherwise “Safe Sex” Practices

17. Conclusions Among homosexual men: • Saliva is commonly used as a lubricant in penile-anal intercourse and fingering/fisting. • Even when conventional “safe sex” is practiced, saliva is commonly being introduced into the rectum • HIV-infected individuals (the most vulnerable for KS) are at particular risk of being exposed to saliva from other HIV-infected persons (the most apt to be KSHV-infected) • No obvious socioeconomic/cultural determinants

18. Implications • Use of saliva during penile-anal intercourse and fisting/fingering needs to be considered as a potential mode of KSHV transmission • Although common, saliva use is not universal, perhaps in part explaining the non-uniformity of KSHV in homosexual men • Use of saliva in these acts must also be considered a potential mode of spread for other pathogens (e.g., hepatitis B) • Greater awareness and education about KSHV needed (only 6.4% of homosexual men aware of KSHV) • Consideration is warranted for altering safe sex guidelines