There are lots of ways to have sex, and some of those can result in HIV transmission.

Sexually, HIV can be transmitted from cum, pre-cum, blood, anal fluid and vaginal fluid. The higher somebody’s viral load, the more likely the virus will be transmitted through these fluids. In some cases, having another STI, infection, illness, or condition, can make HIV transmission more likely.

Anal sex has the highest chance of HIV transmission, particularly for an HIV-negative person on the receiving end (being penetrated) by a condomless penis. This is because HIV in fluids, like cum, can more efficiently cross the very thin lining of the anus/rectum and establish infection. Anal sex, especially when performed without lube can create micro-tears in the skin, which act as an ideal pathway for the virus to enter your body. Sharing sex toys, or needles during needle play, and front hole (vaginal) sex all have high chances of HIV transmission as well. Generally, oral sex has a very low likelihood of HIV transmission.

Often, HIV transmission happens when one partner is HIV-negative, and the other partner thinks they’re HIV-negative, but actually isn’t. People with undiagnosed HIV can have especially high viral loads, increasing the possibility of transmission. Even if you’ve talked about HIV status, it can be tricky — tests may not detect HIV within the first few weeks of infection, which is when viral load is highest, and some folks who say they’re HIV-negative aren’t actually getting tested regularly, or have had sex or used shared drug equipment since their last test.

If you’re choosing your sex partners based on HIV status, or having sex without barrier protection, with no other safety strategies, these practices can make you more likely to be exposed to HIV, so it’s important to get tested regularly so that if you do become HIV-positive, you can find out quickly and get connected to care right away. It’s also a good idea to consider going on PrEP, and to learn more about undetectable HIV viral load, since these are more reliable HIV prevention tools.

Whether you’re HIV-positive or HIV-negative, knowing how HIV can be transmitted through sex can help you sort out what kind of sex you want and how to stay healthy. There are plenty of things you and your partner(s) can get into without having any chance of HIV transmission. You can consider the types of strategies you are using, and if they protect you from other things such as other STIs or unplanned/unwanted pregnancy. Figuring out what combination of strategies works for you is the best way to prevent HIV transmission.

This section was adapted, with permission, from The Sex You Want Website.
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references

Risks Associated with Sex Acts

There is lots to know when it comes to the risks involved in different sexual acts, positions, and roles. That’s not to say that you can’t enjoy any or all of them, just that it’s important to understand how what you are doing in bed influences your risk of contracting, or passing along, HIV so that you can make educated decisions on the prevention methods you and your partner(s) want to use. Remember, if you or your partner has an undetectable HIV viral load, the risk of passing on HIV is virtually zero in any sex position!

Some folks choose sexual positions (such as oral sex, or bottoming during anal sex) as a way to decrease their risk while not using barrier protection. Though better than doing nothing, this kind of “strategic positioning” on its own is not as effective as other sexual health strategies. A lot of folks choose to top or bottom during anal sex in combination with another strategy (such as PrEP), which can make this approach highly effective.

Keep reading to learn more about what positions have higher or lower risks of HIV transmission.

This section was adapted, with permission, from The Sex You Want Website.
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references

Anal Vs. Vaginal Penetrative Sex
There is a significant difference in the risks that are associated with vaginal/frontal and anal sex. As you likely know by now, HIV is passed through blood or cum, and the likelihood of exposure to blood during each of those sex acts is different.

Because the anus doesn’t produce natural lubrication, micro-tears (tiny tears) on the skin inside the anus are not unlikely to happen. This creates an easy environment for HIV to enter the bloodstream. Additionally, the skin on the anus (also known as the mucus membrane) is super thin, and so when tears happen infections are more likely to make their way through this skin into the bloodstream. Because the vagina does (for many people with vaginas) produce natural lubrication those tears are less likely to happen, and the skin of the vagina (it’s mucus membrane) is much thicker than that in the anus. This is one of the reasons lube is so important during anal sex!

It is also important to note that HIV medications (such as PrEP) can take longer to reach protective levels in the vaginal tissues than in anal tissues. You can read more about that in our section on PrEP.

Penetrating with a Penis
It’s less likely for someone penetrating their partner to acquire HIV, but transmission can still occur. So, how does this fit into decisions around sex?

Though penetrating someone with your penis carries a lower chance of HIV transmission than being penetrated does, it is still a common way that folks acquire HIV. This is because HIV can be transmitted through the tip of the penis or foreskin through the other person’s rectal fluids, vaginal fluids, or small amounts of blood in their bottom’s anus or vagina/front hole. This is even more likely if the person bottoming doesn’t know they are HIV-positive, and therefore has a higher viral load.

There is strong evidence that the foreskin is important in increasing the chance of getting HIV when you top during vaginal/frontal sex. But when this has been looked at for folks who have anal sex, the benefit of removing the foreskin is not as clear. This is because the vast majority of folks who primarily have anal sex prefer to switch up their role in anal sex. For trans folks who are topping, there is a lack of research on how hormones and surgical/physical transitions can impact HIV transmission, so we recommend, as always, erring on the side of caution.

This section was adapted, with permission, from The Sex You Want Website. 
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references

Being Penetrated by a Penis
Someone who is receiving or being penetrated by a penis is more likely to acquire HIV than a person who is penetrating. A lot of people like to do both, and you might decide to use the same, or different sexual health strategies depending on what you are doing.

This position makes acquiring HIV more likely because fluids that carry HIV, like cum, are able to cross very easily through the thin lining of the anus or the tissue of the vagina. Additionally, the anus does not produce any natural lubrication, so small tears in the skin are more likely during receptive anal sex. Douching (a method commonly used to ‘clean’ or rinse the anus before anal sex) can also cause increased risks of HIV transmission. This is because inserting the douche is not unlikely to cause mild trauma in the anus including small open wounds or micro tears. The higher the viral load of the person penetrating you, the likelier transmission is.

For trans and nonbinary folks with vaginas/front holes it is possible that hormones may increase the chance of transmission because some bodies produce less natural lubrication when taking testosterone. This can also be true for folks experiencing menopause, who have PCOS, or produce less natural lubrication for another reason. It is always a good idea to use lube – especially if you have lower levels of naturally produced lubrication or if you are having anal sex.

Some HIV-positive folks think that they won’t have to worry about the transmission of HIV if they’re always receiving. Although there is a lower likelihood of transmission when an HIV-positive partner is bottoming, HIV can still enter the top’s body through the tip of their penis.. This is especially true if the top has a foreskin, because there are cells in the foreskin that HIV can use to establish an infection.

This section was adapted, with permission, from The Sex You Want Website.
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references

Oral Sex
Oral sex is not very likely to end up in HIV transmission, regardless of whether you’re giving or receiving. Data suggests that penis-mouth oral sex is likely higher in risk than mouth-anus or mouth-vulva. That being said, it is often difficult to collect data on the risk of oral sex as most folks engaging in oral sex are also having penetrative sex. It is known that, while not impossible, the likelihood of transmission during any time of oral sex is quite low. If you are giving oral sex, there is still a very, very small possibility that cum or other fluids could enter through the mucous membranes in the mouth or throat.

That being said, there are conditions that can make oral sex much riskier. It’s good to be cautious if you have a canker sore, other sore, or cut inside your mouth, and to avoid brushing or flossing your teeth at least 30 minutes before or after giving oral sex or rimming someone. If things get rough and any skin breaks, take a break from oral sex until everyone’s healed up.

The presence of other STIs, especially those that cause sores on the mouth or genitals, can also increase the risk of passing HIV. Refrain from oral sex until the STI has been treated and all sores have healed. It is important to get your throat swabbed during your STI testing routine if you give oral sex.

This section was adapted, with permission, from The Sex You Want Website.
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references

Making Decisions
Are you penetrating or being penetrated? Giving or receiving oral? Doing something else entirely? Or participating in two or more types of sex/sex positions? Your sexual position(s) may affect your decisions around sexual health strategies.

Even though choosing to top or bottom isn’t an effective strategy on its own, when it comes to topping and bottoming, you may ask yourself:

• What other strategies am I combining this with, like condoms/barrier protection, PrEP or undetectable HIV viral load?
• Which is hotter to me, what feels better, or what can my body do?
• If I’m not using condoms or other strategies, do I feel okay knowing that the chances of HIV transmission are higher?

Deciding what types of sex to have as a part of your overall approach to sexual health can be something you do sometimes, or something you plan for in an ongoing way.

This section was adapted, with permission, from The Sex You Want Website.
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references

Sex and Partying
Some people use party drugs when they have sex – or have sex when they use party drugs. These drugs can affect our health, especially if you take them often or in large doses. Party drugs can also affect your HIV medications. Here are some things to be aware of:

Both ecstasy (MDMA) and crystal meth (Tina) can react dangerously to ritonavir (Norvir) and cobicistat (Tybost).
Some studies suggest that drinking alcohol can increase the level of HIV medication abacavir (Ziagen/Triumeq) in your body.

If you want to learn more about which HIV medications you’re on and their interactions with party drugs, speak with your doctor or pharmacist. Talking about drug use with your doctor can be a difficult topic, but having an open and honest conversation will help you get the care and information you need. If you are experiencing challenges with your substance use, you can talk to your doctor or connect with your local HIV/AIDS service organization (like us at HEAL NS) to find resources you need. Check out PartyAndPlay.info for information on safer partying.

If using drugs during sex (sometimes referred to as Chemsex or Party and Play / PnP). It is important to understand the interactions of all the drugs you are putting into your body. Not only might they interact with your HIV medications, but they might also interact with each other, or other medications you are on.

It is also important to consider the ways that substances can impact the decisions we make around sex, and around further substance use. It can be harder to make logical decisions about the sex we have, have conversations about sexual health before sex, and stick to our usual safety measures when we are drunk or high. Sometimes folks are also less likely to remember safety measures around their drug use if they are already high (like using a new needle).

Do your best to plan for this. If you are going to be partying, and there is any chance you will be having sex or using drugs, plan ahead how you want to take care of your health. Keep condoms on you, look into PIP, bring extra needles, or anything else that will help you stick to what feels good to you in the moment.

If you find that you regularly don’t plan ahead, or don’t follow your plans, you might want to look into getting on PrEP as a way to keep yourself protected from HIV transmission. If you are HIV positive monitoring your viral load will help you know when you are undetectable and can’t pass HIV onto partners even when other protection methods are forgotten in the heat of the moment.

If you are interested in Party and Play, or using drugs during sex, CATIE has developed a great handbook full of harm reduction tips that we recommend taking a look at. You can download it for free here. You can also check out this webinar put on by the Community Based Research Centre to learn more about Harm Reduction during Party and Play.

This section was adapted, with permission, from The Sex You Want Website.
You can learn more about where we got this information from at: CATIE, CBRC
*disclaimer: we do not necessarily endorse all of the information, content, or language used in these references