1. Rectal Behaviors: a global overview Shauna Stahlman & Pamina M. Gorbach UCLA Department of Epidemiology

2. Introduction: Rectal Microbicides & Anal Behaviors Anal hygiene and sexual behaviors are part of the behavioral repertoire for rectal microbicide use – Lubricant use – Rectal douching – Other Different types of data needed and broader populations need studying (women, hetero men as well as MSM, cross-cultural data essential)

3. Peri-sexual Rectal practices – Lubricant Use

4. Background: Lubricants US data shows very high use: ex: 89% reported always using lubricant among US MSM in San Francisco (Carballo-Dieguez A et al 2007) There has been little research focused on use of and contents of commercial lubricants Lubricants are classified as “medical devices” so not FDA regulated as drugs; avoid clinical trial testing for safety Some data suggest concerns with certain types of lubricant products

5. Lubricant Use & Non-Use: IRMA/UCLA Internet Survey 59% of 6,124 men and women reporting AI reported always using commercial lubricant in large internet survey Javanbakht J et al 2010 – IRMA & UCLA internet survey

6. 3 City Peruvian Study of Lubricant Use Kinsler JJ, Galea JT, Peinado J, Segura P, Montano SM, Sánchez J. Lubricant use among men who have sex with men reporting receptive anal intercourse in Peru: implications for rectal microbicides as an HIV prevention strategy. Int J STD AIDS. 2010 Aug;21(8):567-72.Lubricant use among men who have sex with men reporting receptive anal intercourse in Peru: implications for rectal microbicides as an HIV prevention strategy.

7. Many Commercial Lubricants Available: Project AWARE Lube Survey For recent US survey we found over 188 products available

8. Percent of Individuals with Rectal STIs By Lubricant Use Frequency (n=272 ): RHB Study LA & Baltimore (n=896) *P<0.05 Gorbach PM, Weiss RE, Fuchs E, Jeffries R, Hezerah M, Brown S, Voskanian A, Robbie R, Anton P, Cranston RD. The Slippery Slope: Lubricant Use and Rectal Sexually Transmitted Infections: A Newly Identified Risk Sex Trans Dis, 39(1): 59-64, January 2012. PMCID: PMC3244680

9. Peri-sexual behaviors: Rectal Douching

10. Douching  The prevalence estimates of douching before RAI from range from 19% - 64%  There is substantial evidence of associations between vaginal douching STIs  Rectal douching has been associated with HIV, HCV, HBV, non-LGV C. trachomatis, and LGV proctitis  No studies have considered the effect of rectal douching/enema use and lubricant use together

11. Anorectal Hygiene Behaviors: RHB Study LA & Baltimore (n=896) MenWomen % Ever used an rectal douche/enema (n=426)7642 Douche/ Enema use past 6 months among those who hv RAI7339 435.7 Frequency past month Mean (SD)4.0(5.9)

12. Percent with Rectal GC/CT/Sy* By Douching Practice (n=614): RHB Study LA & Baltimore (n=896) **Among those douching in past month *n=27 cases of rectal STIs or active syphilis P=0.02

13. Sexual risk behaviors & STI history by douching status: IRMA/UCLA global web- survey respondents (N=708) *chi-square test, p<.01**Wilcoxon rank-sum test, p<.01

14. Characteristics associated with rectal douching*: IRMA/UCLA global web-survey respondents (N=708) CharacteristicAdjusted Odds Ratio 95% Confidence Interval Age1.06(1.03, 1.08)* Number of sexual partners 1.02(1.00, 1.04)* Lube use5.67(2.31, 13.95)* Illicit drug use2.00(1.29, 3.11)* Being HIV positive2.30(1.33, 3.96)* Reported STI1.43(0.77, 2.68) *p<0.05

15. Other Rectal Behaviors

16. Other Rectal Behaviors: RHB Study LA & Baltimore (n=896) Male % (n)Female % (n) Ever used suppository38.4(101/263)40.3 (85/211) > 1 colonic past year15.8 (64/405)13.7 (55/402) Object in butt past month21 (48/229)10.6 (16/151) Rimmed past month35.8 (82/229)16.7 (25/151) Fisted past month6.7 (15/225) 5.3 (8/151) Anal bleaching past year01 “Booty-bumped” -drugs in butt with last partner 71

17. Rectal Sexual Behaviors

18. Chandra A, Mosher WD et al. Sexual Behavior, Sexual Attraction, and Sexual Identity in the United States: Data From the 2006–2008 National Survey of Family Growth. National Health Statistics Reports n Number 36 n March 3, 2011 Anal Intercourse: Lifetime (ever) NSFG US General Population

19. AI Past Year: National Survey of Sexual Health and Behavior ‘10 Journal of Sexual Medicine - http://www.nationalsexstudy.indiana.edu/

20. Low Frequency of AI: NSSHB 2010 (n=5,885) 0 women reported AI > 4x per week < 6% reported AI “a few times per month to weekly” or “2-3 times per week” combined > ¼ of married & partnered women 18-24 years reported AI “about once a month to a few times a year” monthly Most report “not in past year” Highest percent of those reporting any in past year report “few times per year to monthly”

21. Details from Women on AI : RHB Study LA & Baltimore (n=896) 62 % had RAI past month (53/85) At last AI, 89.3% also had vaginal sex (167/187) – 39.1% (70/179) used a condom for vaginal sex – 66.5% (115/173) ejaculated during this For last AI 41.4% used a condom (77/186) – 44.4% had ejaculate inside (79/178) 74% of last RAI partners were main partners

22. Sexual Acts at Most Recent Sexual Event: MSM US Internet Survey (n-24,787) Most commonly reported sexual behaviors: Giving oral sex (75.0%, N = 18,590) Kissing their sexual partner on the mouth (74.8%, N = 18,541) Receiving oral sex (73.4%, N = 18,194) Receptive anal intercourse 35.5% Insertive anal intercourse 33.8% most common among men ages 18–24 (42.7%) 42.3% of all men reported most recent male sexual partner was with a relationship partner. Rosenberger J et al 2011

23. Sexual Behavior: Non US – Focus on AI

24. International: Women Reporting Ever AI Brazil: Silveira MF, 2002; Caetano ME, 2010 South Africa – Lane, Pettior et al 2006Silveira MFCaetano ME Peru: Caceres C et al. 1997Kenya: Schwandt M et al. 2006 China (Anhui) : Lui H et al 1998Nigeria: Bamidele et al 2009 (combined gender)

25. Condom Use for AI: Women South Africa: Kalichman et al 2009US Gen Pop – Indiana NSSHB- 2010 Kenya – FSW- Schwandt M et al. 2006US-MDP – Gorbach, unpublished VOICE – South Africa, Uganda, Zimbabwe – 2011 – baseline unpublished

26. Discussion Worldwide, many have reported ever having AI– but in US data suggest frequency is not high among women Condom use levels for AI in non-Western studies appear to range greatly but more data is needed The sexual repertoire around AI is broad - often includes other activities such as oral sex or VI – but this is based on research in Western countries Not possible to make assumptions about behavioral repertoire around AI in non-Western settings

27. Discussion – Rectal Behaviors Data on rectal behaviors is growing but is still limited outside of Western countries – especially for African countries Non-Western data on rectal behaviors come from small, non-generalizable studies New data on rectal behaviors should be coming soon from microbicide clinical trials and Project ARM – IRMA’s rectal microbicide advocacy effort in Africa…..stay tuned!