1. Use of Saliva as a Lubricant in Sexual Practices Among Homosexual Men: Clues to the Route of KSHV Transmission Butler, L.M., Osmond, D., Graves Jones, A., & Martin, J. (2009) 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. Presented to the International Rectal Microbicide Advocates, 14 May 2009

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 Frequency of Saliva Use % of Participants NeverOnceSometimesMost TimesAlways

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

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

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

12. Determinants of Saliva Use in Insertive Anal Intercourse

13. Determinants of Saliva Use in Receptive Anal Intercourse

14. Saliva Use Despite Otherwise “Safe Sex” Practices

15. 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

16. 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