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29 Nov 2012

Topping versus bottoming

Many HIV negative men think it's safe for them to fuck without condoms, even with a partner who is, or might be, HIV positive, as long as they are the top (i.e. the guy doing the fucking). But is choosing to be the active partner a reliable technique for avoiding getting HIV during unprotected anal sex?

Many HIV negative men think it's safe for them to fuck without condoms, even with a partner who is, or might be, HIV positive, as long as they are the top (i.e. the guy doing the fucking).

Similarly, many HIV-positive men think they can fuck without condoms without putting an HIV negative partner at risk, so long as the HIV-positive guy is the one being fucked.

 

Many men believe this because they have heard that it is easier for HIV to travel from the guy who is fucking to the guy being fucked than the other way round.

 

Although it is easier for HIV to pass from the top to the bottom, many men become HIV-positive as the top (i.e. active partner) when fucking without a condom. The best way to prevent HIV is to use condoms and water based lube.

Why is the guy being fucked more at risk when fucking without condoms?

The guy being fucked is more at risk during unprotected sex for two reasons:

• HIV is carried in body fluids including semen. When someone comes inside you, if they are HIV-positive then the HIV in their semen is also inside you and can enter your bloodstream through the sensitive lining of the anus.

• The sensitive lining of the anus is more susceptible than the skin of your cock to cuts and abrasions caused by friction during anal sex. These cuts and abrasions in the anus offer any HIV present in cum or pre-cum an entry point into the receptive partner's bloodstream.

Does that mean unprotected anal sex is safe for the top?

No. Choosing to be the active partner is NOT a reliable technique for avoiding getting HIV during unprotected anal sex. Many men have become HIV positive as a result of being the top during unprotected sex.

How can HIV enter the active partner's penis?

HIV in body fluids in the bottom's anus can enter the top's cock through the urethra (i.e. the opening at the tip of the penis through which urine and cum passes). It can also enter the cock through any cuts or abrasions caused by friction during sex, or through sores or other irritations caused by the presence of another STI (Sexually Transmitted Infection).

There are other risk factors.

There are other factors that can significantly affect whether being top or bottom reduces the degree of risk of having unprotected sex. For example:

Whether he tops or bottoms, an HIV negative man is more at risk of getting HIV if he already has another sexually transmitted infection (STI) (e.g. syphilis or Chlamydia). The sores or lesions caused by an STI can create an effective gateway for HIV to pass from one body to another during sex. Even if there are no apparent symptoms, an STI can still increase your susceptibility to HIV. As STI's often don't have symptoms, the only way to know if you have one or not is to get a regular sexual health check.

If an HIV positive man has another STI this further increases the risk to his partner. This is because the increased burden of a second STI on an HIV-positive person's immune system means it is less able to suppress the amount of HIV in the body. This results in a much higher viral load (i.e. the amount of HIV in the body), which makes him more infectious. (If you are HIV-positive, having another STI will also have a more serious impact on you and can progress much faster).

The viral load of an HIV-positive person will commonly fluctuate over time, affecting their level of infectiousness. For example, people have a particularly high viral load when they first become HIV positive, as the body's immune system has not yet begun to fight the virus. This makes them particularly likely to transmit the virus during unprotected sex, especially if they are unaware that they have become HIV-positive.

The rougher the fucking, the greater the risk of HIV transmission during unprotected sex. Rough sex increases the likelihood of cuts or abrasions to either partner, increasing the opportunity for HIV to pass from one person to another via semen or blood.

Is there any safe way to have unprotected anal sex?

The only reliably safe way to have anal sex without condoms is with a long-term partner with whom you have been tested for HIV together, then tested again three months later. For this process to work, partners need to continue using condoms with each other (and with any casual partners) until they get the second test results.

If both partners' test results are still negative the second time, and neither of them has had any risk of exposure to HIV in the period between the two tests, then they can be reasonably sure that they are both HIV negative and stop using condoms with each other.

In order to work, the process requires a high level of discussion and trust between the partners about always using condoms if they have sex with anyone else and being honest with each other if one of them breaks this agreement.

For more details about this process see ‘Negotiated Safety' in the ‘Relationships' menu at www.stayingnegative.net.au

Many HIV-positive men choose to have unprotected sex with other HIV-positive men. Although this puts neither partner at risk of being exposed to HIV for the first time, HIV positive men who choose to fuck without condoms run the risk of getting other potentially serious STIs such as syphilis or gonorrhoea.

This article was first published on http://www.top2bottom.org.au and is republished with permission from the Victorian AIDS Council Gay Men's Health Centre (VAC/GMHC). Top2bottom is a campaign developed and maintained by the Victorian AIDS Council/Gay Men's Health Centre in Melbourne, Australia; and is funded by the Victorian Department of Health.

Reader's Comments

1. 2012-11-29 19:48  
20+ years of appeal: rubber up. two words only. nowadays it is more likely well-informed choice not to follow it. with all this www media in a variety of styles, flavours and languages pushed to you through touch-screens for easy digestion (even by the most troglodyte brain) many of LGBT community still marry stone-age stupidity. today's BBC news: 2011 is the year of significant rise of new HIV cases. So, naturally HIV is a brain disease, most and overall. Someone must be suicidal enough to let his guard down for a FUCK sake. Literally. Is it the end of human kind as we know it because the cornerstone of every life form's existence is based on simple fact of survival. From stone-tablets to touch-screen tablets. Human kind failed to evolve. What a waste of time and space.
Comment edited on 2012-11-29 19:54:10
2. 2012-11-29 20:43  
lol
3. 2012-11-29 20:59  
how about mentioning that hiv-positive guys who fuck each other bareback increase the risk of contracting a resistant strain of hiv?
Comment #4 was deleted by its author on 2012-11-30 04:52
5. 2012-11-29 21:18  
I love gay
6. 2012-11-30 00:26  
its obvious ... always practice safe sex! and can you ever really trust someone enough to be SURE using no condoms is gonna be OK?

Play safe, have fun!
7. 2012-11-30 01:45  
It is a fact, the top can be infected by the bottom too. A lot of people have the myth that being the top will automatically immune them from getting infected and there are way too many people computing risk or chance of getting infected practicing risky sex. It is just crazy. It is a simple mathematical question, if you are infected, you are 100% infected, period! What is the point of calculating risk. And also uncircumcised top and with STDs or other skin condition such as balanitis, severe acne or boils (abscesses) and eczema also increase risk of infection too. So guys, just use the condom and don't cum on the body when you have open wounds.
8. 2012-11-30 01:47  
And besides who you can trust anyway, if someone is intended to spread HIV, he will do anything and lie just to have bareback sex, even if he has to take off the condom half way through (so doggy style is definitely out of question if you have sex with strangers), so better to not trust anyone and stick to the rule of safe sex, condom condom condom!
9. 2012-11-30 08:54  
I think it doesn't matter whether you are being bottom or top, or even both. As long as you are doing it safely (with condom). Don't risk yourself ;)
10. 2012-11-30 09:58  
It's not too difficult to wear a condom is it?
Albeit the sensation is different but at least you're protecting yourself and future potential partners.
I guess it's due to lack of awareness of the true facts of STIs/STDs
11. 2012-11-30 12:37  
It's truly up to us informed folks to do two things to combat this situation:

1) educate those who might not know.
2) if anyone insists to bareback, DON'T.

I personally know two people infected. One was ignorant, one wasn't. They both made conscious choices to bb, they both are now suffering. And they were both 19~20 y/o when they were infected. Whatever bb advocates try to tell you about the carnal benefits of bareback, it's really not worth the years subtracted from your life, the money spent on treatment, and the severe restriction on people you can have intimacy with, with a good conscience.
12. 2012-11-30 16:46  
13. 2012-11-30 17:01  
I am flabbergasted about how you all seem to ignore (or perhaps simply are ignorant about) the enormous difference between HIV +ve:
A. untreated individuals (top or bottom) and
B. individuals on retroviral therapy with 'undetectable' viral loads.

Group A tend to become progressivly more infectious (i.e. able to infect others) as time goes along, so those with very high viral loads are highly infectious and most likely to pass the virus on

Group B CANNOT be considered entirely non-infectious but de facto probably carry a very low risk of passing the virus on!

So, all you HIV+ folk, the sooner you are treated and compliant, the less infectious you are! Condoms are a must nevertheless (due to othe STDs and particularly the danger of you contracting a strain of virus which renders your very expensive treatment non-effective because of resistance to your specific medication.....)
14. 2012-11-30 20:03  
Its a good article but its nothing we didn't already know.

We know the biological facts but perhaps the 'heat of the moment' should be discussed more? That being the moment when after lots of foreplay its time to fuck.

That's when people are vunerable. In my humble opinion its this moment when most risks are taken and the decision is made to forget thd condom as its still in the bedside cabinet in its wrapper. Real passion killer right?

So yes guys 'rubber up' of course but have everything ready prior to getting naked. Condom unwrapped, lube bottle to hand.

Just a thought.
15. 2012-12-10 05:48  
Why not give people the scientific stats and let them decide for themselves...

Risk of getting hiv when being fucked by a hiv-positive guy:
50 per 10000 = 0.5%

Risk of getting hiv when fucking a hiv-positive guy:
6 per 10000 = 0.06%
16. 2012-12-14 13:03  
Hi #15 / happyslapper, How did you source those numbers?

So on average those numbers mean bottoms will be positive at 200 fucks and tops will be positive at 1,666 fucks (with a positive guy). That doesn't seem to gel with my limited sample size of positive friends. I doubt they're statistical outliers and their numbers are nothing like that (perhaps this is #13's point - morphing the two groups statistically is wrong, so my friend's are infected by 'A' group, and the stats are for 'A' & 'B').

It would be interesting if positive guys could share their experience. If it's not possible to post directly here, and if you trust me enough feel free to PM me and I will post your comment (or perhaps someone at Fridae could do it). I think it's a good idea to have objective info (as per #15) and also be able to openly talk about it.

Not directly related to the above point, several years ago, I wanted to have an argument with the Red Cross about why they wouldn't accept my blood. So I started searching what proportion of gay guys are positive. It was hard to find stats for many cities, but for San Francisco and Sydney I was able to calculate some numbers. San Fran turned out to be close to 30%, and Sydney was in the low 20's(%). Those numbers shocked me. For Sydney, where I was living at the time, it meant that ~1:5 of my friends should be positive, and it was more like 1:15. I asked my Doctor if my number for Sydney was about right - he said it was.

It's handy to know the risks, but the result is very binary.

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