Are Providers Ignoring Anal Sex as a Health Care Issue for Women at Risk for HIV and Cancer?

Receptive anal intercourse may have accounted for 41% of HIV diagnoses among cisgender women who contracted HIV through heterosexual encounters, a study published online in the American Journal of Reproductive Immunology on May 8 found. The study, while a modeling study to provide an estimate of the role anal sex may play in HIV acquisition among cisgender women in the U.S., does beg the question as to what prevention strategies need to look like for women, and also what ongoing sexual health support is needed for women who are newly diagnosed.

The researchers used the National HIV Behavioral Surveillance surveys from 2010 and 2013, reviewing the sexual behavior data from 9,152 heterosexually active cisgender women in 20 cities with high HIV rates. Researchers included women ages 18 to 60, who completed the survey in English or Spanish and had incomes below the federal poverty line or no more formal education than a high school diploma. Women also had to report at least one incident of receptive anal or vaginal intercourse with a cisgender man in the past year.

The women included in the study were overwhelmingly Black (73%), but four cities had over 40% Latina representation (Denver, San Juan, Los Angeles, and San Diego). The median age was 37 years old, but 24% of all women were under 25 years of age. Forty-one percent reported having only main sexual partners in the past year, and 23% reported exchanging sex for money or other goods. Three percent of the women were living with HIV, and the prevalence rate did not differ between women who’d had receptive anal sex in the past year and those who did not. They excluded women who reported injecting drugs or reported only having oral sex with men during that 12-month period. Number of sex acts per partner during the time period was not collected, and therefore not a part of their analysis.

The researchers then used the survey data to develop an equation model to help determine HIV incidence in women who are at risk of HIV. The researchers then separated the data by race/ethnicity, age, and whether people exchanged anal sex for money anywhere or in a city with high HIV prevalence.

How Much Anal Sex Are Women Having?

Researchers found 32% of all women in the study reported having receptive anal intercourse in the past year. About 22% of women ages 18 to 19 reported anal sex, but older women reported higher rates (more than 31%). White and Latina women had slightly higher anal sex rates than Black women (37%, 35%, and 31%, respectively); women who had more casual sex partners also had more anal sex. Anal sex was much more common among women who reported exchanging sex for money or goods (53%) than women who had only casual sex partners (41%), women who had only main partners (19%), and women with no transactional sex partners (26%).

The researchers also looked at how frequently anal sex was practiced compared to vaginal sex acts in the past year—what the researchers called the receptive anal intercourse (RAI) fraction. They found that 27% of the most recent sex acts among women who had anal sex at all in the past year were receptive anal sex, and 27% of all unprotected sex acts among those women were unprotected anal sex (since the study years were 2010 and 2013, this refers to sex without condoms, as pre-exposure prophylaxis [PrEP] was not available until 2012 and was still rarely available for cisgender women in 2013). Women who exchanged sex for money or goods were more likely to have a higher proportion of receptive anal sex acts compared to women who did not engage in sex work or transactional sex.

“Despite only 11% of all unprotected acts being unprotected RAI, RAI alone may contribute to 41% of heterosexually acquired incident HIV infections annually among low-income women in the NHBS sample, due primarily to the high risk of HIV transmission during RAI,” the researchers write.

The study showed that receptive anal intercourse was lowest among Black women. But Black women have much higher HIV prevalence than white or Latina women. So why didn’t anal sex rank highest among Black women as a primary risk factor for HIV?

“While our results do not exclude RAI as an HIV risk factor for Black women, other factors driving risk, such as partner concurrency and the sexual network, may be more influential,” they write. “Our results are consistent with findings from other studies that women who practise RAI tend to report higher numbers of sexual partners, exchange sex, and lower condom use during vaginal and anal sex.”

Women With HIV Are More Likely to Have Risk for Anal Cancer

While HIV remains a primary issue of concern for the overall health of women, once a woman is diagnosed with HIV, there remain other health risks associated with anal sex. Another recent study published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS) noted that women with HIV have a tenfold increased risk of squamous cell carcinoma of the anus (SCCA) compared to HIV-negative women. SCCA is associated with the human papillomavirus (HPV), and the likelihood that HPV may lead to cancer is increased for women with HIV. Anal sex is a route of transmission of HPV to the anal region of the body.

The JAIDS study is a small retrospective study of 45 women living with HIV who had all been treated for anal histologic high-grade squamous intraepithelial lesions (HSIL), considered to be a precursor to anal cancer. Researchers found that “the cumulative probability of anal HSIL recurrence was 29% at 12 months, 52% at 24 months, and 79% at 36 months post-treatment.”

The authors concluded that women with HIV who develop HSIL need to be monitored after treatment for disease recurrence.

Providers Should Include Discussion of Anal Sex in Routine Care for All Women

So, taken together, these two studies would suggest that unprotected anal sex may be driving more HIV acquisition among cisgender women than we previously knew; and, furthermore, women with HIV are at higher risk for anal cancer. So, are community-based programs and providers doing enough to engage HIV-negative women about safe anal sex, recommend PrEP for those women, and—if women are newly diagnosed with HIV—are they being educated about their risks for anal cancer and how to have a healthy sex life inclusive of anal play?

Lisa Diane White, M.P.H., the deputy director of SisterLove, Inc., an HIV education, outreach, and advocacy organization for women in Atlanta, Georgia, and Johannesburg, South Africa, told TheBodyPro that she thinks the subject of anal sex is still taboo for many women who they see. But SisterLove still finds ways to talk about it and provide education about anal sex—first, from a sexual pleasure point of view, and then into a conversation about sexual health and avoiding risk of HIV or other sexually transmitted infections (STIs) when having anal sex.

“Even in this world now, where the phrase ‘sex positivity’ is thrown around, there has not been a lot of conversations about anal sex in terms of the enjoyment,” she said. “But when we ask women, and we allow them to share their experiences, then the conversations are as thoughtful as all of the ways that people enjoy sex.”

White also talked about the fear or lack of engagement from providers who see women about the kind of sex they’re having, including anal sex. Due to research that has shown a lot of STIs get missed if anal and throat swabs aren’t taken as part of STI screenings in clinics, many clinics in major cities that see a lot of gay and bisexual men have made throat and anal swabs standard of care for those men, whether they disclose their sexual habits as being insertive or receptive partners in anal sex. But White said she didn’t believe that women received the same questions in sexual history taking from providers, nor were women even offered anal swabs as a routine part of STI, sexual, and reproductive health screenings, even though there is data collected showing women are in fact having lots of anal intercourse.

“There’s an assumption that women don’t have and don’t talk about anal sex,” said White. “And why is there an assumption? I think it’s still that idea that this is something we don’t talk about, and they think women don’t talk about. But if you don’t ask us about it, we won’t talk about it.”