The Use of Rectal Douches among HIV-uninfected and Infected Men who Have Unprotected Receptive Anal Intercourse: Implications for Rectal Microbicides

Abstract

Although some rectal douches result in surface epithelium loss and potential increase of HIV transmission, men who have sex with men (MSM) continue to use them. We describe the prevalence of this practice among MSM engaging in unprotected receptive anal intercourse (URAI) in risky circumstances. A multiethnic sample with overrepresentation of HIV-negative MSM who had URAI in the previous year was recruited exclusively through the Internet. Participants were 105 MSM (78 HIV-negative, 27 HIV-positive). A total of 53% of HIV-negative and 96% of HIV-positive men douched in preparation for sex, most of them frequently or always, mainly for hygienic purposes. 27% of HIV-negative and 44% of HIV-positive douched after sex, partly believing douching protected from infections. Douching practices started around age 25. Regression analyses found the association between HIV status and douching occasions persisted after controlling for demographic characteristics and number of URAI occasions. Rectal douching in preparation for sex is common among men who practice URAI. This population could benefit from alternatives to condoms, such as rectal microbicides. Given the popularity of pre-coital douching and its frequency, a harmless rectal douche that could deliver a rectal microbicide could have great acceptability.

An Event-Level Comparison of Risk-Related Sexual Practices Between Black and Other-Race Men Who Have Sex with Men: Condoms, Semen, Lubricant, and Rectal Douching

“…Last event activities were compared across racial groups (Black, White, Hispanic/Latino, and Asian/Pacific Islander) controlling for relevant sociodemographic and partner characteristics and stratifying by sexual position (receptive/insertive/both). Consistent with previous literature reporting equal or lesser risk-taking among Black MSM, 13,14,18,25 we hypothesized that relative to other races, a higher or not significantly different proportion of Black MSM would endorse condom use and a lower or not significantly different proportion would report semen exposure, rectal douching, and lubricant use.…”

“…35,36 Moreover, skin-to-skin contact alone would have enabled the spread of some STIs (e.g., genital herpes, human papilloma virus/genital warts), which confer vulnerability to others (e.g., HIV). 35 As in other studies documenting the popularity of rectal douching among MSM, 25,26,37 such behavior was fairly prevalent (18-53% among Black participants). Unfortunately, several common forms of rectal douching (soapsuds, tap water) have been reported to damage the surface epithelium of the colon or rectum in human 29 and animal 38 studies, thereby potentially enhancing vulnerability to HIV and other STIs.…”

“…Other studies of lubricant use among MSM, though variable in their definition of lubricant, measurement time frame, and ethnic composition of the sample, have generally demonstrated lubricant to be widely utilized (e.g., 94% lifetime use and 93% past year use among Latino MSM living in NYC). 25 Despite the enhanced comfort and pleasure lubricants afford, recent literature has highlighted the enhanced risk they may also confer. 22 Laboratory research has shown that many of these agents compromise the integrity of the epithelial lining of the rectum and colon, which could increases susceptibility to infection, 20,21,24,39 and that several products even amplify HIV replication in vitro.…”

“…18 Moreover, documentation of condom use often relies on aggregate retrospective self-reports, which have proven vulnerable to distortion, with MSM more commonly underestimating than overestimating unprotected PAI. 19 Additionally, Black MSM's participation in other behavioral practices known or suspected to influence vulnerability to HIV and other STIs, including lubricant use [20][21][22][23][24] and precoital rectal douching or enema use, [25][26][27][28][29][30] has received insufficient attention in the literature.…”

Missing safer sex strategies in HIV Prevention:A call for further research

“…Third, even when no trauma occurs, vaginal mucus helps prevent HIV transmission. 14 The prevalence and practice of dry sex varies greatly by cultural context, so it is impossible to generalize conclusions to Africa as a whole. To illustrate the differences in perceptions of vaginal moisture and sexual gender roles, we consider two contrasting case studies: Malawi, where many people favor a dry and tight vagina during sex, and Rwanda, where wetness is emphasized.…”