Online Extra: Tips abound for having sex during the pandemic
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People have questions about sex and intimacy during the novel coronavirus pandemic.
Do they need to keep taking PrEP if they're not having sex while sheltering in place? How can people keep getting PrEP if they need it? Is the new coronavirus transmitted through semen? Are there safer ways to have sex and protect themselves and others?
As physical distancing becomes the new normal, public health agencies have begun to issue new COVID-19 safer sex guidelines. And despite the many unknowns about the new coronavirus, community norms are evolving, from an abstinence-only policy to a harm reduction approach.
These issues were the topic of a May 6 virtual forum sponsored by the GLBT Historical Society as part of its "Fighting Back" series.
"I sensed a consensus that each person deals with unique factors when making decisions about having sex amid the pandemic," said panelist Race Bannon, author of the Bay Area Reporter's leather column. "Some of those factors are related directly to public health science, some to personal situations and environments, and some to societal inequalities and disparities. This means that how each person crafts their approach to having sex or not will vary.
"Everyone agreed that unlike HIV, where transmission is confined to only those who partake in the sex act, COVID-19 adds another wrinkle in that one's exposure could potentially infect others with whom you come in casual contact and this must also be balanced among all the decision factors," Bannon told the B.A.R.
People who are not having sex while sheltering in place do not need to continue taking PrEP, health experts said. When stopping, some health officials advise taking PrEP for four weeks after the last sexual exposure, but the World Health Organization notes that most programs for gay and bisexual men advise that PrEP can be stopped after two daily doses following the last exposure. When it's time to restart, the Centers for Disease Control and Prevention says that it takes seven days to achieve protection for anal sex but may take up to 20 days for vaginal or frontal sex.
"One of the great things about PrEP is that it can be adapted to whatever is going on in people's lives. It's perfectly fine to take a break from PrEP while not having sex," Julia L. Marcus, Ph.D., MPH, an assistant professor at Harvard Medical School, wrote in an email.
Another option for some people is taking Truvada (tenofovir disoproxil fumarate/emtricitabine) on demand according to the "2-1-1" schedule. This involves taking two doses between two and 24 hours before anticipated sex, one dose 24 hours after the initial double dose and a final dose 24 hours after that. Although this regimen is not yet approved by the U.S. Food and Drug Administration, it was found to be highly effective for gay and bi men in clinical trials and some local providers now offer it.
The CDC recently issued guidance for people who wish to continue taking PrEP. Quarterly HIV and sexually transmitted infection tests are recommended for people on PrEP, and shelter-in-place restrictions and limited services at medical facilities are now entering the third month.
Lab visits for HIV and STI testing are preferred, if available, according to Dr. Eugene McCray and Dr. Jonathan Mermin of the CDC. But if not, home HIV test kits that use blood from a fingerstick or an oral swab sample are an option. Self-collected genital and anal swabs or urine samples may be used for STI testing. These tests kits are mailed to a lab and results are returned to an individual or their physician. Once HIV-negative status is confirmed, doctors can prescribe PrEP for 90 days, rather than the usual 30 days, to minimize trips to the pharmacy.
Despite rumors to the contrary, there is currently no evidence that HIV PrEP or antiretroviral treatment can prevent acquiring the coronavirus or becoming severely ill. Several studies are underway, but meanwhile people taking these medications should observe all the precautions recommended for the general public.
Safer sex tips
The CDC does not offer safer sex tips for the COVID-19 era, but local public health agencies have stepped in to fill in the gap, as was mentioned in a recent B.A.R. op-ed.
Studies conducted to date suggest that the new coronavirus probably is not transmitted in semen. One study from China, where the pandemic emerged late last year, did not find the virus in semen samples collected about a month after diagnosis from 34 men with mild to moderate COVID-19. Another Chinese study did detect coronavirus RNA in samples from six out of 38 men, four of whom had acute infection and two of whom were recovering, but it is not known whether this genetic material signals the presence of infectious virus.
The coronavirus has been detected in feces, suggesting that transmission may be possible through activities such as rimming or fisting. Studies so far have not seen the virus in vaginal fluid.
Even if the new virus cannot be transmitted directly through sexual activity, it can still be spread through the air, and potentially via contact with surfaces and objects, when people kiss, cuddle, or have sex. The virus is present in saliva and experts think this is an easy transmission route.
The San Francisco Department of Public Health's COVID-19 Sexual Health Tips fact sheet, adapted from guidelines issued by the New York City Department of Health and Mental Hygiene, recommends avoiding sex with anyone outside your household. If you do have sex with others, have as few partners as possible and avoid group sex. Limiting sex to a small circle of people lessens the risk of exposure.
"Washing up before and after sex is more important than ever," the fact sheet says. Don't forget to wash sex toys. Condoms can reduce the risk of coming into contact with the coronavirus in saliva or feces during oral or anal sex.
Similarly, the Netherlands recently recommended that single people choose a like-minded "sex buddy" and reach an agreement about how many other people they will see and what other risks they will take.
As alternatives, the tips suggest masturbation, video dates, sexting, and chat rooms. Participants at the historical society forum had some other ideas, including establishing closed "bubbles" or "pods" of people who have sex only with each other after a mutual quarantine period and glory-hole set-ups that put partners on opposite sides of a partition.
Public health experts have learned lessons from HIV about the futility of a "just say no" approach when it comes to reducing risks related to sex.
"Given that abstinence-only recommendations are likely to promote shame and unlikely to achieve intended behavioral outcomes," Dr. Kenneth Mayer of Fenway Health in Boston and colleagues recently wrote in the Annals of Internal Medicine, "sex-positive recommendations regarding remote sexual activity are optimal during the pandemic, balancing human needs for intimacy with personal safety and pandemic control."
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