Use of Saliva as a Lubricant in Anal Sexual Practices Among Homosexual Men

Abstract

Compared with other sexually active adults, men who have sex with men (MSM) are more frequently infected with several pathogens including cytomegalovirus, hepatitis B virus, and Kaposi sarcoma-associated herpesvirus. Because one common element between these organisms is their presence in saliva, we evaluated saliva exposure among MSM in a heretofore relatively unrecognized route-via use of saliva as a lubricant in anal sex.
MSM in a San Francisco population-based cohort were interviewed regarding use of saliva by the insertive partner as a lubricant in various anal sexual practices.
Among 283 MSM, 87% used saliva as a lubricant in insertive or receptive penile-anal intercourse or fingering/fisting at some point during their lifetime; 31%-47% did so, depending upon the act, in the prior 6 months. Saliva use as a lubricant was more common among younger men and among HIV-infected men when with HIV-infected partners. Even among MSM following safe sex guidelines by avoiding unprotected penile-anal intercourse, 26% had anal exposure to saliva via use as a lubricant.
Among MSM, use of saliva as a lubricant is a common, but not ubiquitous, practice in anal sex. The findings provide the rationale for formal investigation of whether saliva use in this way contributes to transmission of saliva-borne pathogens in MSM.

Full text

CLINICAL SCIENCE
Use of Saliva as a Lubricant in Anal Sexual Practices
Among Homosexual Men
Lisa M. Butler, PhD, MPH, Dennis H. Osmond, PhD, Alison Graves Jones, MPH,
and Jeffrey N. Martin, MD, MPH
Objectives: Compared with other sexually active adults, men who
have sex with men (MSM) are more frequently infected with several
pathogens including cytomegalovirus, hepatitis B virus, and Kaposi
sarcoma-associated herpesvirus. Because one common element
between these organisms is their presence in saliva, we evaluated
saliva exposure among MSM in a heretofore relatively unrecognized
route—via use of saliva as a lubricant in anal sex.
Methods: MSM in a San Francisco population–based cohort were
interviewed regarding use of saliva by the insertive partner as
a lubricant in various anal sexual practices.
Results: Among 283 MSM, 87% used saliva as a lubricant in
insertive or receptive penile–anal intercourse or fingering/fisting at
some point during their lifetime; 31%–47% did so, depending upon
the act, in the prior 6 months. Saliva use as a lubricant was more
common among younger men and among HIV-infected men when
with HIV-infected partners. Even among MSM following safe sex
guidelines by avoiding unprotected penile–anal intercourse, 26% had
anal exposure to saliva via use as a lubricant.
Conclusions: Among MSM, use of saliva as a lubricant is a common,
but not ubiquitous, practice in anal sex. The findings provide the
rationale for formal investigation of whether saliva use in this way
contributes to transmission of saliva-borne pathogens in MSM.
Key Words: homosexual, saliva, lubricant, anal intercourse
(J Acquir Immune Defic Syndr 2009;00:000–000)
In contrast to other sexually active adults, men who have sex
with men (MSM) are at greater risk for infection with
a variety of pathogens including cytomegalovirus (CMV),
1
hepatitis B virus (HBV),
2
and the more recently discovered
Kaposi sarcoma-associated herpesvirus (KSHV).
3,4
Why these
pathogens are disproportionately represented among MSM is
not well understood. Although a simply greater number of
partners among some MSM could be responsible, the other
common link between these 3 pathogens is their presence in
saliva.
5–12
For example, for one of the organisms, KSHV, saliva
is the body fluid that most commonly harbors the virus.
5,6
HBV, although most commonly found in blood, is also com-
monly shed in saliva; between 15%–67% of individuals with
chronic infection have detectable HBV DNA in saliva.
11–14
In
the largest studies of CMV, HIV-infected men, in particular,
commonly harbor CMV in their saliva with 50%–60%
prevalence.
7,9
Directly investigating the role of saliva in spreading
pathogens is difficult, but for at least HBV and KSHV, there is
evidence for saliva as a conduit in transmission.
15–17
Hence, it
is surprising that limiting exposure to saliva as a means for
avoiding infection has received little attention. For example,
for CMV, guidelines for the prevention of opportunistic
infections among HIV-infected persons note the presence of
CMV in saliva, but only recommend as an intervention the use
of condoms.
18
For HBV, guidelines make no mention of the
role of saliva.
18
It is only for KSHV where caution regarding
a specific saliva-exchanging act, kissing, is given.
18
In part, the
lack of attention to saliva may stem from the belief that
exposure to saliva, via kissing, is ubiquitous and cannot be
avoided. However, kissing is common among both heterosex-
ual adults and MSM, yet CMV, HBV, and KSHV all are less
common among the heterosexual population.
1–4,19
This sug-
gests that kissing alone is not the sole means of spreading these
organisms. Despite this, very little is known about what other
avoidable practices might spread saliva from person to person.
One relatively unrecognized mode in which saliva may
be exchanged among MSM is via the use of saliva for
lubrication in anal-based sexual activities, a practice acknowl-
edged in condom failure research,
20,21
anecdotally in internet-
based forums,
22
and more recently as underemphasized
components of broad surveys of sexual practices among
MSM.
23,24
To systematically address the prevalence and
determinants of the use of saliva as a lubricant in anal sexual
acts, we examined a population-based sample of MSM.
METHODS
Population and Sampling
Participants were part of the San Francisco Young Men’s
Health Study (SFYMHS), a population-based cohort study of
Received for publication March 31, 2008; accepted October 9, 2008.
From the Department of Epidemiology and Biostatistics, University of
California, San Francisco, San Francisco, CA.
Supported by National Institutes of Health (K01 HD052020, T32 MH19105,
U01 CA078124, R01 CA119903, P30 MH062246, and P30 AI027763)
and the University of California University wide AIDS Research Program
(CC99-SF-001).
Parts of the data were presented at the 7th International Conference on
Malignancies in AIDS and Other Immunodeficiencies: Basic, Epidemi-
ologic, and Clinical Research, April 28–29, 2003, Bethesda, MD.
Correspondence to: Lisa M. Butler, PhD, MPH, Department of Epidemiology
and Biostatistics, University of California San Francisco, 50 Beale Street,
Suite 1200, San Francisco, CA 94105 (e-mail: lbutler@psg.ucsf.edu).
Copyright Ó2009 by Lippincott Williams & Wilkins
J Acquir Immune Defic Syndr Volume 00, Number 0, Month, 2009 1
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HIV infection in MSM. Full details on the sampling have been
previously described.
25
Briefly, the SFYMHS obtained a pro-
bability sample of unmarried men, aged 18–29 years, residing
in the 21 census tracts in San Francisco with the highest
accumulation of AIDS cases. Men who self-identified as
homosexual/bisexual, or reported having sex with another man
within the prior 5 years, were invited to participate. This cohort
was followed at 6-month intervals, and in the present study, we
have evaluated the use of saliva as a lubricant in anal-based
sexual acts, about which questions were introduced in 2001.
Measurements
Sexual Behavior
At each study visit, participants completed a self-
administered questionnaire that covered sociodemographic
characteristics and sexual behavior including number of
partners with whom the participant engaged in various sexual
practices, the HIV serostatus of partners, and condom use. In
particular, participants were asked about penile–anal inter-
course and practice of ‘‘fingering’’ or ‘‘fisting,’’ where one
man inserts his finger or fist into another man’s anus. Insertive
acts referred to when the participant inserts his penis (for anal
intercourse) or finger/fist (for fingering/fisting) into his
partner’s anus; receptive acts referred to when the participant’s
partner inserts his penis or finger/fist into the participant’s
anus. For these insertive and receptive acts, participants were
asked about the use of saliva as a lubricant during their lifetime
and the 6 months before the study visit. For example, to
determine the frequency of saliva use as a lubricant for
receptive fingering/fisting over a participant’s lifetime,
participants were asked ‘‘Thinking about the times when
another man 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)?’’ Use in the prior 6 months of saliva as
a lubricant was measured according to partner type,
categorized by the participant’s perception of their partner’s
HIV infection status.
Statistical Analysis
We first performed analyses to determine the prevalence
of saliva use as a lubricant in penile–anal intercourse and
fingering/fisting over participants’ lifetimes and over the prior
6 months. Logistic regression was then used to evaluate
determinants of using saliva as a lubricant in the prior
6 months for one of the acts, penile–anal intercourse. Factors
associated with saliva use as lubricant in unadjusted models at
aPvalue ,0.20 were subsequently evaluated in a multivariable
model.
26
In models in which we assessed the effect of HIV
serostatus of our participants and their partners, individual
participants could be represented more than once. To
accommodate potential nonindependence in these models,
we used generalized estimating equations in Stata version 9.1
(Stata Corp, College Station, TX). Interaction terms were
evaluated in these models to assess whether the effect of given
characteristics of our participants on saliva use as a lubricant
differed according to their partner’s HIV infection status.
RESULTS
Of the 283 MSM enrolled in the SFYMHS at the time
questions on saliva use were introduced, the median age was
35 years (interquartile range 33–36) and approximately 75%
identified as white, 4.9% as African American, 10% as Latino,
4.6% as Asian, and 4.6% as ‘‘other.’’ The majority (65%) of
participants had at least a 4-year college degree, and the
median annual income was between $30,000 and $40,000,
with 22% below $24,000 and 20% above $60,000. Seventeen
percent were HIV infected.
Lifetime Use of Saliva as a Lubricant in Insertive
and Receptive Anal Sexual Acts
Overall, of the 283 participants, 87% reported using
saliva as a lubricant in an insertive and/or receptive anal sexual
practice (ie, penile–anal intercourse or fingering/fisting) at
some point during their lifetime (80% as insertive partner and
84% as receptive partner). For penile–anal intercourse, 63%
reported ever using saliva as a lubricant, whereas the insertive
partner and 68% reported saliva use as the receptive partner.
For fingering/fisting, 72% reported saliva use at some point as
the insertive partner and 77% as the receptive partner. When
quantifying the frequency of saliva use as a lubricant in penile–
anal intercourse or during fingering/fisting over their lifetime,
the majority of participants (47%–58%, depending on act)
reported ‘‘some of the times’’, 3.2%–20% reported ‘‘most of
the times’’, and less than 3% reported ‘‘all of the times’’.
Saliva Use as a Lubricant in Insertive and
Receptive Anal Sexual Acts in the Past
6 Months
To estimate the recent use of saliva as a lubricant and
more precisely determine the frequency of such use, partic-
ipants were asked about their use of saliva over the past
6 months. Of the 283 participants, 91% reported having any
type of sexual contact with other men in the prior 6 months. Of
these sexually active men, 31% reported saliva use in the prior
6 months with at least 1 partner in insertive penile–anal
intercourse, 31% in receptive penile–anal intercourse, 47% in
insertive fingering/fisting, and 45% in receptive fingering/
fisting. When restricted to only those men who practiced each
of the respective acts (with or without saliva) in the 6 months
before the visit, the prevalence of saliva use during the act was,
as expected, somewhat higher (Table 1). In terms of the
number of partners with whom participants used saliva as a
lubricant, the median was between 0 and 1 partner, depending
on act. However, there was considerable variability with
as many as 4.5%–12% of participants reporting saliva use
with $5 partners.
Use of Saliva as a Lubricant in Penile–Anal
Intercourse According to HIV Serostatus
We examined the use of saliva as a lubricant according to
the HIV serostatus of the participants and of their partners.
Focusing on penile–anal intercourse, we found that among
HIV-infected participants who engaged as insertive partners,
there was a significantly higher percentage of partnerships
where saliva was used as a lubricant when these men were
involved with HIV-infected partners (57%) as compared with
2q2009 Lippincott Williams & Wilkins
Butler et al J Acquir Immune Defic Syndr Volume 00, Number 0, Month, 2009
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HIV-uninfected partners (6.7%, P= 0.007) (Table 2).
Similarly, among HIV-infected participants who engaged as
receptive partners in penile–anal intercourse, there was a
significantly higher percentage of partnerships where saliva
was used as a lubricant when these men were involved with
HIV-infected partners (72%) compared with HIV-uninfected
partners (30%, P= 0.002). The patterns were similar, although
not as marked and not reaching conventional statistical
significance, among the HIV-uninfected participants (Table 2).
Determinants of Saliva Use as a Lubricant
In addition to the role of HIV infection status, we
evaluated other potential determinants of the use of saliva as
a lubricant in penile–anal intercourse. Because of the
importance of HIV infection status (as described above),
these analyses were initially stratified according to partner’s
HIV serostatus (Table 3). For insertive penile–anal intercourse,
in unadjusted analyses, we again observed the importance of
HIV infection status. Compared with HIV-uninfected partic-
ipants, HIV-infected participants were less apt to use saliva as
a lubricant when their partners were HIV uninfected [odds
ratio = 0.09, 95% confidence interval (CI) = 0.01 to 0.70] but
were more apt to do so when their partners were HIV infected
(odds ratio = 2.9, 95% CI = 0.94 to 9.2). That these measures
of effect were different was reflected in the Pvalue for
interaction (P= 0.002). For the other characteristics evaluated
(age, race/ethnicity, income, and education), there were no
important differences according to partner’s HIV infection
status (Pvalues for interaction .0.20), and hence, all partner
types were analyzed together (Table 3, all partners). For age,
the odds of using saliva as a lubricant decreased by 15% (95%
CI = 2% to 25%) with every additional year. There was no
significant effect of race/ethnicity, education, or income. When
age, income, participant HIV infection status, and partner HIV
infection were evaluated together in a multivariable model,
there continued to be a significant role for age (odds ratio =
0.84, 95% CI = 0.73 to 0.96) and the effect of the participant’s
HIV infection status continued to qualitatively differ according
to partner’s infection status (Pvalue for interaction = 0.001).
Income was not significant at conventional levels of statistical
significance.
We observed a similar pattern when evaluating
determinants of saliva use as a lubricant in receptive penile–
anal intercourse (Table 3). Again, the effect of HIV infection
status in our participants differed markedly according to the
HIV infection status of their partners (P,0.001 for
interaction), but the effects of age, race/ethnicity, education,
and income did not vary according to partner’s HIV infection
status. In a multivariable model with age, income, and
participant and partner HIV infection status, only the effect of
TABLE 1. Prevalence and Magnitude of Saliva Use as a Lubricant in Insertive and Receptive Anal Sexual Acts in the Prior 6 Months
Among Homosexual Men Reporting Any Participation (With or Without Saliva Use) in These Acts During the Reporting Period
Act
No. Who Engaged
in Act at
Least Once
No. (%) Who
Used Saliva During
Act at Least Once
No. Partners With
Whom Saliva Was
Used, Median (IQR)
No. (%) Who Used Saliva
With 5 or More
Partners
Insertive penile–anal intercourse 177 79 (44.6) 0 (0–1) 8 (4.5)
Receptive penile–anal intercourse 173 80 (46.2) 0 (0–1) 8 (4.6)
Insertive fingering/fisting 182 121 (66.5) 1 (0–2) 21 (11.5)
Receptive fingering/fisting 167 116 (69.5) 1 (0–2) 17 (10.2)
IQR, interquartile range.
TABLE 2. Proportion of Participants Who Used Saliva as a Lubricant During Penile–Anal Intercourse in the Prior 6 Months,
According to Participant and Partner HIV Infection Status
Role of Participants
Participant HIV
Infection Status
Partner HIV
Infection Status*
No. Participants
Engaging in
Act With Partner
No. (%) Participants
Reporting Saliva Use as
a Lubricant During Act
Odds Ratio
(95% CI)† P
Insertive‡Infected Uninfected 15 1 (6.7) Reference
Infected Infected 21 12 (57.1) 13.5 (2.0 to 89.4) 0.007
Uninfected Uninfected 112 50 (44.6) Reference
Uninfected Infected 32 10 (31.3) 0.62 (0.30 to 1.3) 0.20
Receptive§ Infected Uninfected 20 6 (30.0) Reference
Infected Infected 25 18 (72.0) 5.4 (1.9 to 15.3) 0.002
Uninfected Uninfected 115 45 (39.1) Reference
Uninfected Infected 23 5 (21.7) 0.45 (0.19 to 1.04) 0.06
*Denotes participants’ perception of partners’ HIV infection status.
†As estimated by generalized estimating equations.
‡For each partner type, participants were asked ‘‘In the last 6 months, with how many men did you put penis in the man’s rectum (with or without a condom)?’’ For men who indicated
that they had had insertive anal intercourse within the past 6 months, the following question was asked: "With how many of these men did you use your own saliva as a lubricant (‘‘lube’’)?
§For each partner type, participants were asked ‘‘In the last 6 months, with how many men put their penis in your rectum (with or without a condom)?’’ For men who indicated that
they had had receptive anal intercourse within the past 6 months, the following question was asked: "How many of these men used their own saliva as a lubricant (‘‘lube’’)?
q2009 Lippincott Williams & Wilkins 3
J Acquir Immune Defic Syndr Volume 00, Number 0, Month, 2009 Saliva as a Lubricant in Anal Sexual Practices
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

HIV infection status in our participants continued to be
significant, and again, this differed according to their partner’s
infection status (Pvalue for interaction ,0.001). Neither age
nor income was significant at conventional levels of statistical
significance.
Use of Saliva as a Lubricant Despite Otherwise
Safe Sex Practices
To assess saliva use among MSM who were otherwise
practicing safe sex by conventional guidelines, we evaluated
the 160 participants who avoided unprotected penile–anal
intercourse in the prior 6 months. Among 105 men who
reported having no receptive penile–anal intercourse, 17
(16%) were exposed to saliva via fingering/fisting. Of the 55
who reported using a condom with all receptive penile–anal
intercourse partners, 24 (44%) were exposed to saliva either
via penile–anal intercourse (where saliva was used as
a lubricant on top of a condom) or via fingering/fisting.
Overall, of the 160 participants who avoided unprotected
penile–anal intercourse, 26% had anal exposure to saliva via
its use as a lubricant.
DISCUSSION
The high prevalence of infection among MSM with
pathogens such as CMV, HBV, and the more recently
discovered KSHV has been well documented but not
adequately explained. Because each of these organisms is,
in part, considered to be sexually transmitted, much of the
focus of their transmission-related investigation in MSM has
been on conventional means of sexual contact. However,
a common thread between these 3 pathogens is their presence
in saliva, and, remarkably, saliva is not often considered as
a conduit for sexual transmission. Specifically, other than
kissing or oral–anal contact (known as ‘‘rimming,’’ where, in
any case, most of the interest has been on exposure to fecal
contents), how saliva might be passed from person to person
has received little attention. Here, we have documented in
TABLE 3. Determinants of Saliva Use as a Lubricant During Insertive and Receptive Penile–Anal Intercourse
HIV-Uninfected Partners* HIV-Infected Partners* All Partners†
Odds Ratio (95% CI) POdds Ratio (95% CI) POdds Ratio (95% CI) P
Insertive participation
Age, per year 0.85 (0.73 to 0.99) 0.04 0.88 (0.71 to 1.1) 0.25 0.85 (0.75 to 0.98) 0.02
HIV infection status of participant
Uninfected Reference — Reference — — —
Infected 0.09 (0.01 to 0.70) 0.02 2.9 (0.94 to 9.2) 0.07 ‡—
Race/ethnicity
White Reference — Reference — Reference —
Other 0.76 (0.30 to 1.9) 0.56 0.34 (0.06 to 1.8) 0.21 0.65 (0.28 to 1.52) 0.32
Education
Postgraduate Reference — Reference — Reference —
#4 yrs college 1.6 (0.73 to 3.3) 0.25 1.2 (0.38 to 3.5) 0.80 1.36 (0.71 to 2.6) 0.35
Income
$$60,000 Reference — Reference — Reference —
$30,000–59,999 1.3 (0.59 to 2.8) 0.53 1.0 (0.28 to 3.9) 0.95 1.2 (0.61 to 2.5) 0.57
,$30,000 1.4 (0.51 to 4.0) 0.50 2.4 (0.57 to 10.4) 0.23 1.8 (0.76 to 4.3) 0.18
Receptive participation
Age, per year 0.92 (0.80 to 1.1) 0.27 0.84 (0.67 to 1.1) 0.13 0.89 (0.79 to 1.0) 0.08
HIV infection status of participant
Uninfected Reference — Reference — — —
Infected 0.67 (0.24 to 1.9) 0.44 9.3 (2.5 to 34.7) 0.001 n/a‡—
Race/ethnicity
White Reference — Reference — Reference —
Other 1.3 (0.54 to 3.3) 0.54 0.38 (0.07 to 2.2) 0.28 1.0 (0.45 to 2.3) 0.98
Education
Postgraduate Reference — Reference — Reference —
#4 yrs college 1.1 (0.49 to 2.3) 0.87 1.14 (0.35 to 3.7) 0.82 1.1 (0.58 to 2.2) 0.72
Income
$$60,000 Reference — Reference — Reference —
$30,000–59,999 1.5 (0.68 to 3.2) 0.33 0.89 (0.22 to 3.6) 0.87 1.4 (0.69 to 2.8) 0.35
,$30,000 2.0 (0.71 to 5.5) 0.19 2.4 (0.52 to 11.0) 0.26 2.1 (0.92 to 5.0) 0.08
*Denotes participants’ perception of partners’ HIV infection status.
†As estimated by generalized estimating equations.
‡Effect of HIV infection status in participant differed according to partner’s HIV infection status (Pvalue for interaction = 0.002 for insertive participation and ,0.001 for receptive
participation), obviating the all-partners analysis.
4q2009 Lippincott Williams & Wilkins
Butler et al J Acquir Immune Defic Syndr Volume 00, Number 0, Month, 2009
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

a population-based sample of MSM a high prevalence of the
use of saliva in a heretofore relatively unrecognized
practice—as a lubricant in penile–anal intercourse and
fingering/fisting. Used in this way, potentially pathogen-
bearing saliva comes into contact with anal/rectal mucosa,
plausibly setting the stage for transmission. Conceivably, the
adjunctive trauma and/or deeper penetration associated with
the penile–anal intercourse or fingering/fisting acts per se may
facilitate transmission in ways that are not present, for
example, in oral–anal acts.
We observed different patterns of saliva use by HIV-
infected and HIV-uninfected men depending on the HIV
serostatus of their partners. This is consistent with another
report which showed less frequent use of saliva as a lubricant
in anal sex by HIV-uninfected men when with HIV-infected
partners compared with all other partners.
23
Our observations
suggest that HIV-infected men are less concerned about
exchanging saliva in seroconcordant partnerships, perhaps
because such men feel ‘‘safe’’—thinking that nothing worse
can be transmitted because they are already HIV infected.
However, from a clinical perspective, it may be unfortunate if
HIV-infected individuals expose themselves to saliva in this
way in that various pathogens (such as CMV and KSHV
27
) are
more frequently found in the saliva of their HIV-infected
partners and therefore constitute potential higher risk for
transmission. Furthermore, it is HIV-infected persons who are
at greatest risk of developing clinical manifestations of these
infections if they become infected. Although the role of HIV
infection status in determining the use of saliva as a lubricant
suggests that some MSM may be thinking about potential
transmission of pathogens via saliva used this way, we suspect
that most MSM are not aware. This is perhaps best evidenced
by our finding of the high frequency of use of saliva as
lubricant even among MSM who otherwise were adhering to
safe sex guidelines by avoiding unprotected penile–anal
intercourse. Lack of awareness of KSHV (and hence its routes
of transmission) among MSM has been previously docu-
mented,
28
and although CMV and HBV are more commonly
known about in the community, it is unlikely that their
presence in saliva is widely recognized.
We found that although the use of saliva as a lubricant in
various anal sexual acts is common among MSM, it is not
ubiquitous. For example, in a 6-month period, fewer than half
of MSM used saliva in this way. Our observations are
consistent with and extend data from a prior report showing
that approximately 38% of 809 HIV-uninfected MSM used
saliva as a lubricant in anal sex at least once in the prior
6 months.
23
Even among those who did use saliva in this
manner, the number of partners with whom they practiced it
was highly variable. This variability in the practice and hence
in exposure of MSM to saliva via this route could help
explain why many but not all MSM are infected with, for
example, HBV and KSHV. We were not able, however, to
explain much of the variability in this practice with the mea-
surements available to us. It is likely that contextual variables
that we unfortunately did not collect, such as the environ-
ment where the sexual encounter occurred or the availability
of other lubricants, might explain a substantial degree of
the variability.
A limitation of our work is the self-reported nature of the
use of saliva as a lubricant. However, given that prevention
messages do not mention saliva, we do not believe that men
have underreported this practice to provide socially desirable
responses. Although not a threat to the validity of the data at
hand, our lack of data regarding the presence of infection in
our participants with saliva-borne pathogens such as CMV,
HBV, and KSHV precludes our ability to directly establish that
these organisms can be transmitted by the use of the saliva as
a lubricant in anal sexual acts. Indeed, there are reasons to
believe that transmission via saliva is not a foregone
conclusion. For example, presence of neutralizing Immuno-
globulin A, as has been reported for HIV,
29
may counterbal-
ance infectiousness. Establishing an independent relationship
between the use of saliva as a lubricant in anal-based sexual
acts and acquisition of saliva-borne pathogens will be
complex, given the close correlation in practice of various
sexual acts (eg, penile–anal, oral–anal, and penile–oral
contact) among MSM, which all could conceivably transmit
these pathogens.
30
It is likely that only longitudinal studies of
very young MSM, initially uninfected with these organisms,
will be able to tease out the independent contribution of saliva
used as a lubricant.
Our findings provide the rationale for formal investiga-
tion of whether saliva used as a lubricant in anal sex may
contribute to the transmission of saliva-borne pathogens in
MSM. Until it can be disproved that saliva-borne pathogens
are transmitted through this route, there now needs to be
debated as to whether prevention guidelines should be
expanded to include avoidance of saliva exposure via this
route. In opposition of this expansion is that nonsaliva
lubricants may not be affordable to everyone, and a premature
call to avoid use of saliva as a lubricant could have unintended
consequences of limiting sexual contact and its attendant
benefits to well-being. In support of this expansion is the view
that avoidance of saliva use as a lubricant would seem to be
feasible especially because the avoidance of sexual contact per
se is not the issue. Education alone regarding the risks of saliva
use in this manner may be all that is needed to facilitate
behavior change. Structural interventions, such as the
copackaging of condoms with packets of sterile jelly
lubricants, might also be useful in sustaining the message.
This debate will likely only be settled through collection of
more epidemiologic data directly examining the infectivity
of saliva when used as a lubricant and novel data from the
community on the perceived consequences among MSM
of a message that suggested avoidance of the use of saliva in
this way.
ACKNOWLEDGMENT
We gratefully acknowledge Amber Cheng for data
management.
REFERENCES
1. Drew WL, Mintz L, Miner RC, et al. Prevalence of cytomegalovirus
infection in homosexual men. J Infect Dis. 1981;143:188–192.
2. Dietzman DE, Harnisch JP, Ray CG, et al. Hepatitis B surface antigen
(HBsAg) and antibody to HBsAg. Prevalence in homosexual and
heterosexual men. JAMA. 1977;238:2625–2626.
q2009 Lippincott Williams & Wilkins 5
J Acquir Immune Defic Syndr Volume 00, Number 0, Month, 2009 Saliva as a Lubricant in Anal Sexual Practices
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

3. Smith NA, Sabin CA, Gopal R, et al. Serologic evidence of human
herpesvirus 8 transmission by homosexual but not heterosexual sex.
J Infect Dis. 1999;180:600–606.
4. Martin JN, Ganem DE, Osmond DH, et al. Sexual transmission and the
natural history of human herpesvirus 8 infection. N Engl J Med. 1998;338:
948–954.
5. Pauk J, Huang ML, Brodie SJ, et al. Mucosal shedding of human
herpesvirus 8 in men. N Engl J Med. 2000;343:1369–1377.
6. Koelle DM, Huang ML, Chandran B, et al. Frequent detection of Kaposi’s
sarcoma-associated herpesvirus (human herpesvirus 8) DNA in saliva of
human immunodeficiency virus-infected men: clinical and immunologic
correlates. J Infect Dis. 1997;176:94–102.
7. Fidouh-Houhou N, Duval X, Bissuel F, et al. Salivary cytomegalovirus
(CMV) shedding, glycoprotein B genotype distribution, and CMV disease
in human immunodeficiency virus-seropositive patients. Clin Infect Dis.
2001;33:1406–1411.
8. Lucht E, Brytting M, Bjerregaard L, et al. Shedding of cytomegalovirus
and herpesviruses 6, 7, and 8 in saliva of human immunodeficiency virus
type 1-infected patients and healthy controls. Clin Infect Dis. 1998;27:
137–141.
9. Lucht E, Albert J, Linde A, et al. Human immunodeficiency virus type 1
and cytomegalovirus in saliva. J Med Virol. 1993;39:156–162.
10. Karayiannis P, Novick DM, Lok AS, et al. Hepatitis B virus DNA in
saliva, urine, and seminal fluid of carriers of hepatitis B e antigen. Br Med
J (Clin Res Ed). 1985;290:1853–1855.
11. Jenison SA, Lemon SM, Baker LN, et al. Quantitative analysis of hepatitis
B virus DNA in saliva and semen of chronically infected homosexual
men. J Infect Dis. 1987;156:299–307.
12. Davison F, Alexander GJ, Trowbridge R, et al. Detection of hepatitis B
virus DNA in spermatozoa, urine, saliva and leucocytes, of chronic
HBsAg carriers. A lack of relationship with serum markers of replication.
J Hepatol. 1987;4:37–44.
13. van der Eijk AA, Niesters HG, Hansen BE, et al. Paired, quantitative
measurements of hepatitis B virus DNA in saliva, urine and serum of chronic
hepatitis B patients. Eur J Gastroenterol Hepatol. 2005;17:1173–1179.
14. Zhevachevsky NG, Nomokonova NY, Beklemishev AB, et al. Dynamic
study of HBsAg and HBeAg in saliva samples from patients with hepatitis
B infection: diagnostic and epidemiological significance. J Med Virol.
2000;61:433–438.
15. Martinson FE, Weigle KA, Royce RA, et al. Risk factors for horizontal
transmission of hepatitis B virus in a rural district in Ghana. Am J
Epidemiol. 1998;147:478–487.
16. Scott RM, Snitbhan R, Bancroft WH, et al. Experimental transmission
of hepatitis B virus by semen and saliva. J Infect Dis. 1980;142:
67–71.
17. Dedicoat M, Newton R, Alkharsah KR, et al. Mother-to-child trans-
mission of human herpesvirus-8 in South Africa. J Infect Dis. 2004;190:
1068–1075.
18. CDC. Guidelines for preventing opportunistic infections among HIV-
infected persons. MMWR Recomm Rep. 2002;51(RR08):1–46.
19. Winkelstein W Jr, Lyman DM, Padian N, et al. Sexual practices and risk of
infection by the human immunodeficiency virus. The San Francisco Men’s
Health Study. JAMA. 1987;257:321–325.
20. Smith AM, Jolley D, Hocking J, et al. Does additional lubrication
affect condom slippage and breakage? Int J STD AIDS. 1998;9:
330–335.
21. Golombok S, Harding R, Sheldon J. An evaluation of a thicker versus
a standard condom with gay men. AIDS. 2001;15:245–250.
22. Ask the Experts About Safe Sex and HIV Prevention: Saliva as Lubricant.
September 8, 2000. Available at: http://www.thebody.com/Forums/AIDS/
SafeSex/Archive/PreventionSexual/09685.html. Accessed on March 15,
2008.
23. Casper C, Carrell D, Miller KG, et al. HIV serodiscordant sex partners and
the prevalence of human herpesvirus 8 infection among HIV negative men
who have sex with men: baseline data from the EXPLORE Study. Sex
Transm Infect. 2006;82:229–235.
24. Nguyen TA, Nguyen HT, Le GT, Detels R. Prevalence and risk factors
associated With HIV infection among men having sex with men in Ho Chi
Minh City, Vietnam. AIDS Behav. 2008;12:476-482.
25. Osmond DH, Page K, Wiley J, et al. HIV infection in homosexual and
bisexual men 18 to 29 years of age: the San Francisco Young Men’s Health
Study. Am J Public Health. 1994;84:1933–1937.
26. Vittinghoff E, Glidden DV, Shiboski SC, et al. Regression Methods in
Biostatistics. New York, NY: Springer; 2005.
27. Miller CS, Berger JR, Mootoor Y, et al. High prevalence of multiple
human herpesviruses in saliva from human immunodeficiency virus-
infected persons in the era of highly active antiretroviral therapy. J Clin
Microbiol. 2006;44:2409–2415.
28. Phillips AM, Graves Jones A, Osmond DH, Pollack LM, Catania J,
Martin JN. Awareness of Kaposi’s sarcoma-associated herpesvirus
among men who have sex with men. Sex Transm Dis. 2008;35:
1011–1014.
29. Devito C, Hinkula J, Kaul R, et al. Cross-clade HIV-1-specific neutralizing
IgA in mucosal and systemic compartments of HIV-1-exposed,
persistently seronegative subjects. J Acquir Immune Defic Syndr. 2002;
30:413–420.
30. Martin JN, Osmond DH. Invited commentary: determining specific sexual
practices associated with human herpesvirus 8 transmission. Am J
Epidemiol. 2000;151:225–229. Discussion 230.
6q2009 Lippincott Williams & Wilkins
Butler et al J Acquir Immune Defic Syndr Volume 00, Number 0, Month, 2009
Copyright © 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.