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Oral sex is one of the most common sexual activities. Although evidence supports that unprotected oral sex carries a risk of the transmission of sexually transmitted infections (STIs), especially if the individual has a poor oral health, the risk of human immunodeficiency virus (HIV) transmission through oral sex is much lower than that through anal sex (1). Many people, including people living with HIV (PLWH), may think that oral sex carries little or no risk for the transmission of HIV and other STIs. After knowing their HIV status, they may increase the frequency of oral sex and decrease that of anal sex in order to minimize HIV transmission to others. As a result, PLWH may be more likely to have regular oral sex than the uninfected population (2). Unprotected oral sex is common among men who have sex with men (MSM) (3). A cross-sectional study from China showed that only 6.87% of 5,181 MSM reported condom use in their last oral sex (4). Sarah et al. found that a higher proportion of HIV-infected MSM (75.00%) reported having oral sex than uninfected MSM (59.00%) (2). Another study from Thailand showed that 85.00% of HIV-infected MSM had reported unprotected oral sex, significantly higher than the proportion of unprotected anal sex (32.00%) (5). The purpose of the current study was to investigate oral sexual behavior and factors associated with the use of condoms in oral sex among HIV-infected MSM in China. Most participants in this study never used a condom when giving oral sex (89.30%, 718/804) or receiving oral sex (90.32%, 709/785). Among the 85 participants with a detectable viral load who received oral sex without a condom, 40.00% reported that they had ever ejaculated in their partner’s mouth. It is necessary for clinicians and public health practitioners to develop targeted education and interventions for HIV-infected MSM to minimize the risk from unprotected oral sex.
We conducted a nationwide cross-sectional online survey in February 2021 in China. Convenience sampling was applied in this study. A total of 873 eligible participants were recruited through Li Hui Shi Kong, a WeChat official account with more than 76,000 HIV-infected followers. Details of the description of Li Hui Shi Kong are available in a previously published literature (6). Eligibility criteria included self-identified MSM, having oral sex with at least one man in the past six months, and having a known diagnosis of HIV. The following measures were taken to ensure the quality of the questionnaire results: 1) each mobile phone or computer could only be used once; 2) a pre-investigation of 12 HIV-infected MSM was conducted to modify questionnaires before the formal launch of the survey; 3) invalid questionnaires were identified by the logic checks built into the back-end system; 4) quality-controlled questions were designed to exclude participants filling in wrong answers (e.g., “How many seasons are there?”); 5) participants who finished questionnaires within a short answer time (less than 5 minutes), and those who chose the same option in all choice questions were also excluded. Every eligible participant received a reimbursement of 4.6 USD to 15.4 USD as an incentive through an online random lottery. Oral sexual behaviors included the following questions: in the past six months, 1) type of oral sex (given, received, or both); 2) frequency of oral sex; 3) number of oral sex male partners; 4) condom use when giving or receiving oral sex; 5) ever ejaculated in partners’ mouth; 6) mouthwash use before or after performing oral sex. To ensure that all participants were using the same definition of oral sex, a short statement was given on the survey, defining giving oral sex as “putting your mouth on your partner’s penis (Oral-Penis)” and receiving oral sex as “putting your penis in your partner’s mouth (Penis-Oral).” Unprotected oral sex in this study was defined as the absence of condom use during oral sex.
The chi-squared test was used to compare the oral sexual behavior between different viral loads of HIV in the last six months of HIV-infected MSM. Univariate logistic regressions were performed to identify factors potentially associated with unprotected oral sex. Odds ratios (OR) and 95% confidence intervals (CI) were calculated in univariate analysis. Variables with P<0.2 in univariate analysis were included in multivariable modeling, which was performed using multiple logistic regression. All analyses were conducted using IBM SPSS (version 20.0, SPSS, Inc. Chicago, USA), and P<0.05 was considered significant.
The proportion of transgender women was 9.85% (86/873). The age of participants ranged from 16 to 63 years (median=29, interquartile range: 25–34). In all participants, 59.22% (517/873) used social apps to find sexual partners, and 37.46% (327/873) had regular male partners (Table 1). In the past 6 months, the proportions of participants who reported ever giving oral sex and receiving oral sex were 92.10% (804/873) and 89.92% (785/873). Most participants never used a condom when giving oral sex (89.30%, 718/804) or receiving oral sex (90.32%, 709/785). Overall, 35.26% (250/709) of the participants reported ejaculation in their partner’s mouth when receiving oral sex without a condom, and 53.15% (464/873) used mouthwash before or after performing oral sex. Among the 126 participants with a detectable viral load in the past 6 months, 67.46% (85/126) reported receiving oral sex without a condom.
Characteristics n (%) Number of participants 873 (100.00) Gender identity Cisgender male 787 (90.15) Transgender women 86 (9.85) Age (years) ≤25 276 (31.62) 26–44 570 (65.29) ≥45 27 (3.09) Education High school or below 181 (20.73) Bachelor or college 611 (69.99) Master or doctor 81 (9.28) Chinese geographical division* North China 155 (17.75) Northeast China 66 (7.56) East China 256 (29.32) Central China 114 (13.06) South China 124 (14.20) Southwest China 109 (12.49) Northwest China 49 (5.61) Marital status Unmarried 757 (86.71) Married 75 (8.59) Other 41 (4.70) Employment status Full-time employment 523 (61.89) Freelancer 167 (19.76) Student 86 (10.18) Unemployed 69 (8.17) Salary (CNY) 0–1,999 132 (15.12) 2,000–4,999 331 (37.92) 5,000–9,999 302 (34.59) ≥10,000 108 (12.37) Sexual orientation Heterosexual 10 (1.15) Homosexual 691 (79.15) Other or not sure 172 (19.70) Way to find sex partners Regular partner 327 (37.46) Social app 517 (59.22) Bar/party/bathhouse 40 (4.58) Workmates 19 (2.18) Friend recommendation 31 (3.55) Gym 20 (2.29) Gay community 20 (2.29) HIV status of regular male partner Positive 116 (35.47) Negative 153 (46.79) Unknown 58 (17.74) Time since HIV diagnosis (months) <12 162 (18.56) 13–35 300 (34.36) ≥36 411 (47.08) Viral load of HIV in the last year Detectable (at least once) 126 (14.43) Undetectable 613 (70.22) Not sure 134 (15.35) Taking HIV medications Yes 801 (91.75) No 72 (8.25) Recreational drug use before or during sexual activities Yes 525 (60.14) No 348 (39.86) Alcohol use before or during sexual activities Yes 316 (36.20) No 557 (63.80) Circumcised Yes 226 (25.89) No 647 (74.11) Type of oral sex Ever giving oral sex† 804 (92.10) Receiving oral sex§ 785 (89.92) Frequency of oral sex ≥10 times per month 55 (6.30) 4–9 times per month 106 (12.14) 1–3 times per month 296 (33.91) <1 time per month 416 (47.65) Number of oral sex male partners ≥6 per month 27 (3.09) 2–5 per month 177 (20.27) 1 per month 259 (29.67) <1 per month 410 (46.96) Condom use when giving oral sex Sometimes/often 86 (10.70) Never 718 (89.30) Condom use when receiving oral sex Sometimes/often 76 (9.68) Never 709 (90.32) Ever ejaculated in partners’ mouth when receiving oral sex without a condom Yes 250 (35.26) No 459 (64.74) Mouthwash before/after oral sex Yes 464 (53.15) No 409 (46.85) Note: Numbers may vary due to missing data.
Abbreviations: CNY=Chinese Yuan; PLAD=provincial-level administrative division; HIV=human immunodeficiency virus.
* Chinese Geographical Divisions by PLADs: North China (Beijing, Tianjin, Hebei, Shanxi, Inner Mongolia); Northeast China (Heilongjiang, Jilin, Liaoning); East China (Shanghai, Jiangsu, Zhejiang, Anhui, Jiangxi, Shandong, Fujian, Taiwan); Central China (Henan, Hubei, Hunan); South China (Guangdong, Guangxi, Hainan, Hong Kong, Macao); Southwest China [Chongqing, Sichuan, Guizhou, Yunnan, Xizang (Tibet)]; Northwest China (Shaanxi, Gansu, Qinghai, Ningxia, Xinjiang).
† Giving oral sex: putting your mouth on your partner’s penis (Oral-Penis).
§ Receiving oral sex: putting your penis in your partner’s mouth (Penis-Oral).Table 1. Basic characteristics of HIV-infected men who have sex with men in China who ever had oral sex in the past six months.
HIV-infected MSM with an undetectable viral load were more likely to receive oral sex in the past 6 months (P<0.001), and those with a detectable viral load were on a more frequent basis (P=0.005) (Table 2). A higher proportion of HIV-infected MSM with detectable viral load reported condom use when giving oral sex (19.13% vs. 7.96%, P<0.001) and receiving oral sex (15.84% vs. 8.17%, P=0.042) in the past 6 months compared to those with undetectable viral load. Among the 85 participants with detectable viral load who had ever received oral sex without a condom, 40.00% (34/85) reported ejaculation in their partner’s mouth.
Variables Detectable
n (%)Undetectable
n (%)Not sure
n (%)P value Ever giving oral sex* 0.924 Yes 115 (91.27) 565 (92.17) 124 (92.54) No 11 (8.73) 48 (7.83) 10 (7.46) Ever receiving oral sex§ <0.001 Yes 101 (80.16) 563 (91.84) 121 (90.30) No 25 (19.84) 50 (8.16) 13 (9.70) Frequency of oral sex 0.005 ≥10 times per month 16 (12.70) 27 (4.40) 12 (8.96) 4–9 times per month 20 (15.87) 69 (11.26) 17 (12.68) 1–3 times per month 40 (31.75) 208 (33.93) 48 (35.82) <1 time per month 50 (39.68) 309 (50.41) 57 (42.54) Number of oral sex male partners 0.001 ≥6 per month 5 (3.97) 14 (2.28) 8 (5.97) 2–5 per month 32 (25.40) 107 (17.46) 38 (28.36) 1 per month 43 (34.13) 187 (30.51) 29 (21.64) <1 per month 46 (36.50) 305 (49.75) 59 (44.03) Condom use when giving oral sex <0.001 Sometimes/often 22 (19.13) 45 (7.96) 19 (15.32) Never 93 (80.87) 520 (92.04) 105 (84.68) Condom use when receiving oral sex 0.042 Sometimes/often 16 (15.84) 46 (8.17) 14 (11.57) Never 85 (84.16) 517 (91.83) 107 (88.43) Ever ejaculated in partners’ mouth when
receiving oral sex without a condom0.258 Yes 34 (40.00) 173 (33.46) 43 (40.19) No 51 (60.00) 344 (66.54) 64 (59.81) Mouthwash before/after oral sex 0.050 Yes 79 (62.70) 320 (52.20) 65 (48.51) No 47 (37.30) 293 (47.80) 69 (51.49) Total 126 613 134 Detectable: HIV viral load can be detected at least once in the past six months.
Abbreviations: MSM=men who have sex with men; HIV=human immunodeficiency virus.
*Giving oral sex: putting your mouth on your partner’s penis (Oral-Penis).
§ Receiving oral sex: putting your penis in your partner’s mouth (Penis-Oral).Table 2. Characteristics of oral sex in MSM with different HIV viral loads in China.
In multivariable logistic regression analysis, HIV-infected MSM who were circumcised [adjusted odds ratio (aOR)=0.6, 95% CI: 0.4–0.8] were less likely to have unprotected oral sex. HIV-infected MSM who found sexual partners via social apps (aOR=2.5, 95% CI: 1.7–3.7), used alcohol before or during sexual activities (aOR=1.7, 95% CI: 1.2–2.4), and with an undetectable viral load in the past 6 months (aOR=2.1, 95% CI: 1.3–3.3) were more likely to engage in oral sex without a condom. (Table 3)
Characteristics Unadjusted OR
(95% CI)P value Adjusted OR
(95% CI)P value Gender identity Cisgender male Ref Transgender women 0.7 (0.4–1.1) 0.107 0.8 (0.5–1.3) 0.371 Age (year) ≤25 Ref 26–44 1.2 (0.9–1.7) 0.270 ≥45 1.6 (0.6–4.4) 0.353 Education High school or below Ref Bachelor or college 0.8 (0.6–1.3) 0.407 Master or doctor 1.4 (0.7–2.7) 0.326 Marital status Unmarried Ref Married 0.8 (0.5–1.3) 0.311 Other 1.3 (0.6–2.9) 0.508 Have a regular partner Yes 0.7 (0.5–0.9) 0.040 1.1 (0.8–1.7) 0.541 No Ref Find sexual partner through social apps Yes 2.4 (1.8–3.3) <0.001 2.5 (1.7–3.7) <0.001 No Ref Time since HIV diagnosis <12 months Ref 13–35 months 1.0 (0.7–1.6) 0.970 ≥36 months 1.4 (0.9–2.1) 0.132 Viral load of HIV in the last year Detectable Ref Undetectable 2.4 (1.6–3.6) <0.001 2.1 (1.3–3.3) 0.001 Not sure 1.8 (1.1–3.0) 0.029 1.3 (0.7–2.3) 0.384 Taking HIV medications Yes Ref No 0.5 (0.3–1.0) 0.067 0.5 (0.3–1.1) 0.072 Recreational drug use before or during sexual activities Yes Ref No 0.8 (0.6–1.2) 0.294 Alcohol use before or during sexual activities Yes 2.2 (1.6–3.0) <0.001 1.7 (1.2–2.4) 0.001 No Ref Circumcised Yes 0.4 (0.3–0.6) <0.001 0.6 (0.4–0.8) 0.002 No Ref Abbreviations: OR=odds ratio; CI=confidence interval; Ref=reference; HIV=human immunodeficiency virus; MSM=men who have sex with men. Table 3. Factors associated with unprotected oral sex among HIV-infected MSM in China.
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The study found a high proportion of HIV-infected MSM engaged in oral sex without a condom. Since the risk of HIV transmission through oral sex is much lower than that during anal sex, people might mistakenly believe that unprotected oral sex is not a risky sexual behavior. Our findings showed that among the 85 participants with detectable viral loads who had ever received oral sex without a condom, 40.00% had ever ejaculated in the partner’s mouth. Being exposed to semen and having sores in the mouth or on the genital may increase a person’s chance of getting HIV or other STIs during oral sex, even when the infected partner has an undetectable viral load (7). The results of this study indicated that it was possible for HIV-infected MSM to transmit HIV to their sexual partners, who were also at the risk of STIs and infection of HIV of a different genotype. Therefore, condom use is necessary in oral sex among HIV-infected individuals, especially when they receive oral sex and ejaculate in their partner’s mouth.
The findings suggested that HIV-infected MSM who found sexual partners through social apps were more likely to engage in oral sex without a condom. A previous study showed that HIV-positive MSM were more likely to engage in high-risk sexual behaviors in the context of casual sex encounters than in steady sexual relationships (8). A possible explanation is that casual partners who meet through social apps, will not be informed of the HIV status of participants during oral sex, so they are more likely to engage in oral sex without a condom due to their negligence of the risk of this sexual practice. This study supported the integration of social apps commonly used by MSM into sexual health education. In addition, the results of this study also showed that alcohol drinking before or during sexual activity was significantly related to the use of condoms in oral sex of HIV-infected MSM. People under the influence of alcohol may become disinhibited and are more likely to engage in risky sexual behaviors (9). This study emphasized the need to implement alcohol risk reduction programs in HIV-infected MSM.
A previous study showed that 85% of HIV-infected MSM reported having oral sex without a condom, which was similar to the finding of this study (5). A qualitative study among HIV-infected MSM showed that in the absence of information about whether oral sex posed a significant risk of HIV transmission, HIV-infected MSM would give up condom use during oral sex but were usually accompanied by anxiety (10).
The study was subject to at least four limitations. First, the convenience sampling might produce selection bias and might not represent the entire HIV-infected MSM in China. Second, the partner’s serostatus was not mentioned in the questionnaire. Third, the cross-sectional data in this study may be subject to potential recall bias and could not establish a causal relationship. Fourth, information on STIs history was not collected, so the connection between oral sex and STIs was unable to be evaluated.
HIV-infected MSM should be informed of the potential risk of unprotected oral sex. Targeted educational strategies and interventions are needed for HIV-infected MSM to minimize the risk of unprotected oral sex. The public health sectors in China should recommend condom use during oral sex among HIV-infected MSM, especially when in-mouth ejaculation is involved.
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No conflicts of Interest declared.
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