QUESTION
My boyfriend is an HIV+ top, and I am a HIV- negative bottom. He's been asking to have unprotected anal sex and ejaculate inside me. I am wondering what is the risk of getting HIV when the ejaculate is in your ass? Is it a lot higher than withdrawing before ejaculation?

ANSWER
The situation you describe:
- HIV+ top/ HIV- bottom
- anal sex without a condom
- ejaculation in the ass
is one of the highest risk sexual activities for transmitting HIV.

We cannot say that it is safe if the top pulls out before ejaculating, but it is safer. Pre-cum does contain small amounts of the virus and transmission can occur without full ejaculation.

If your partner is on HIV meds and has a very low viral load in his blood, this may decrease the risk to you. If either one of you has an STD such a gonorrhea, chlamydia, syphilis or herpes, your risk of transmission will be significantly increased.

The more important issue is to talk frankly with your partner about what you both want and what you feel comfortable doing. If your goal as a couple is to make sure that you stay HIV- while still enjoying a satisfying sex life, then that is completely achievable!

Moving along the continuum of sexual safety towards safer sex is different for each couple. For you, it could mean using a condom for anal sex; you being the top more often and not the bottom; having more oral sex; or having non-penetrative sex by using mutual masturbation, erotic massage, videos, or sex toys.

If you are non-monogamous, it is also important that both you and your partner get tested for STDs every 3-6 months. Prompt diagnosis and treatment of other STDs will decrease the chances of transmitting or acquiring HIV.

To your health,
Dr. K