Condomless anal intercourse is recognized as the primary transmission route for most human immunodeficiency virus (HIV) epidemics. However, considering the recent advancements in a range of biomedical strategies, voluntary medical circumcision, and the improved knowledge of behavioral preventative methods, using all forms of condomless anal intercourse indiscriminately does not expose the true complexity of sexual risk. Recognizing the potential of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), antiretroviral therapy (ART), and Undetectable equals Untransmittable (U=U), increasing the accessibility and acceptance of these options have shown to be critical for HIV/acquired immune deficiency syndrome (AIDS) prevention. Despite proven HIV/AIDS protection, these recent advances may be accompanied by sexual behavioral changes that lead to increases in other sexually transmitted infections (STIs), specifically Neisseria gonorrhea/Chlamydia trachomatis (NG/CT), and syphilis. Regardless of this possible trend, key communities at higher risk are not benefiting equally from condoms, PrEP, PEP, ART, or U=U. Collectively, sexual hygiene-based practices may have renewed importance in HIV/STI risk reduction. Yet, there is limited research evaluating the usability and clinical outcomes associated with sexual practices of lubrication, genital cleansing, postcoital urination, and rectal douching (enema use). Promoting these practices’ potential benefits, risks, and safest techniques nevertheless show promise to reduce STI risk and their sequelae. Although the safety and efficacy of some hygiene-based practices are relatively known, literature is lacking on how populations understand and use these practices and the potential interventions that could promote accurate information about them. This article primarily presents a narrative review of the prevalence, safety, and efficacy of common hygiene-based practices. We also briefly highlight the potential acceptability and feasibility of interventions in Peru that leverage mobile technologies. We conclude with future research directions within the context of PrEP, PEP, doxycycline as doxy-PEP, ART, U=U, and Peruvian communities where access to these methods may be limited. Please refer to Supplementary Materials for a full text Spanish version of this article.
Background
Biomedical HIV/AIDS prevention
Despite global and community efforts to curb HIV/AIDS and other sexually transmitted infections (STIs), transgender women (TW) and gay, bisexual, and other men who have sex with men (GBMSM) of color are experiencing ongoing, local inequities in HIV/STI epidemics [1]. Similar to many countries, HIV/STI acquisition in Peru is disproportionately concentrated among TW and GBMSM [2]. This unfortunate disparity may be due to multiple socio-behavioral factors, considering that Peruvian TW and GBMSM have reported a significant number of lifetime sexual partners, less condom usage with casual partners, a significant number of lifetime transactional sex, and early initiation of sexual contact during adolescence. Following the World Health Organization’s (WHO) recommendation of oral pre-exposure prophylaxis/post-exposure prophylaxis (PrEP/PEP) and antiretroviral therapy (ART), these strategies have been shown to prevent HIV acquisition and reduce mortality among people living with HIV/AIDS, respectively [3, 4, 5, 6, 7]. In 2016, the empowering campaign U=U was introduced to help curb the HIV/AIDS epidemic and HIV-related social stigma with a message to encourage consistent ART treatment, reach viral suppression, maintain undetectable HIV viral load, and therefore making HIV untransmittable among people living with HIV/AIDS [8]. Additionally, doxy-PEP (an antibiotic used for bacterial infections) has been considered an STI-preventative strategy by the Centers for Disease and Prevention and has proven to significantly reduce the acquisition of Neisseria gonorrhea/Chlamydia trachomatis (NG/CT) and syphilis after condomless oral, vaginal, or rectal sex [9, 10]. For those who have access and are adherent to PrEP, PEP, doxy-PEP, ART, or U=U, these methods may encourage a new way of thinking about HIV/STI-preventative health and one’s range of non-condom-based risk reduction techniques. As communities adopt proven strategies for HIV/AIDS prevention, some individuals may increase their number of sexual partners or be less motivated to use condoms, which may contribute to an increased incidence of NG/CT, syphilis, and other STIs [11, 12, 13]. Although early clinical trials have not reported increased sexual risk or STI incidence, a meta-analysis of 17 studies found an increase in condomless anal sex and bacterial STIs among GBMSM following PrEP use [3, 14, 15, 16]. However, what can appear to be higher rates of STI incidence may be due to many factors, considering that individuals who seek PrEP-related services tend to report an increased number of sexual partners at baseline, less condom usage at baseline, and increased frequency of STI testing offered during these services [17, 18].
Current barriers, future trends
Access and consistent uptake of effective HIV/STI services and treatment remain a devastating issue among TW and GBMSM of color due to many members of these communities frequently facing neglect, stigmatization, discrimination, victimization, criminalization, and many other sociopolitical disparities that also result in insecurities in personal well-being, health care, income, housing, education, and nutrition [19]. Sexual practices of lubrication, genital cleansing, postcoital urination, and douching may be of particular importance as people of higher-risk communities or lower-income households may rely more heavily on these behaviors for hygienic or preventative purposes—especially in areas of the world where acceptance, access, and consistent uptake of condoms, PrEP, PEP, doxy-PEP, ART, U=U, and other effective strategies may be limited [20]. The emergence of these advances and the ongoing disparities in their usability have contributed to diverse support for the enhanced understanding of routine behaviors that may alter one’s risk for HIV/STI [21]. In addition to HIV/AIDS-preventative care, focusing on innovative strategies that address the higher incidence of NG/CT and syphilis is needed due to the recent inattention to STI-preventative health and the serious public health issue of concurrent HIV acquisition in association with NG/CT and syphilis [2, 22, 23, 24, 25].
Sexual hygiene-based practices are an underappreciated area of research [26]. Although coital practices of lubrication, genital cleansing, postcoital urination, and douching are prevalent among general and key populations, research evaluating the association of these behaviors in the context of HIV/STI risk is sparse [27, 28, 29]. Therefore, a hygiene-based message prioritizing key communities may be pivotal for the development of impactful sexual health campaigns that mitigate the morbidity and mortality of HIV/STI acquisition [30].
Sexual hygiene-based practices and behavioral patterns in Peru
Lubrication
Research suggests HIV pathogens can cross the foreskin or the mucosal layer of the mouth (low estimated HIV risk but non-zero probability), urethra, vagina (estimated HIV risk of 0.08%), or rectum (estimated HIV risk of 1.4%) and subsequently enter the body through cell-to-cell translocation mechanisms or tears within the skin or mucosal layer that may occur during unprotected, rough, lengthy, or sex without an adequate amount of lubrication [31, 32, 33, 34, 35, 36]. A survey conducted among Peruvian GBMSM, TW, and heterosexuals showed that 50% reported at least an occasional use of commercial lubricant, with all participants using the product Love Lub—a lubricant commonly found at Peruvian pharmacies [37, 38]. Despite the prevalence and recommendations of water-based lubrication to decrease epithelial/mucosal trauma and condom breakage/slippage, some research suggests that certain characteristics in particular lubricants may alter HIV/STI risk, with risk varying based on the type, brand, chemical composition, and osmolality of the lubricant used [39, 40, 41, 42]. Substances not identified as sexual lubricants are also commonly used, such as saliva and oil-based household products, which may pose an additional factor of HIV/STI transmission as the use of saliva and oil-based products may host existing pathogens or harmful irritants to the mucosa/skin or condom integrity [43]. Despite the beneficial evidence of water-based lubrication, the mechanism by which all potential lubricants (whether commercial or non-commercial) may affect sexual well-being remains unclear [44]. Nevertheless, recommendations of using condoms with water-based lubricants and limiting lubricants with high osmolality and harmful chemical compounds appear to be standard practice and widely accepted by WHO to limit condom breakage and slippage [45]. To our awareness, no scientific study has explored the attitudes of preferred modalities for the development of an educational campaign to promote the usage of water-based lubricants with condoms.
Rectal douching
Douching is a common practice among bottoms (or partners performing receiving or receptive sex) to remove fecal remnants in the rectum before intercourse [46]. A study among Peruvian GBMSM found that 27% reported a history of douching, with prevalence as high as 53% previously reported in a survey among GBMSM in the United States [27, 47]. Given the commonality of douching, ongoing research is being conducted to explore the safety and efficacy of using enemas as a vector for HIV prevention, specifically as a tool for PrEP application [48]. However, despite its possible utility, douching with tap water, large volume enemas, improper techniques/supplies, and sharing supplies may be associated with increased trauma to the mucosal lining, alterations to the rectal microbiome, or introduction of HIV/STI pathogens into the body [49, 50, 51]. Additionally, colonic inflammation was noted with common solutions used for douching, including soap, laxative-based enemas, and household solutions [52, 53]. Considering the literature documenting mucosal irritation and trauma in the setting of douching, the best evidence-based recommendations are to limit the use of enemas, especially with tap water, large volume enemas, harmful solutions, improper techniques/supplies, and sharing of supplies. Despite the lack of sexual educational interventions about douching, these findings suggest that harm reduction strategies that promote public knowledge of potential harms while encouraging solutions, supplies, and techniques that minimize mucosal damage may be warranted. As we understand, there is no study that explored the knowledge and attitudes of potential benefits, harms, and safest techniques of douching.
Postcoital urination and cleansing
Postcoital practices may prove to be significant for HIV/STI prevention. Despite the documented use of postcoital urination and washing coming centuries ago, their importance for HIV/STI prevention was not immediately apparent [26]. Although previous literature has reported an increased incidence of HIV following penile washing, various global studies have found postcoital urination and genital washing to be effective in reducing STI acquisition among tops (or partners performing insertive or penetrative sex) [54, 55, 56, 57, 58, 59]. In addition, research has demonstrated that cultured strains of HIV and syphilis were highly susceptible to commercial soaps [60, 61]. Gonococcal transmission and postcoital practices were also explored in a previous U.S. Navy study [62]. To our awareness, this was the only study that statistically estimated the potential benefit of both postcoital urination and washing. Although the STI rates per 100 men were lower for those who either washed within an hour (46% risk reduction) or urinated within 30 minutes (24% risk reduction) after sex, this difference between users and non-users was not shown to be statistically significant (x2 = 1.0, P > 0.25), likely due to a small sample size. Nevertheless, these results show promise that with enhanced technique, usage of antibacterial soap and clean water, stricter intervals of urination and washing, and in conjunction with ensuring dryness after washing may significantly reduce infection rates of GC and other STIs [63]. Unfortunately, evidence-based guidance on these practices has been loosely described and not well-standardized. Additionally, alcohol-based cleansing agents (such as hand sanitizer and hand wipes) and other household cleansers may be used for sexual hygienic purposes, with unclear consequences in the context of HIV/STI risk. Further investigation is needed on the prevalence, safety, and efficacy of all genital cleansing practices, especially postcoital washing with commercial soaps and clean water. To the best of our knowledge, no study has explored the prevalence, acceptability, feasibility, and preferred techniques of postcoital urination and genital washing among TW and GBMSM.
Mobile and social media technologies
One novel approach to HIV/STI-preventative care is to focus efforts on sexual health interventions that leverage mobile and social media technologies [64, 65]. Although limited studies in Peru have investigated whether digital interventions are acceptable and feasible, technology-based strategies show favorability for delivering successful sexual health initiatives [66, 67]. In the TransPrEP study, there are also accounts of beneficial evidence of utilizing in-person workshops with social media technologies to promote a comprehensive approach to enhancing HIV knowledge and preventative behaviors among Peruvian TW [68]. Given that 82% of Peruvians now use the Internet via cell phones, the broad penetration of mobile technologies and the ongoing advancements in their application offer a potentially cost-effective opportunity to overcome some of the barriers present in traditional approaches to HIV/STI education [69]. However, some studies have acknowledged barriers to mobile technologies in Peru, including limitations with rural settings and potential literacy and understandability concerns [70, 71]. Nevertheless, prioritizing a hygiene-based intervention that leverages mobile strategies could be an impactful educational package in a world of expanding access to Internet-based technologies [72]. However, this specific area of research is still under-researched, and little is known about the preferred intervention modalities and learning methods of TW and GBMSM in Peru.
Discussion
Considering these findings and gaps, we prioritized the local community and conducted exploratory research on the knowledge, attitudes, and behaviors of hygiene-based practices, proven biomedical/barrier strategies, and preferred learning modalities among TW and GBMSM in Lima-Callao and surrounding districts. This ethnically diverse region on the western coast of Peru accounts for about 77% of all new HIV infections and is a location with one of the highest prevalence of new STI infections in the country [73, 74]. Considering the commonality of hygiene-based practices, usage of lubrication, genital cleansing, postcoital urination, or douching present as modifiable lifestyle behaviors that may have a considerable impact on sexual health and well-being. Understanding the perspectives and techniques of these behaviors while also exploring the type of lubricant, enema solution, soap, and other cleansing agents that may contribute to or lessen the risk of HIV/STI shows promise for the development of meaningful sexual health campaigns. The phrase ¡Lubricarte, Liberarte, Lavarte+! was coined to describe this scientific concept and the future campaign to promote it. This hygiene-based approach is fundamentally different from previous biomedical and barrier strategies. Still, it holds attractive HIV/STI-preventative potential that could add value and be highly complementary with condoms, PrEP, PEP, doxy-PEP, ART, U=U, and potentially among individuals in areas where these methods may be limited. Nevertheless, these hygiene-based practices are substandard and not intended to replace condoms, PrEP, PEP, doxy-PEP, ART, U=U, and other effective methods.
The research team recognizes the limitation of this review and future studies to only non-heterosexual communities of people assigned male at birth. This focus will likely decrease the external validity of our assumptions. However, we also clearly acknowledge how TW and GBMSM of color have been historically left behind in policy affairs and research interests, which has likely contributed to the disproportionate HIV/STI risk compared to general populations. To combat this disparity and lopsided societal attention, the L3+ team agreed upon prioritizing TW and GBMSM in low- and middle-income countries, specifically in Peru. Nevertheless, the research team hopes that some evidence presented in this review and future studies can be applied to understanding a variety of common behaviors that may impact sexual health and favorable approaches to sharing health-related information among all communities around the world.
Conclusion
Evolving changes in sexual health and HIV/STI prevention support the exploration of hygiene-based practices to inform the future development of educational interventions that promote the potential benefits, risks, and safest techniques of proven biomedical strategies, condom use, and other non-condom-based behaviors, such as lubrication, genital cleansing, postcoital urination, and douching.
Data accessibility statement
No new data was created or shared from this article, therefore, data sharing is not applicable.
Supplemental files
The supplemental files for this article can be found as follows:
Spanish version.docx
Acknowledgments
The authors acknowledge and sincerely thank all research consultants and members of the research team for their crucial contribution to the conceptualization and refinement of L3+.
Funding
This project was supported by the Office of AIDS Research, Sexual & Gender Minority Research Office, and Fogarty International Center of the National Institute of Health (NIH) under Award Number D43TW009343 and the UCGHI. This study also received support from the National Institute of Mental Health through the Center for HIV Identification, Prevention, and Treatment Services (P30MH058107), the UCLA Center for AIDS Research (P30AI028697), and the NIH National Center for Advancing Translational Science (NCATS) UCLA Clinical and Translational Science Institute (UL1TR001881). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or UCGHI.
Competing interests
None declared.
References
How to cite this article: Timmons-Vendryes R, Swendeman D, Cisneros Asca J, Cáceres C, Comulada WS, Bazargan-Hejazi S, Silva-Santisteban A. Sexual hygiene: Is it time for a renewed focus for HIV/STI prevention? Adv Glob Health. 2025;4(1). https://doi.org/10.1525/agh.2025.2453630
Editor-in-Chief: Craig R. Cohen, University of California San Francisco, CA, USA
Section: Improving Health and Well-Being