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Thank you for visiting nature. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser or turn off compatibility mode in Internet Explorer. Matters Arising to this article was published on 22 September


Participants who completed HIV testing and oral sex questions at enrollment were selected. Oropharyngeal swab testing for Neisseria gonorrhoeae NG and Chlamydia trachomatis CT began in and for those with diagnostic at enrollment, the unadjusted association of oral sex practices with oropharyngeal STIs was conducted. Factors associated with increased odds of engaging in oral sex included living with HIV adjusted [a]OR: 1.

In the absence of screening and treatment guidelines, condoms continue to be the mainstay for oral STI prevention. A pre-exposure prophylaxis for bacterial STIs would complement current prevention strategies to curb transmission. This is an open access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The study investigators and ethical review committees have implemented additional measures to ensure participant anonymity is maintained in all reporting of research data. The IRB-approved protocol for this study allows the publication of aggregate data only and specifically prohibits the publication or distribution of individual-level data.

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Distribution of de-identified participant-level data and accompanying research resources will require compliance with all applicable regulatory and ethical processes, including establishment and approval of an appropriate data-sharing agreement. To request a minimal data set, please contact the Research Administrator: Ashley Shutt at ashutt ihv. Funding: U. The funders had no role in study de, data collection, analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist. Condomless oral sex allows transmission of STIs, such as gonorrhea, chlamydia, and human papillomavirus, through the oral mucosa. Other factors associated with oral sex practices globally included using a phone every day, internet use, low-risk perception of HIV, and recently being pregnant [ 17 — 21 ]. Additionally, having multiple sexual partners, anal sex, forced sex, and paid sex were also indicators of oral sex practices [ 1720 ].

However, many of these risk factors were derived primarily from large heterosexual studies [ 171821 ] with only a couple from MSM [ 1920 ].

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Whether these factors are consistent among MSM and TGW as compared to reproductive-aged adults is yet to be determined. We hypothesized that participants living with HIV had a higher prevalence of oral sex than those who were not and this association would be modified by sexual practices with women.

In addition, we evaluated whether oral sex practices were associated with oropharyngeal STIs among those with complete oropharyngeal laboratory testing for NG and CT. Age inclusion criteria differed between sites because of differences in institutional review board IRB recommendations. In Abuja, those aged 16—17 years were considered emancipated minors and exempt from parental consent.

At enrollment, participants completed structured survey instruments collecting information on demographics and sexual practices, underwent physical examinations, and provided biological specimens for laboratory diagnosis of HIV and anogenital STIs. Oropharyngeal swabs collected after October were tested for pharyngeal NG and CT using the same diagnostic assays.

The primary exposure variable was binary categorization of those living with or without HIV. The primary outcome was binary categorization of engaging in any oral sex practices. The primary covariates were derived from the literature or identified through directed acyclic graphs. These included mobile phone ownership, alcohol use, condom use during most recent anal sex act with a male partner, prior HIV testing, receptive and insertive anal sex, of male anal sexual partners in the past 12 months, of female vaginal sex partners in the past 12 months, and any transactional sex in the past 12 months where participants received money, drugs, food, shelter or transportation in exchange for anal or oral sex.

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Self-identified gender was categorized as man, woman, or non-binary. Alcohol use was binary categorized no or yes if participants reported at least one drink in the last 30 days.

To assess confounding, crude associations of the covariates with the exposure and outcome were conducted separately. Our final model assessed the odds of having oral sex among those living with HIV as compared to those who were at risk of HIV independent of other demographic and behavioral characteristics. Bivariate logistic regression was used to assess the crude association of oral sex and oropharyngeal STIs.

Of 1, participants who completed both enrollment visits between March to Augusta total of 1, individuals underwent HIV testing and completed questions on oral sex practices and other ificant covariates. HIV prevalence increased as of male sexual partners increased, however HIV prevalence decreased with two or more female partners Table 1.

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Additionally, those who self-identified as women, owned a mobile phone, had a prior HIV test, and engaged in transactional sex were more likely to report oral sex practices Table 2. After stratification by female partners, the association between HIV and oral sex practices did not ificantly differ 0—1 partners, OR: 1. No other variables were assessed for effect modification. Women identifying participants had higher odds of reporting oral sex as compared to participants who identified as men. Other independent predictors included owning a mobile phone, prior HIV testing, and engaging in receptive anal sex.

Those with more than 5 male partners reported higher odds of oral sex as compared to 4 or fewer. Those with more female partners reported a lower likelihood of oral sex with male partners. Alcohol use and condomless anal sex did not confound our main association and were not included in the final model. The prevalence of NG was 5.

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Of those who reported oral sex partners or condom practices with oral sex, 8. Overall, oral sex practices among MSM and TGW in Nigeria fall within the range of prior estimates but evaluating consistency is somewhat limited by the of studies, differences in the type of data captured, and mode of data collection in-person interviews versus apps and internet surveys [ 3132 ].

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Multiple sexual partners were independently associated with a 2-fold higher odds of oral sex, as has been ly described in the United States and China [ 63334 ]. Our data expands on prior work, as it demonstrates an increased odds of oral sex with increasing of male anal sexual partners, and decreased odds of oral sex with two or more female sexual partners independent of HIV status. Many of these prior studies did not assess oral sex practices independent of HIV infection, which may have confounded the association between oral sex and partner type.

Although, our data suggest gender of sexual partners may be related to the frequency of behavior. Prior studies found HIV testing behavior was ificantly associated with sexual practices, but anal sexual practices were pooled with oral under an all-inclusive category [ 38 — 40 ] or the studies only evaluated anal sex [ 4142 ]. In Cameroon, prior HIV testing was associated with having 4 or more oral or anal sexual partners in the past year as compared to 1 to 3 sexual partners, but this association was not stratified by sexual practice [ 40 ].

In another study, individuals who knew their HIV status and received counseling were more likely to adopt less risky sexual practices, but the authors did not define what sexual practices were less risky [ 42 ]. Our findings suggest other independent correlates of oral sex include gender identity and owning a mobile phone.

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Women-identifying participants also reported a higher odds of oral sex, consistent with a quantitative study in Thailand that suggested TGW were more likely than MSM to prefer receptive anal sex and engage in only oral sex [ 44 ]. Moreover, our study identified an association between mobile phone ownership and oral sex, a sexual practice that has not been differentiated from anal sexual practices in prior studies [ 45 — 47 ].

Many oropharyngeal bacterial STIs such as NG and CT are often asymptomatic [ 48 — 51 ] and estimates of their prevalence is limited by insufficient testing [ 52 — 54 ]. Our findings from Nigeria are comparable with studies from higher-income countries and suggest oral sex behaviors are associated with a 3-fold higher odds of oropharyngeal STIs.

Although, oropharyngeal STIs are relatively uncommon as compared to STIs at urogenital and anorectal sites [ 2357 ], it is important to increase STI screening and condom use at all sites to reduce the overall population burden.

This study has some limitations. The questionnaires surveyed participants about sexual behaviors in the past 12 months, making reporting susceptible to recall bias. Although, asking specifically about the of oral sex partners and condom use with oral sex gave structure to the participants in order to minimize reporting bias on oral sex practices. Moreover, testing for oral bacterial STIs was initiated later in the study, limiting our estimates for the entire cohort.

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However, in comparison to most studies our sample size for oropharyngeal STI testing is still considerably large with over participants with laboratory diagnoses rather than self-report. Additionally, we were limited in temporality because of the cross-sectional de, but utilized behavioral questions with time components to attempt to capture sexual behavior over a year-long period. This cohort draws from two large cities in Nigeria and therefore may not be generalizable to other areas or on a national scale. Lastly, we were unable to differentiate insertive and receptive oral sex.

However, our findings established the frequency of this behavior that will support future work investigating specific oral sex positions. Without clear guidelines on screening and treatment of oropharyngeal STIs, our data reinforce the importance of condom messaging for oral sex together with other sexual practices. Future work could evaluate biomedical pre-exposure prophylaxis for bacterial STIs to complement current prevention strategies. Disclaimer: The content is solely the responsibility of the authors and should not be construed to represent the positions of the National Institutes of Health, the U.

The investigators have adhered to the policies for protection of human subjects as prescribed in AR Browse Subject Areas?

Click through the PLOS taxonomy to find articles in your field. Exposure, outcome and covariates The primary exposure variable was binary categorization of those living with or without HIV. Download: PPT. Table 1.

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Table 2. Evaluation of effect modification After stratification by female partners, the association between HIV and oral sex practices did not ificantly differ 0—1 partners, OR: 1. Table 3. Supporting information.

S1 Questionnaire. S2 Questionnaire. References 1. National Sample of College Students. Arch Sex Behav. Case-control study of risk factors for incident syphilis infection among men who have sex with men in Tokyo, Japan. Correlates of condomless anal sex among men who have sex with men MSM in Tijuana, Mexico: The role of public sex venues.

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