This ASHM document is designed for clinicians and other healthcare workers to support the health and wellbeing of their patients who are having casual sex during the COVID-19 pandemic. 

Despite social distancing remaining in place, some individuals continue to engage in casual sex. ASHM recently reported that although both attendance and positivity rates of some sexually transmitted infections (STIs) have fallen in Sexual Health Clinics around Australia, people continue to present with STIs. As social distancing restrictions ease it is likely that an increase in casual sex will occur. In line with its approach to other areas of health, ASHM believes it is crucial during the COVID-19 pandemic to support clinicians and other healthcare workers to promote harm reduction strategies. It is also crucial to engage communities in health seeking behaviours, in ways that recognise the needs and experience of those communities. Information for the community about how to adopt a harm reduction approach to casual sex during the COVID-19 pandemic has been provided by community based organisations such as Thorne Harbour Health (1), ACON (2),  Scarlet Alliance, the Australian Sex Workers Association (3),  the New Zealand AIDS Foundation (4), as well as the NSW Ministry of Health (5) and the New York Department of Health (6).

Casual sex plays a very important social function for many individuals and communities. Healthcare providers should be aware that being disconnected from social and sexual networks may have an impact upon individuals’ physical and mental health and wellbeing. For example, for some men who have sex with men (MSM), sexual networks may be their only connection to other MSM; for sex workers, social distancing restrictions may directly impact upon their connections to peer networks and source of income. 
 

SARS-CoV-2 (which leads to COVID-19 disease) is a highly infectious respiratory virus and can be transmitted through close contact with a person who has the virus (7). Transmission can also occur as a result of contact with surfaces, or objects where infectious droplets from coughing, sneezing, speaking or breathing have landed (7). 

People can protect themselves and others from the virus by practicing good hand hygiene, refraining from touching their face, covering their nose and mouth when coughing and sneezing with a tissue or a flexed elbow, practising physical distancing which includes not having sex with casual partners, or with regular partners if their partner has COVID-19, or has COVID-19 symptoms, staying at home if they are unwell, by following jurisdictional guidelines on limitations on private and public gatherings, accessing COVID-19 testing if they have symptoms of COVID-19 and isolating themselves if they are required to do so.
 

SARS-CoV-2 has been detected in saliva (8), faeces (9, 10), and in semen in some (11), but not all (12, 13),  studies. A small study detected no SARS-CoV-2 in vaginal fluids (14), however angiotensin-converting enzyme2 (ACE 2), which is the receptor used by SARS-CoV-2 to enter host cells, is expressed in the vagina, uterus and ovaries (15). Currently there is no evidence that transmission of SARS-CoV-2 occurs via the faecal-oral route or via exposure to semen, or vaginal secretions. 

There are no data currently available on whether different types of sexual practices have different levels of risk for transmission of SARS-CoV-2.

When discussing sex and sexual health with an individual, it is important to be non-judgemental and take a thorough sexual history. The Australian STI Management Guidelines for use in Primary Care recommend using normalising language and using a hook to engage individuals in a conversation about their sexual health. Guidance on how to take a sexual history can be found here. 

During the COVID-19 pandemic, clinicians should continue to take sexual histories from patients and should be aware that patients may be reluctant to disclose that they have been having casual sex while social distancing restrictions are in place and may be afraid of being prosecuted or discriminated. 

Telehealth and other remote consultations may offer both barriers and benefits to taking a sexual history from patients. In line with the results of ASHM’s provider survey on telehealth, patients engaging in a consultation from their own homes may be more comfortable to discuss their health. However, it may also be more difficult to establish the patient rapport required for sensitive topics such as sexual health via a telehealth consultation.

In addition, clinicians should recognise that individuals may experience stigma in both healthcare settings and in the broader community as a result of having casual sex during the pandemic. It is also important to be aware of the additional stigma attached to key populations such as gay, bisexual and other MSM, people living with HIV, hepatitis B, and hepatitis C, sex workers and people who inject drugs.

Clinicians should educate all patients about how SARS-CoV-2 is transmitted and that the close contact that occurs during sex is a key risk factor for infection with this virus. 

There are a number of measures that clinicians can recommend to patients who are having casual sex that may help reduce their risk of COVID-19 transmission (1, 3, 6).    

• Refrain from having sex if the patient, or their partner is unwell, especially if they have they symptoms of COVID-19, which include a sore throat, cough, fever, shortness of breath, runny/blocked nose, headache, loss of smell/taste, diarrhoea, muscle aches or joint pains
• Wash or shower with soap and water before/after sex 
• Have an encounter that does not involve touching 
• For sex workers, adopting workplace harm reduction strategies and seeking peer education
• Avoiding positions which involve face to face contact 
• Avoid kissing, saliva exchange, close face-to-face contact, face touching 
• Avoid sharing personal objects that may have saliva or other bodily fluids on them
• Thoroughly clean frequently touched objects, sex toys, sheets, other surfaces 
• Have sex that reduces the amount of contact with bodily secretions and faecal material bodily secretions, e.g.  use condoms and dental dams to reduce contact with saliva, semen, vaginal secretions and faeces
• Have online encounters using webcams, apps, sexting
• Have short encounters that observe the guidelines for close contact
• Discuss the COVIDSafe App which is designed to facilitate contact tracing in the case of a positive COVID-19 test result
• Discuss the merits of ensuring that each partner has the other’s contact details and understands they should be notified in the case of a positive COVID-19 test result, either directly or via an anonymous service such as web-based SMS
• As feasible, limit the number of sexual partners
• As feasible, avoid group sex
• As feasible, limit sex to people with whom the individual is living 
• As feasible, limit sex to small, trusted networks

Clinicians should encourage their patients to remain on HIV pre-exposure prophylaxis (PrEP) or commence PrEP if they are planning to have casual sex with HIV acquisition risk during the COVID-19 pandemic. Patients who prefer to use condoms for HIV prevention should be encouraged to use condoms consistently if they are having casual sex with HIV and STI acquisition risk during the pandemic.  PEP should be offered to patients who have had a possible exposure to HIV and who present within 72 hours of that exposure. 

Clinicians in Australia are reporting that they are diagnosing recently acquired HIV infection in patients who had stopped PrEP during the early stages of the pandemic when social distancing requirements commenced. The ASHM PrEP Clinical Guidelines can be found here. 

Clinicians should encourage people to use safe injecting practices, including during times when they are having casual sex.

It is important during the COVID-19 pandemic for healthcare workers to continue to encourage all sexually active individuals, and particularly those who identify as key populations, to engage in regular HIV and STI screening as per regular screening guidelines (15, 16). 

The Australian STI Management Guidelines for use in Primary Care provide guidance on STI screening. 

If an individual is identified as requiring STI screening during a Telehealth consultation they will need to attend the practice, or clinic for appropriate clinical follow-up and STI testing.

1. Thorne Harbour Health: Sex and COVID-19 https://thorneharbour.org/covid19/sexcovid19/ adapted from information written by PrEPster (PrEPster.info)
2. ACON: https://www.acon.org.au/what-we-are-here-for/covid19/#sex-in-the-era-of-covid-19
3. Scarlet Alliance: https://redbook.scarletalliance.org.au/covid-19/ 
4. New Zealand AIDS Foundation:https://www.endinghiv.org.nz/articles/culture/playing-safe-post-lockdown/ 
5. NSW Ministry of Health: https://playsafe.health.nsw.gov.au/2020/06/01/everything-you-need-to-know-about-sex-and-covid-19/ 
6. New York City Health Department: Sex and COVID-19 Fact Sheet https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-sex-guidance.pdf?utm_source=morning_brew
7. WHO Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
8. To KK, Tsang OT, Leung WS, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. 2020. Lancet Infect Dis. 2020;20(5):565‐574. doi:10.1016/S1473-3099(20)30196-1
9. Chen Y, Chen L, Deng Q, et al. The presence of SARS-CoV-2 RNA in the feces of COVID-19 patients [published online ahead of print, 2020 Apr 3]. J Med Virol. 2020;10.1002/jmv.25825. doi:10.1002/jmv.25825
10. Xu, Y., Li, X., Zhu, B. et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nat Med 26, 502–505 (2020). https://doi.org/10.1038/s41591-020-0817-4
11. Li D, Jin M, Bao P, Zhao W, Zhang S. Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019. JAMA Netw Open. 2020;3(5):e208292. Published 2020 May 1. doi:10.1001/jamanetworkopen.2020.8292
12. Paoli D, Pallotti F, Colangelo S, et al. Study of SARS-CoV-2 in semen and urine samples of a volunteer with positive naso-pharyngeal swab [published online ahead of print, 2020 Apr 23]. J Endocrinol Invest. 2020;1‐4. doi:10.1007/s40618-020-01261-1
13. Song C, Wang Y, Li W, et al. Absence of 2019 Novel Coronavirus in Semen and Testes of COVID-19 Patients [published online ahead of print, 2020 Apr 16]. Biol Reprod. 2020;ioaa050. doi:10.1093/biolre/ioaa050
14. Yan Jing, Li Run-Qian, Wang Hao-Ran, Chen Hao-Ran, Liu Ya-Bin, Gao Yang, Chen Fei, Potential influence of COVID-19/ACE2 on the female reproductive system, Molecular Human Reproduction, , gaaa030, https://doi.org/10.1093/molehr/gaaa030
15. The Eight National HIV Strategy 2018-2022 https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-1/$File/HIV-Eight-Nat-Strategy-2018-22.pdf
16. The Australian STI Guidelines for use in Primary Care http://www.sti.guidelines.org.au/