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HIV can be transmitted via exposure to contaminated body fluids, such as blood,23,24 semen,23,25 or breast milk.26-29 Potential routes of transmission include blood transfusions,30 intravenous drug use,24,31 and unprotected sexual intercourse32; HIV-infected females can transmit the virus to their children in utero,33,34 during delivery,34 or via breastfeeding.35

Anal sex is associated with a much higher risk of HIV transmission than vaginal sex. One factor that may contribute to this is that the rectum contains a thin membrane (the lamina propria) that harbors an abundance of HIV target cells—and only one layer of tissue separates these target cells from the rectal lumen.36,37

Although oral sex generally presents a relatively low risk of HIV transmission,38 the risk of transmitting HIV increases if the mouth or genitals contain cuts or open sores (eg, recent dental work) that could provide an entryway for the virus.39 Similarly, the risk of transmission during anal or vaginal sex increases in the presence of sexually transmitted diseases, such as herpes or syphilis, that produce ulcers or sores that compromise mucosal integrity, leaving the individual more susceptible to infection.40,41 Additional risk factors include sexually transmitted infections such as gonorrhea or chlamydia, which produce genital inflammation that can weaken mucosal barriers that would normally help shield the body from infection. Gonorrhea also interferes with CD4 cell activation and proliferation, potentially increasing the opportunity for infection.42

Uncircumcised men are at higher risk of contracting HIV than those who are circumcised. This may be because the foreskin possesses numerous Langerhans cells, which contain a protein called Langerin. Langerin helps protect the body from HIV infection by quickly degrading the virus. However, if a viral onslaught occurs and the cells run out of available Langerin, these cells become viral transporters for infection and deliver the virus to lymph nodes. Thus, removing the foreskin diminishes the opportunity for the Langerhans cells to promote viral infection as transporters.43,44