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Still Sleepless in Brazil - Worrying sick
Jun 7, 2004

Dear Doctor Bob,

It is me again begging you to post this. Will you????

First of all, it is a blessing to share the world with people like you, who in face of great adversity can maintain your sanity, serenity and transform the lives of thousands, if not millions, of people you touch with your organization and with this site.

As a matter of fact, this site has been one of a very few sources of internet information that seriously deals with HIV/AIDS in a rational and humane manner. It is amazing and perplexing the quantity of AIDS scare sites that provide the "worst case scenario" for any questions posed by viewers. It is shocking to me to realize everyday that many people, organizations, and government official sites that disseminate terror among confirmed HIV patients and the desperate poor souls that think (or have) they have placed themselves in a risky situation.

My indignation isn't against having a really serious and frank dialogue regarding HIV/AIDS; I believe this is necessary not to mask the problematic of this epidemic. HIV/AIDS is real and all societies and peoples must properly address and prevent the spread of this terrible disease, but scare tactics imprinting fear and despair may backfire and cause people to put themselves in risky situations because they may stop caring.

I often read your postings and really thank God for having the support of someone like you. It is like needing to have Doc Bob say that my situation, whatever it may be, is not the end and there is a chance that I may not be infected. I guess that the important thing with you Doc, is not to get back an answer that is good to me, but one that is grounded on scientific knowledge, but which is not the "oh shit you fucked up so go get tested because you most likely have AIDS". This is the usual speech at most places that I and other people turned to for information! It is like these people have vested in them, since they work with AIDS, the necessity to alarm society beyond what is necessary for prevention. It is like, "if we scare the shit out every single one, people will start to protect themselves and we may reduce the infection rate around the world". This is not very productive in my point of view!

Well, getting to my situation. I live in Brazil in the city of Belo Horizonte and about one-month ago I had protected sex with a call-girl. Very cute, very nice, and very sexy, but nevertheless a sex pro from an internet site. Up to this point I am pretty clear, after all as you always say, "protected sex is indeed protected".

However, I did perform unprotected oral sex on the girl. I know from your posting and most sites, even the scary ones, that oral transmission from cunnilingus if a very very rare event, if indeed an event. That the mouth is not the best environment for HIV infection given the fact that saliva offers some good protection, albeit not 100%, against the virus. That vaginal fluids present lower quantities of HIV than blood or semen. That even, an often claimed higher risk oral exposure, one that involves ejaculation in the mouth of a HIV- person by a known HIV+ person the risk of contamination is a small fraction of the already low probability (0.01% to 0.3%)of infection in a single unprotected episode of receptive anal sex between a negative bottom and a positive top.

Doc, I hold a PhD in economics, so you can take that I took more than my fair amount of stats in college. I know that the probability is dismally small, but I still find myself freaking out! I know that this fear is irrational, and irrationality is not a word that comes easily in an economist's vocabulary, but I am acting very irrationally with this fear. I have talked to many doctors and even visited a few, and they all say my fear is unwarranted and no one even suggested a TEST, saying that my exposure did not consist in a high risk one.

But yet, I am in panic! Is this fear of HIV normal? You earned my respect for your compassion and reason, and I need to hear your views on my case.

1) Do you think this oral sex episode offers a real danger of HIV transmission? Am I at any real danger?

In similar questionings by other participants of the site you said that you thought that testing was not even warranted for this type of exposure (oral sex with a woman of unknown serological status). Your opinion regarding testing unnecessary because this level of exposure is shared by your site mate Dr. Krall.

2) Another question I have is regarding the window period. I know this is extremely controversial and information is diffuse. But, since most serumconversions occur within 22-28 days after exposure, why wouldn't a 30 day (one month) test be reliable? Would a 4 week negative test be a good indication for prognosis?

You say that a qualitative PCR test is not good for diagnosing HIV. You say that because the false-positive rate or because it fails to diagnose HIV infections (false negatives)?

You never mentioned anything about false-negative rates in PCR tests, only false-positives. In my mind I could live with a negative result out of a test that spews out a higher rate of false positives than a negative result from a test that spews out a high rate of false negatives. Do I make sense??

Doctor Bob, please answer my question!!

I wish you all the best and that your strength be enhanced and that you keep on ding this beautiful and extremely meaningful job that you are doing for many years.

My sincere respect for you!

A very worried Brazilian guy.

Response from Dr. Frascino

Hello Brazilian Guy,

"Belo Horizonte?" What's that? Having fun in a horizontal position perhaps?

Thank you for writing in. Yes, I do try to provide information that is well grounded in science. The "oh shit you fucked up . . ." type philosophy isn't very helpful, because most everyone knows that already or they wouldn't be asking a question or searching the Internet in the first place. The ". . . . you most likely have AIDS" advice is equally foolish and profoundly unscientific.

Regarding statistics, I need to correct one on your post. The risk for HIV transmission per episode of receptive penile-anal sex with an HIV-positive partner is estimated to be 0.1% to 3%, not 0.01% to 0.3%.

OK, on to your specific questions:

1. Your understanding of the potential risk associated with oral sex is indeed rational and scientific the risk is extremely low. Yet you state you are "in a panic" and ask if your fear of HIV normal? Well, according to your own understanding, your degree of fear, based on the scientific estimates, would be irrational, right? So you've answered your own question. Irrational fear of HIV is common, but since it's irrational, it's not normal. Do I think you are in any real danger? Statistically and rationally speaking, I have to say your HIV risk is incredibly small. Whether to get HIV tested is a personal decision. The best I can offer is to advise you of the degree of risk. Even with extremely minimal risk, sometimes testing can be the most efficient way to put irrational fears to rest and may be very helpful, and therefore warranted, in this regard.

2. Yes, the vast majority of HIV-positive individuals will have detectable antibodies to HIV, and consequently, a positive HIV ELISA test, within one month; however, the "vast majority," although very good, isn't "good enough" for the accuracy required to make this a recommendation for reliable HIV screening. Yes, the problem with PCR testing is primarily false-positive results. Because of this, I do not recommend it for HIV screening. As for a "good prognosis" -- a negative 30-day ELISA plus an additional negative viral load test (even one with minimal false-negative results) is encouraging, but there is not enough scientific data to say the results are definitive, due to limitations of the various tests and the variability of the immune response. I should also mention there are differences in PCRs (RNA vs. DNA), as well as in branched-chain DNA techniques. All of this makes the interpretation of HIV tests within the window period complex and not exactly straightforward.

Bottom line your risk is extremely minimal. If you want to take a definitive HIV test to put your irrational fears to rest, I'd recommend a single ELISA test at three months.

Stay well.

Dr. Bob



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