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Should I be more concerned because I'm uncircumcised?
Dec 22, 2007

Dear Dr.,

Today I had a single act of unprotected anal intercourse as the insertive partner. Knowing this was a huge mistake (the first time I have ever "slipped up" like this), I immediately researched the likelihood of HIV infection, and I'm also considering PEP treatment. I've come across the statistic of 6.5 out of 10,000, both on your forum and other websites. I am uncircumcised, and it appears the current consensus is that uncircumcised tops are at greater risk. I suppose I have two questions: first, do you agree with the conclusion that circumcision affects HIV transmission? Second, if so, would you change the 6.5 / 10,000 number significantly upward for uncircumcised tops?

My "slip up" happened a few hours ago, so I'm still within the PEP window. Any thoughts are greatly appeciated!!

Thanks for offering this great service.

Response from Dr. Frascino

Hi,

So you "slipped up" by "slipping in" without your protective "slip-on"???

To answer your specific questions:

1. Yes, cut versus uncut does affect HIV-transmission risk. Being uncut increases HIV transmission risk.

2. No, I would not change the estimated-risk statistic you quoted, as those numbers are only estimates and were based on large population studies that included both cut and uncut guys. I should also point out these statistical estimates cannot be applied to an individual case, as there are many potentially confounding variables involving the virus (viral strain, viral load, etc.) and the host (cut/uncut, immune integrity, trauma, etc.). See below.

3. To PEP or not to PEP, that is indeed the question! Unfortunately it's difficult for me to advise you over the Internet with such incomplete information. A local HIV specialist would be best suited to evaluate your risk and need for PEP. He would assess your general health and obtain more details about your "slip-up," including information about the likelihood of your partner being HIV infected, etc. However, since it is now the weekend and a major holiday is fast approaching, it may be difficult for you to see an HIV specialist quickly. Consequently you could go to an urgent care facility or emergency room and get started on a generic PEP regimen and then make an appointment with an HIV specialist next week. If the specialist feels PEP was not warranted, he could stop it at that time. If he feels it is warranted, he may want to change or optimize your PEP regimen. In addition he would evaluate and treat any PEP-related side effects or toxicities and arrange for and interpret all post-PEP HIV tests.

Hope that helps. Good luck.

Dr. Bob

HIV STATISTICS Sep 13, 2007

Doc,

Ive written to you many times over the past 3 years and youve answered several of my questions. Thank you! What I really need to know now is how accurate are your statistics about oral and anal sex. Is it really 1 per 10,000 for oral and 50 per 10,000 for anal? Im trying to explain to my negative partner exactly what our specific risk is. Neither one of us are math whiz-kids but this seems reasonably straight forward. He could expect to become infected once for every 10,000 blowjobs. Right?

Thanks Dr. Bob

Response from Dr. Frascino

Hello,

"He could expect to become infected once for every 10,000 blowjobs. Right?"??? Well actually no, that would be a wrong conclusion to draw from those statistics!!! I've covered this topic numerous times in the past, but I know HIV statistics can be a confusing topic. So even though this questions has now become a QTND (question that never dies) with an ATNC (Answer that never changes), I'll try to explain the limitations of these statistics once again.

The statistics I quoted are "estimated per-act risk statistics for acquisition of HIV by various exposure routes" published in a CDC document. These statistics were generated by combining a variety of published reports and did not control for many different potential variables that occur in different populations and among individuals. In other words, these statistics are primarily useful in determining relative risk, but not specific risk or actual risk for any individual. The reason for this is that any specific sexual coupling has a wide variety of variables to take into consideration when attempting to quantify specific HIV-transmission risk. These would include both viral factors, such as viral strain and viral load, as well as host factors, such as immune integrity, concurrent illnesses, circumcised/uncircumcised, genetic susceptibility, etc. Add to this nonspecific factors/extenuating circumstances, such as roughness of the encounter possibly causing trauma to mucous membranes, menstruation, etc., and perhaps you will begin to see the difficulty in providing transmission-risk statistics for any specific coupling. Also I should point out we cannot conduct prospective controlled epidemiological studies to try to account for theses variables, as that would be unethical. There are some published reports that address risk associated with specific sexual practices that control for some variables, but these studies usually have relatively small sample sizes and again are not applicable to everyone's specific situation. Another reference that I quote frequently is http://hivinsite.ucsf.edu/InSite?page=kb-07-02-02 (SAFER SEX METHODS). If you review the specific epidemiologic studies in this well referenced report, you'll get a better understanding of the complexity involved in these issues.

So why do I quote the statistics that I do? Good question! The main reason is that I am constantly barraged by anxious wrecks desperately trying to quantify their risk. I use the CDC statistics, because CDC is a very conservative organization and the numbers they generated are an amalgamation of many studies. They also standardized the relative risk to a common denominator ("10,000 exposures to an infected source"), which allows us to discuss relative risk. For instance, unprotected receptive anal sex is approximately 10 times more risky than unprotected insertive penile-vaginal sex, which in turn is approximately 10 times more risky than unprotected insertive oral sex.

I hope that this will help clarify the limitations of these estimated HIV-transmission risk statistics.

The bottom line is really much more concrete and easy to comprehend. If someone has placed himself or herself at risk for HIV, he or she should be HIV tested. Period. End of story.

I can just about hear all the paranoid panicky worried wells beginning to type away furiously, providing me with a blow-by-blow of their latest blow-by-blow and begging for me to quantify their specific risk. But unfortunately, unless the other person they were having sex with was me, I will not have enough specific detail to give them an accurate response. Hell, even if it were me, I still might not be able to give a completely accurate risk quantification!

Dr. Bob



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