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% of MSM HIV transmission from protected anal sex magnetic couple
Jul 14, 2009

Hey Dr. Bob

Thanks for all your great work! I'm in a magnetic relationship, and I was just curious if there are statistics regarding routes of transmission? Particularly, everyone says that unprotected receptive anal sex is the riskiest, but what about protected receptive anal sex? Is there a quatifiable percentage of individuals who seroconvert where protected receptive anal sex is a the plausible route of transmission? I ask becuase I have been under the impression that consistent protected sex with condoms is safe. I have a friend who shook this belief when he told me that he thinks he got HIV from protected receptive anal sex with an HIV+ guy. Of course, maybe he had unprotected sex with someone who self identifies as HIV- and in fact didn't know, but it raised some obvious concerns for me because I'm in a magnetic relationship.

Thanks so much for any information you have regarding this topic (specifically I guess I'm curious if there is any data of guys who got HIV from protected receptive anal sex)

Patrick

Response from Dr. Frascino

Hey Patrick,

What you've read is correct: Unprotected receptive anal sex carries the highest per-act statistical risk for sexual HIV transmission. As for "protected" receptive anal sex, this is indeed considered "protected" if the latex condom is used properly and does not fail (break). HIV cannot permeate intact latex (or polyurethane). No way. No how.

There are unfortunately far too many folks who don't know how to use a condom properly. (See below.) In addition condoms, even properly used, can very rarely fail (break).

Consequently, rather than say condom-protected sex is "safe," we prefer to say it's "safer."

Dr. Bob

PEP Treatment HELP? (PROPER CONDOM USE, 2009) (PEP AND THE NEED FOR HIV SPECIALIST, 2009) Feb 20, 2009

Hi there,

I found your contact details online and your help would be very much appreciated as I am currently in a panic mode!

Here it goes:

1. I had anal sex (me top HIV neg) with a partner (bottom HIV pos with viral load 20k 26k copies) unfortunately the condom broke but I did not ejaculate.I am concerned that I might be exposed to infection and therefore I received PEP treatment from my local hospital on the 02.02.2009.

I had to travel to South Africa for 10days on the 03.02.2009 and I was due to go back to the hospital for tests and to receive my 2nd dosis of the PEP treatment (another 2weeks supply to make up a total of 4weeks/ 28 days) on the 12.02.2009. Unfortunately my flight had to be rescheduled and I only returned back to the UK on Wednesday the 18.02.2009. My medication ran out on Monday evening the 16.02.2009.

2. On Wednesday I had intercourse again with the same person and the condom broke again! Once again I did not ejaculate and penetration was only for a few seconds!

3. Thursday 19.02.2009. I returned to my local hospital to receive my further 2 weeks supply of PEP. By this time I missed 2 an half days worth / 60 hours of medication. I explained this to the doctor and there was explained to me that the PEP might not be effective. I am quite concerned about this...? 4. I did not tell the Doctor about the 2nd occasion on my return when the condom broke again. Now I would like to know if my PEP treatment needs to be increased or do I just continue with the normal dosage of 28days keeping in mind that I missed 60hours of treatment two weeks into the course and then their might be a second chance of infection at the time when my medication ran out.

I would appreciate if you could please get back to me ASAP with further thoughts on this.

Many thanks.

Response from Dr. Frascino

Hi,

First off, what's up with your condoms? Did you buy them during the Reagan era? Have you been storing them in the glove box of your car parked in sweltering heat? Are you using oil-based lubricant (incompatible with latex)? I think it's time you reviewed proper condom technique. (See below.)

Next, as I have mentioned previously in this forum, anyone who has had an HIV exposure significant enough to warrant PEP should be followed by an HIV specialist. I suggest you contact an HIV specialist. Tell him the whole story. And I do mean the whole truth and nothing but the truth! He will evaluate your current PEP regimen and possible need for an additional course.

I'll repost below some information about the role of HIV specialists for folks taking PEP.

Good luck.

Dr. Bob

Chihuahua guy again (PROPER CONDOM USE, 2008) Oct 16, 2008

Protected" sex is indeed protected, if the latex condom was used properly and did not break. HIV cannot permeate intact latex (or polyurethane). No way. No how. This is the answer that you gave me, but can you clarify this: 1. - What is the proper use of a condom? In my case I pull it off the envelop, I put it in my penis till the base of it, I didnt take it off right after I cum but my penis was still hard when I take it off (about a minute or so, after cum), then with my hands I kind of squeeze it a little bit to look for any leak, which wasnt any, then into the garbage bowl. Is this a proper use? 2. is there any risk of hiv acquisition for touching the exterior side of the condom and manipulated it whit my hands? 3. Am I paranoid?

Thank you so much doctor you are such a wonderful person

Response from Dr. Frascino

Hi,

1. The description of your use of the latex condom suggests proper usage. (See below.)

2. No.

3. Yes.

Dr. Bob

Another question and problem caused by Bush's abstinence policy (PROPER CONDOM USE) May 23, 2008

Basically, I'm 19, and we never had sex ed in high school. Specifically I never learned how to use a condom. I go off to college and I start dating this girl. Now the reason I am worried is that one of her ex's was found to be HIV positive. As such I was scared of having sex with her and still haven't. But I did have oral with her, but I made sure we used a condoms as in the archives it says if condoms are used correctly there is no chance of HIv transmission. Now this is what scares me, after she gave me oral I checked to see there were no breaks, and I didn't think there were because it appeared to be intact and there was no semen around me. But then I found a bit of I guess rubber on the tip of my penis. Could this be a sign the condom broke, as it did not appear broken, and furthermore if it broke wouldn't it just be a tear, like a bit of it just wouldn't fall off? Anyway this happened 4 weeks ago and I now have tonsillitis, a bit of eczema, a fever, and I feel dizzy. I am worried out of my mind and I am angry as I may get HIV due to not being taught how to use a condom properly. I think I did use it properly I just want reassurance on my risk and whether I did.

Thankyou so much in advance

Response from Dr. Frascino

Hi,

You never had sex education in high school and now you're in college and "worried out of (your) mind "that you may have contracted HIV "due to not being taught how to use a condom properly." Yours is another prime example of how Dubya's sex-phobic, anti-science policies have placed people at risk for unwanted pregnancies as well as STDs, including HIV. I can assure you President Obama and a strongly democratic House and Senate will help rectify this (as well as many other) disastrous policies. (I'm counting on you to rally your college buddies to vote for Obama and the democrats!!!)

Here's the scoop on condoms. HIV cannot permeate intact latex or polyurethane. No way. No how. However, condoms are not 100% effective, because they are often used improperly and also extremely rarely they can fail (break). When a condom breaks, it is usually very obvious. The thin piece of latex or polyurethane is stretched tightly over a throbbing tallywhacker. Consequently, when it tears, it rips dramatically and Mr. Happy's head usually comes poking out, similar to your head poking out of a turtleneck sweater. Regarding what you should have been taught in school about proper use of condoms, see below. You can also read much more about condoms in the archives and also in the chapter titled "HIV Prevention Basics" on this site.

Regarding your HIV risk, it remains exceedingly low. Oral sex, even unprotected, carries only a very low risk for HIV transmission.

"Symptoms" are notoriously unreliable in predicting who is or is not HIV infected. The reason to get tested or even to worry about HIV would be having placed yourself at risk for possible acquisition of the virus. I would not be concerned that your bout of tonsillitis, bit of eczema, fever or feeling dizzy might be HIV related. These are extremely common symptoms and certainly not HIV specific.

If after reviewing the information below, you feel you may have been exposed to HIV, a single simple rapid HIV test at the three-month mark will provide you with an accurate test result in as few as 20 minutes. From what you've told me, the results would undoubtedly be negative.

Good luck. Get informed. Stay safe. And remember to vote Democratic to prevent others having to endure what you are currently experiencing.

Dr. Bob

Condoms April 12, 2007

What Are Condoms?

A condom is a tube made of thin, flexible material. It is closed at one end. Condoms have been used for hundreds of years to prevent pregnancy by keeping a man's semen out of a woman's vagina. Condoms also help prevent diseases that are spread by semen or by contact with infected sores in the genital area, including HIV. Most condoms go over a man's penis. A new type of condom was designed to fit into a woman's vagina. This "female" condom can also be used to protect the rectum.

What Are They Made Of?

Condoms used to be made of natural skin (including lambskin) or of rubber. That's why they are called "rubbers." Most condoms today are latex or polyurethane. Lambskin condoms can prevent pregnancy. However, they have tiny holes (pores) that are large enough for HIV to get through. Lambskin condoms do not prevent the spread of HIV. Latex is the most common material for condoms. Viruses cannot get through it. Latex is inexpensive and available in many styles. It has two drawbacks: oils make it fall apart, and some people are allergic to it.

Polyurethane is an option for people who are allergic to latex. One brand of female condom and one brand of male condom are made of polyurethane.

How Are Condoms Used?

Condoms can protect you during contact between the penis, mouth, vagina, or rectum. Condoms won't protect you from HIV or other infections unless you use them correctly.

Store condoms away from too much heat, cold, or friction. Do not keep them in a wallet or a car glove compartment.

Check the expiration date. Don't use outdated condoms.

Don't open a condom package with your teeth. Be careful that your fingernails or jewelry don't tear the condom. Body jewelry in or around your penis or vagina might also tear a condom.

Use a new condom every time you have sex, or when the penis moves from the rectum to the vagina.

Check the condom during sex, especially if it feels strange, to make sure it is still in place and unbroken.

Do not use a male condom and a female condom at the same time.

Use only water-based lubricants with latex condoms, not oil-based. The oils in Crisco, butter, baby oil, Vaseline or cold cream will make latex fall apart.

Use unlubricated condoms for oral sex (most lubricants taste awful).

Do not throw condoms into a toilet. They can clog plumbing.

Using a Male Condom:

Put the condom on when your penis is erect -- but before it touches your partner's mouth, vagina, or rectum. Many couples use a condom too late, after some initial penetration. Direct genital contact can transmit some diseases. The liquid that comes out of the penis before orgasm can contain HIV.

If you want, put some water-based lubricant inside the tip of the condom.

If you are not circumcised, push your foreskin back before you put on a condom. This lets your foreskin move without breaking the condom.

Squeeze air out of the tip of the condom to leave room for semen (cum). Unroll the rest of the condom down the penis.

Do not "double bag" (use two condoms). Friction between the condoms increases the chance of breakage.

After orgasm, hold the base of the condom and pull out before your penis gets soft.

Be careful not to spill semen onto your partner when you throw the condom away.

Nonoxynol-9

Nonoxynol-9 is a chemical that kills sperm (a spermicide). It can help prevent pregnancy when it is used in the vagina along with condoms or other birth control methods. Nonoxynol-9 should not be used in the mouth or rectum. Because nonoxynol-9 kills HIV in the test tube, it was considered as a way to prevent HIV infection during sex. Unfortunately, many people are allergic to it. Their sex organs (penis, vagina, and rectum) can get irritated and develop small sores that actually make it easier for HIV infection to spread. Nonoxynol-9 should not be used as a way to prevent HIV infection.

Condom Myths

Condoms don't work: Studies show condoms are 80% to 97% effective in preventing HIV transmission if they are used correctly every time you have sex. Condoms break a lot: Less than 2% of condoms break when they are used correctly: no oils with latex condoms, no double condoms, no outdated condoms.

HIV can get through condoms: HIV cannot get through latex or polyurethane condoms. Don't use lambskin condoms.

The Bottom Line

When used correctly, condoms are the best way to prevent the spread of HIV during sexual activity. Condoms can protect the mouth, vagina or rectum from HIV-infected semen. They can protect the penis from HIV-infected vaginal fluids and blood in the mouth, vagina, or rectum. They also reduce the risk of spreading other sexually transmitted diseases. Condoms must be stored, used and disposed of correctly. Male condoms are used on the penis. Female condoms can be used in the vagina or rectum.

For more information, see Condomania's World of Safer Sex at www.condomania.com or the FDA's condom brochure at www.fda.gov/oashi/aids/condom.html.

Where the Rubber Meets the Road

April 1997

When used correctly, latex and polyurethane condoms stop the spread of HIV almost 100% of the time. Condoms are like cars: If you have an accident with one, the cause is almost certainly operator error, not mechanical failure. The estimated failure rate of latex and polyurethane condoms is between 2% and 5% -- and when a condom does tear during sex, the break is usually the result of misuse, not a defect in the condom itself. The Food and Drug Administration -- which considers condoms to be "medical devices," regulates their production, and makes frequent, unannounced inspections of condom-manufacturing plants -- has declared that the difference in quality between the best and worst condoms on the market "is tiny compared with the problems that users introduce." Condoms are like cars in another respect: They work best when you follow the manufacturer's instructions. The most common cause of condom failure is a simple mistake, one that people make almost as soon as the condom is out of the wrapper: They place the rolled condom on the head of the penis upside down. In this position the condom looks like a mushroom cap, and it can be unrolled down the shaft of the penis only with difficulty.

You may have to wedge your fingers between the condom and your penis to unroll it this way. The condom will still cover the penis, but because it is inside out, the ring at the base will usually be tangled, not snug and secure. This makes the condom more likely to slip off or tear during sex.

The rolled condom should be placed over the head of the penis the same way that a knit cap is placed on your head, with the rolled "brim" outside the cap, not tucked under. This way it rolls easily down the shaft of the erect penis. The condom ends up right-side out. The ring at bottom of the condom fits snugly at the base of the penis, and the condom stays in place during sex.

There's one more way in which a condom is like a car: You need to keep a condom well-lubricated. If you never change the oil in your car, the parts will grind against each other and break. A condom that is not kept lubricated is also much more likely to break -- but you should never use oil to lubricate a condom. Oil-based lubricants like Vaseline, cooking oil, Crisco, baby oil, suntan lotion, and most skin moisturizers will dissolve a latex condom, creating tiny holes. You can't see these holes, but they are there, and HIV can get through them.

For this reason you should always use water-based lubricants with condoms. And you should always use condoms made of latex or polyurethane, because non-latex condoms have pores that HIV can get through. Check the label. If the condom does not have the word LATEX or the word POLYURETHANE clearly printed on it, don't use it. And check the labels on all lubricants. Most lubricants designed specifically for sex -- brands like KY, ForPlay, and Astroglide -- are water-based, and the labels will clearly say so.

Many of these lubricants also contain an ingredient called nonoxynol-9 which may increase someone's risk of HIV. Using a lubricant that contains nonoxynol-9 without a condom will not prevent the transmission of HIV, and should be avoided because it could increase your risk of getting HIV.

Generously apply a water-based lubricant to your penis (or to the inside of the condom) before putting the condom on. (This allows the penis to move around slightly within the condom.) Once the condom is securely in place, rub lubricant on its outer surface, then apply more of the lubricant to your partner's vagina or anus. During sex, rub on more lubricant at frequent intervals. Keeping everything well-lubed cuts down on friction and puts less strain on the condom, making it even less likely that the condom will tear.

There is no such thing as a learner's permit for condom users, as there is for beginning drivers, and there are no mandatory driver- education programs for condom users either. That's too bad, because learning how to handle a condom with skill and confidence takes practice. Condoms do work. But they only work when they are used consistently and correctly.

Both women and men should study the following diagrams and instructions, and both should know that a newly developed "female condom," which is inserted directly into the vagina instead of placed on the penis, offers the same effective protection as a regular condom. Learning how to use condoms is like learning how to achieve sexual fulfillment. In both situations experience is the best teacher.

Correct Use of Condoms Condoms Worn by Men 1. Always use a new latex or polyurethane condom each time you have vaginal or anal sex. (Condoms are also recommended for oral sex with a partner who is known to be, or is suspected to be, HIV-positive.) Open the package carefully, so that you do not tear the condom.

2. Place a few drops of water-based lubricant on the inside of the condom or on the penis itself.

3. Before any form of direct sexual contact with your partner, place the condom over the head of the erect penis, leaving about a half-inch of empty condom at the end (Figure 1). Note: On an uncircumcised penis, pull back the foreskin to expose the head of the penis before you place the condom over it.

4. Gently squeeze the tip of the condom to force out any trapped air. The condom should fit over the head of the penis like a small rubber cap, with the rolled "brim" outside the "cap" -- so that it will unroll easily down the shaft of the penis.

5. Hold the tip of the condom against the head of the penis and unroll the rest of the condom all the way down to the base of the penis (Figure 2). Rub water-based lubricant over the condom-covered penis and, for extra safety and comfort, apply additional lubricant to your partner's vagina or anus.

6. Slowly insert the covered penis into the vagina or anus. If at any point you feel the condom break -- or you even think it may be broken -- pull the penis out immediately. If broken, throw the condom away and use a new one.

7. After you ejaculate (cum), hold the condom to the base of the penis while pulling out of your partner. This keeps the condom from coming off while it is still in your partner's vagina, anus, or mouth. Gently peel the used condom off the tip of your penis (Figure 3) and throw it away. Never use a condom more than once.

PEP and sore neck/ars (PEP AND THE NEED FOR HIV SPECIALIST 2008) Sep 29, 2008

Hi Dr. Bob

I just finnished PEP (zodivudine, lamivudine, crixivan) a week ago. After taking PEP I had a couple side effects, tingling in the fingers, a tiny bit in the neck and toes an exhaustion. After a while I stated to have a lot of pain in my neck, especially when I turned it to the left. The neck pain started to get better, especailly after the PEP finnished. However, the pain hasn't fully gone away and think I may have felt two swollen lypmh nodes on the back left of my neck. Is this a sign of ARS and PEP failure. I checked my groin and armpits and didn't notice any other lymph nodes swelling. My back is also a bit tense and stiff right now. I asked this quesiton the other day and didn't get s response. I know you are quite busy, but I am very nervous and stressed out right now.

Response from Dr. Frascino

Hello,

As I have frequently stated in this forum, I recommend anyone who has had an HIV exposure significant enough to warrant a course of PEP (post-exposure prophylaxis) be followed by an HIV specialist. (See below.) It seems the vast majority of folks who take PEP have many concerns about "symptoms" that arise during or after PEP. The HIV specialist would be able to evaluate such symptoms and relieve those fears more effectively and efficiently than I because I do not have access to your medical history and file, all your laboratory tests and I cannot conduct a physical examination. That said, from what you've told me, I do not believe your symptoms are HIV related.

Dr. Bob

pep and the worst year of my life. (PEP AND THE NEED FOR HIV SPECIALIST) Jul 13, 2008

I'm a bit nervous because I just took PEP and I don't know what the side effects are so maybe you can help out with it.

I've been having pains in my right abdomen for about a month now but my liver enzymes are normal. I'm still a bit scared because it is where my liver is.

Yesterday, I has receptive anal sex with a stranger. I put a condom on him and he was doing what he was doing. Then he said, I THINK SOME ONES COMING, So I look around, there was nobody there and looked behind me. Saw that the condom with lube was on the floor and his zipper was zipped up. Didn't think anything of it. Went home and pooped. I saw a glob of his semen in the toilet and was going to kill myself.

My possible exposure before this one was 4 months ago. It was anal receptive without condom with a guy I barely knew who I can't get in touch with. I came down with flu symptoms and was told to test at 3 months and then 6 months and then a year because I got really sick.

So my result was negative today before I started pep. I wanted to know if my testing window period will change for the sexual encounter that took place 4 months ago or should I trust in a 4 month negative??????

PEP treatment is 1 month.

When should I test again.

Should I stop taking the pep?

Does pep have hiv in it that will effect me if I have previously been exposed(4 months ago), ruining my chances of being negative?

I've had the worst luck any guy can have. I didn't have sex for 4 months and the one day I decided to cruise, I got violated.

Will pep have a bad effect on me if I am infected and don't know it from the 4 month issue?

I know that you're the only one that can answer these questions for me.

Response from Dr. Frascino

Hello,

Why would you think I am the only one who could answer your questions! Your questions are not uncommon or particularly challenging. Any HIV specialist should be able to help. I'm a bit concerned by your first statement, ". . . I just took PEP and I don't know what the side effects are . . . ." The prescribing physician (hopefully an HIV specialist) should have explained potential side effects at the time the medications were recommended. I can't specifically answer this question, because side effects are different from person to person and also the range of potential side effects differs depending on which antiretroviral medications are in the PEP regimen. I'm also concerned about several of your other questions, such as "Does PED have HIV in it?" Questions like this demonstrate a profound lack of understanding of post-exposure prophylaxis and antiretroviral therapy. (The brief response is no, of course these medications do not contain HIV!)

Your multiple concerns clearly demonstrate why I strongly recommend that all folks who have had an HIV exposure significant enough to warrant PEP have an HIV specialist involved in their care. The HIV specialist will:

1. Evaluate and document the HIV risk exposure.

2. Recommend PEP if warranted.

3. If PEP has already been started, the HIV specialist will revise, optimize or suggest discontinuation of the PEP regimen as indicated.

4. Evaluate and manage all PEP-related side effects and toxicities.

5. Evaluate all symptoms, including potential acute retroviral syndrome symptoms, occurring during the course of PEP therapy.

6. Arrange for and interpret post-PEP HIV testing.

My advice to you is to contact an HIV specialist. He or she will specifically address all your concerns in detail. I would also suggest that you be a bit more discerning regarding your sexual partners. When that last jerk said "I THINK SOME ONES COMING," apparently he was talking about himself! If he managed to ditch the condom without your realizing it, you really need to pay more attention to "what he is doing while he's doing what he's doing," particularly when he's "doing" you!

Good luck!

Dr. Bob

ARS or PEP side-effect? Jul 3, 2008

Hi Doc,

Thank God for you and this website! Quite concerned over the following:

I'm on PEP (Kaletra and Truvada) after a potential exposure (4 days ago) and noticed yesterday for a time (and again today) that my face is quite warm and I feel flushed. I have had the usual loose stool, stomach-related side-effects of the meds but I'm REALLY hoping that you can tell me if a slight temperature might also be a side effect and not a result of the "ARS" I see so many here concerned about. Obviously self-diagnosis is a BIG mistake, as is worrying and stressing but I'd very much appreciate your honest opinion.

Many thanks

Response from Dr. Frascino

Hi,

Your question graphically demonstrates the reason I suggest anyone who has had an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist. The HIV specialist can document your true degree of HIV risk, optimize PEP regimens, evaluate and manage all PEP-related side effects or toxicities, monitor for and evaluate any possible ARS symptoms and arrange for an interpret all post-PEP HIV tests. Having to take a course of PEP is indeed stressful. Having an HIV specialist involved can significantly reduce that stress. I cannot evaluate symptoms or make diagnoses over the Internet. What I can tell you is that "feeling flushed" and actually having a significant fever are two very different things. Also, even if you were to have an elevated temperature, there are many conditions other than HIV that could be the cause. I can also advise you that symptoms four days after exposure would not be related to HIV. It takes weeks, not days, for the symptoms of acute retroviral syndrome (ARS) to appear.

Dr. Bob

condom broke during the act Jan 20, 2007

First, Thank you so much for this forum.

about 4 days ago i had vaginal sex with a woman who i later discovered to be very high risk. the condom broke during our act and it was less than 3 or four minutes later that i finished. i don't know if she was hiv positive and have no way of finding out. the following day I went to the emergency room and was perscribed ATRIPLA. and of course i am not feeling very well at all on it. I go to the bathroom often and have the symptoms of a low fever at times during the day. cottonmouth, sore throat ...

I live in san francisco, and am wondering if I should have a follow up visit with a specialist in the area. And How I would find such a doctor.

Also was my risk and exposure high enough to warrant such a drastic step as ATRIPLA?

And of course I am completely freaking out that one stupid drunk moment has damaged my body to such a degree, has anyone built a time machine yet?

Response from Dr. Frascino

Hi,

Personally, I feel anyone who has had an HIV exposure significant enough to warrant a course of PEP should be followed by an HIV specialist, if possible. The HIV specialist would:

1. Evaluate the risk to see if PEP was really warranted.

2. Optimize the PEP regimen.

3. Evaluate and manage PEP-related side effects and toxicities.

4. Arrange for and evaluate post-PEP HIV testing.

Living in San Francisco, you have many options from which to choose regarding HIV specialist. Certified HIV/AIDS specialist physicians in your area can be located by consulting the American Academy of HIV Medicine Web site, www.aahivm.org.

Finally, if you do find that time machine, let me know. I know millions of folks who want to go back to 2000 and 2004 and recast their presidential vote.

Good luck.

Dr. Bob



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