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This is more a general comment (Dr. BOB'S RESPONSE IS INADEQUATE AND CONTRDICTORY)
Aug 11, 2009

Hi I recently wrote to Dr. Bob about a question about bareback topping situation to which his response was rather inadequate. Further he provided me with information that he himself has contradicted before. He told me it only takes one bareback exposure to get HIV whereas in a similar question asked previously he stated the risk is 6.5 percent per 10000 exposures. I am not sure of what's going on.

When people write to you, you must understand their state of mind. Yes we must all have protected sex but everyone is fallible. Dr. Bob's tone in his response to my question had scathing undertones. Of course, as gay men, we all should ideally be safe. But we all make mistakes. And Dr. Bob does sound very judgmental and morally self-righteous for whatever reasons.

Anyway, I hope you take what i am saying in your stride and consider your thoughts before responding in your sarcastic and witty manner.

Response from Dr. Frascino


You may feel that my response was "inadequate" and "contradictory;" however, I can assure you it was indeed factual and completely consistent with everything I've ever written on this site or elsewhere! I've reposted your question and my response below.

First off I commented on my disappointment that a health care professional (nurse) would be so cavalier about having unsafe sex. I continue to be disappointed. I also pointed out why being told by a partner that their HIV status is negative is not reliable. I quoted a well-documented statistical fact about the number of HIV-infected Americans who do not know they are infected. Consequently these HIV-positive folks could in all sincerity advise sexual partners that to the best of their knowledge that they are not HIV infected. In reality these untreated folks are often highly contagious because they have very high HIV plasma viral loads.

I then accurately responded to your specific question pertaining to the "minimum number" of bareback exposures that would constitute a substantial HIV-transmission risk. The answer is one. HIV transmission can occur with a single exposure! That is a fact, whether you want to believe it or not. You misquoted the statistical estimate in your post! It is not 6.5 "percent" per 10,000 exposures! The correct statistic is "6.5 per 10,000 exposures!" It's a CDC estimate of the per-episode statistical risk of acquiring HIV from unprotected insertive anal sex with a partner confirmed to be HIV positive. This is a population statistic that provides relative risk compared to other sexual activities. It does not mean that you can play Brokeback Mountain Commando Rambo 9993.5 times before you would contract HIV! (See below for a more detailed description of these statistical estimates.) If you have difficulty believing these statistics I suggest you contact the CDC!

I stand by my response! A single barebacking incident with an HIV-positive partner is indeed risky business! Perhaps an analogy would help. How many lottery tickets does it take to win the lottery? Yep, only one. Even if you buy 10 tickets, each individual ticket still has the same identical statistical chance of winning and it only takes one ticket to win.

I'll accept that by design some of my responses may be written in a "witty" or even "sarcastic" manner. However, I will not accept that my responses are either "inadequate" or "contradictory." Also, if you feel my responses are "judgmental" or "morally self-righteous," all I can say is that either you have never accurately read anything I have written or that you are living in some altered state of reality.

If, after reflection, you choose to write back, I'd suggest you begin with an apology.

Dr. Bob

HIV Risk for bareback topping Aug 10, 2009


I recently started dating a guy who's a nurse. I met him online. Things were going well until I saw his sex ads on Craigslist and I got suspicious. He told me he is HIV negative and disease free. He recently had an incident at work where blood got squirted into his eyes and he got tested again. He claimed he was negative. Based on that we engaged in unprotected anal sex 4-5 times. I was the insertive partner. I am also uncircumcized but my foreskin is completely pulled back. I've confronted him about his ads and asked him about his HIV status and he insists he is negative. Yet I feel horrible for having unprotected sex with him. I am getting tested next week. But my question is : Is there a minimum number of exposures through bareback topping that the HIV risk becomes substantial?

I've stopped seeing this guy completely.

Response from Dr. Frascino


A barebacking nurse on Craig's List? That's worrisome. Health care professionals certainly should know better! Even if a dude strapped a lie detector to his Mr. Happy, I still wouldn't believe his report of his HIV negative status. Remember, one fifth of the over one million HIVers in the U.S. today have no idea they are "positive charged," so to speak.

Responding to your specific question:

"Is there a minimum number of exposures through bareback topping that the HIV risk becomes substantial?!

The answer is a definitive yes! And that minimum number is exactly one!

Dr. Bob

Confused in Fort Worth (HIV STATISTICS, 2009)(HIV STATISTICS, 2009) May 8, 2009

Hey there Doctor Frascino, Been on your site over the years and am still a bit confused and concerned, even after reading through the archives. Can you try to clarify something for me. I have avoided sex over the years due to my fears but as I age, I continue to imagine how nice it would be to be in a loving relationship. I decided to experience a little more with a guy who has not really been willing to tell much about his background or previous sexual activity. But I wanted to see how it felt to be close to him and after reading though the archive as to what was fairly safe, I rimmed him and also gave him oral sex on 2 occasions. I had not brushed my teeth in a few hours, did taste a small amount of pre-cum. I know that the rimming is supposed to be safe. But I am confused about what I've read on the site about giving oral sex having a 1 in 10,000 chance of being infected with hiv. Does that mean that: Out of every 10,000 times people in the world give oral sex, one of them is infected with hiv, or Does that mean that if you personally gave 10,000 people oral sex, you would statisticly be infected 1 by one of them? The second way does make giving oral sex seem fairly safe. And the first way seems like the whole world would die before long. I was still apprehensive afterward and would like to become more comfortable with it. Thanks for reading.

Response from Dr. Frascino


The HIV-risk statistics I quote are merely statistical estimates that give relative risk. They are not meant to be applied to a specific coupling to gage actual risk. Rather they help advise someone of the relative risk of one type of activity compared to another. See below.

Dr. Bob

hiv risk ratio (HIV STATISTICS, 2009) Mar 8, 2009

Doctor, i simply can't buy the ratio stat you mention, such as "the estimated per-act risk for acquiring HIV for unprotected receptive anal sex with a partner confirmed to be HIV positive is 50 per 10,000".

First off... why not just say 1 in 200? Isn't that the same ratio as 50 in a 10,000?

2ndly... that seems outrageous. You mean to tell me that for the average person to get hiv, they have to have sex with a poz person 200 times?!

I've not had 10 at-risk encounters with poz OR neg people, yet i came down with it. Might i have been unlucky? Sure,... but EVERY poz person i've ever spoken to has nailed down the one chance encounter they had which they believe infected them.... Basically, it was a 1/1 ratio. Unsafe sex? one time? check, hiv.

My belief is that if one comes into direct contact with the virus that triggers HIV antibody tests, they WILL contract that virus on that day, for sure.

Response from Dr. Frascino


1. 50 per 10,000 is the same as 5 per 1,000 or 1 per 200. The reason I use the 10,000 exposures denominator is it helps people put their exposure in context with the other potential HIV risks I frequently quote in this forum. The CDC published these estimated per-exposure risk statistics with a common denominator of 10,000 specifically for this purpose. It allows folks who don't understand statistics or fractions to see that one type of activity, say receptive anal sex, is riskier than other type of activity, say receptive vaginal sex. OK?

2. The reasons the numbers seem "outrageous" to you is mostly related to your incomplete understanding of estimated-risk statistics for large populations. You comment "You mean to tell me that for the average person to get HIV, he has to have sex with a poz person 250 times!" reflects your inaccurate understanding. Neither I nor the statistics are telling you anything of the sort! (See below.)

3. Were you unlucky to contract HIV with only a few exposures? Yes, you were. However, it's extremely important to note that HIV can be acquired on a very first exposure.

4. As for your assumption, "unsafe sex, one time equals HIV infected," no, that is not reality. Just peruse the archives for at least a gazillion personal testimonials that disprove your hypothesis. I should also point out we have over a quarter century of epidemiological scientific study of exactly how and how often HIV is transmitted/acquired.

5. I'll repost below information about how to interpret HIV statistics and also a testimonial of someone who did acquire the virus with a single unprotected heterosexual exposure.

Dr. Bob

Interpreting HIV and testing statistics (HIV STATISTICS) Oct 10, 2008

Greetings. I recently tested HIV+ on a rapid blood test, and am awaiting Western Blot results. Needless to say, I'm extremely worried, almost resigned. I've been reading about testing statistics and through questions on this forum, and have a few questions.

Firstly, I notice that a lot of people have questions about indeterminate results, or results on separate tests that bring back different results. I notice that in some answers, unless tests are conclusively negative or positive, that diagnosis can include risk assessment.

Well, I can pinpoint my exposure, as I had only one sexual encounter within the window period. The man I was with was rubbing and probing around my anus without a condom, inserted about a quarter of the way in, and then I stopped him and said he needed to use a condom, and we didn't even have oral sex. So, this might be seen as risky as unprotected anal receptive sex, as I was exposed to his precum, but it did not last long, he did not insert all the way, and did not ejaculate in me. This is the closest I've had to unsafe sex in years, and at the time, considered it foreplay and didn't worry. Two weeks later, I had classic sero-conversion sickness for 5 days, and five weeks after the exposure, tested preliminary positive.

Now, I am almost sadly sure that this means I am HIV+, just because the timing of the positive result is too perfect. However, the day I got sick was the same day that almost everyone I knew felt feverish and achy due to a sudden drop in temperature (perhaps a "bug" that was going around).

As I've read, ELISA tests are 99.9% sensitive and 99.8% specific, which means there's only a 3 in 1000 chance that I got a false positive. But then I read about prevalence at the testing site (i.e. I went to a supposedly low prevalence site, so let's say there will be 20 true positives and 3 false positives out of 1000 tests).

And of course, all I've been inundated with in education, HIV campaigns, and even on this site, is that in the risk assessment of my particular case, since I have not had unprotected sex otherwise . . . that I might be considered in a lower risk group. I've read over and over that transmission rates of receptive anal unprotected sex are about 1% (i.e. even if you're having risky sex it might take multiple exposures).

So I'm confounded by the fact that I may have gotten HIV by a single half-assed (literally) exposure, despite making such a "successful" effort to stay away from the drug scene, be very healthy, very direct and open in my communication with sexual partners, and vigilant about safe sex.

Obviously, I want to have hope, despite the statistics. I've read about quite a few false positive stories here, and I secretly *want* to hear the rapid blood test might be unreliable, that I might even have mono or just had a regular flu. I'm not finding my help on the web as I've found mostly outdated articles or answers that are too general. So, if you would be so kind, I have some specific questions.

- Would you say that the .3% false positive ELISA rate is accurate? If so, does this statistic mean that the .3% *includes* human error and all the possible complications like Epstein Barr and pregnancy or a recent immune system event that can cause a false positive, or does it mean that on top of that, the test itself, if performed perfectly, has a .3% fail rate?

- When it is said that the estimated rate of transmission via unprotected receptive anal sex is 1%, does this mean that if you are actually exposed to HIV, you will get it 1 out of 100 times; or does it mean that *real* exposure actually doesn't occur 99 out these 100 times? (In addition, can an actual positive status be result of "cumulative" exposure?) If it's the former, as I think we are lead to believe when reading statistics, then wouldn't my luck just be truly awful and almost defy the statistics?

- I know that I just must wait for my Western Blot confirmation results. But in that you've given your assessment based on risk factors, and with your knowledge of testing -- would you say I have any reason to hope that my preliminary test is a false positive?


Response from Dr. Frascino


I'll respond to your three specific questions first:

1. The sensitivity and specificity of a test assume the test is performed properly and free from confounding variables.

2. The estimated statistical risk assumes unprotected sex with a partner confirmed to be HIV positive. Please note, however, these general population estimated-risk statistics are useful in assessing relative risk and cannot be applied to a single specific encounter. (See below.)

3. Yes, there is a distinct possibility your initial rapid test was falsely reactive. Remember that a reactive (positive) rapid test is only considered to be "preliminarily" positive. If it is followed by a negative Western Blot, the two tests together are considered a "negative HIV test."

Your HIV-transmission risk was low, but not completely nonexistent. Write back with your Western Blot results. We are all rooting for you! However, no matter what the outcome, I'm here if you need me, OK?

Good luck.

Dr. Bob

Are you following what goes on in Mexico? (HIV STATISTICS) Aug 11, 2008

Dr. Bob

In AIDS conference in Mexico they said that the rates of transmission that the CDC quotes could be way off and actually be much higher than stated. They said some instances of Vaginal sex could be as low as 1 in 10 exposures and anal sex 1 in 3 exposures. I have always followed your advise and use a condom for both these acts( wife poz)but I am wondering if this were to be true could getting oral maybe turn into the 1 in a 1000. We never use condom when I get oral from her and really would just love to here your expert opinion on this.I know you said getting oral is a extremely low risk(theoretical under extenuating circumstances) but want to make sure this would not make you change your mind or at least think twice.(meaning do you think it could also be riskier than everyone has thought)THANKS, Here is the article

Response from Dr. Frascino


Not only am I following what's going on in Mexico City, I'm actually in Mexico City participating in the conference! There have been over 5,000 presentations, including the one you reference. The take-home message of this study of HIV infectivity is that population based HIV statistical estimates can not be applied as actual risk to one specific sexual action. I've made this point many times in the forum (see below). The presentation from the group at North Carolina focused on the effect of co-factors that can affect the risk of heterosexual HIV transmission (circumcision, genital ulcer disease, anal rather than vaginal sex and other biological cofactors). I'll reprint the article you reference below.

Dr. Bob

Condom broke exposing my turkey now i'm worried sick (HIV STATISTICS) Nov 26, 2007

Hello Doc. Hopefully you can help me with my fears. Eight days ago I had protected anal sex with another gay male of unknown HIV status. I was the top. After completion, which lasted less than five minutes, I pulled out and noticed the condom i was wearing had broke. I immediately went into a panic. I checked my penis and there was no sign of blood or anything else. I do not know at what point the condom broke. As the top, how much should I be worried? What are the chances that I might have contracted HIV, if indeed this person is positive and that's an assumption. Please help. I'm stressing out here and scared to death and depressed. What are your thoughts? Should I be worried? Thanks.

Response from Dr. Frascino


So it appears the "turkey" got exposed while you were doing the "stuffing!"

The estimated per-act risk for acquisition of HIV from unprotected (or broken-condom) insertive anal sex with a partner confirmed to be positive is 6.5 per 10,000 exposures. However, please note these are merely estimated risk statistics and cannot be applied as an actual statistical risk for your particular situation. (See below.)

Should you be worried? No, not excessively. But you should get a rapid HIV test at the three-month mark, OK?

Good luck.

Dr. Bob



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


"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 (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

Commonly Used HIV Infectivity Rate Misses Risks

Tuesday, August 5, 2008; 12:00 AM

TUESDAY, Aug. 5 (HealthDay News) -- A widely used HIV infectivity rate doesn't take into account multiple risk factors, say U.S. researchers who reviewed published data.

The heterosexual infectivity of HIV (the virus that causes AIDS) is often cited as a fixed value of one transmission per 1,000 sexual contacts. However, most studies estimating this value were conducted among stable couples with a low prevalence of risk factors, which can increase the risk of HIV transmission by several to several hundred times, according to Kimberly Powers, of the University of North Carolina, and colleagues.

They reviewed published data on HIV (up to April 2008) in order to estimate the effects of transmission co-factors that can affect the risk of heterosexual HIV transmission.

They found wide variations, with estimates ranging from zero transmissions after more than 100 penile-vaginal contacts in some serodiscordant couples (one partner HIV-positive and one partner HIV-negative), to one transmission for every 3.1 episodes of heterosexual anal intercourse, which is more than 300 times the commonly-cited fixed heterosexual infectivity rate.

Other infectivity differences, expressed as number of transmissions per 1,000 contacts, were:

13.2 for uncircumcised susceptible males vs. 5.1 for circumcised males.7.5 for susceptible people with genital ulcer disease vs. 1.5 for those without such disease.3.2 for early-stage index cases, 2.6 for late stage index cases, and 0.7 for mid-stage index cases.

"The use of a single, 'one-size-fits-all' value for the heterosexual infectivity of HIV-1 obscures important differences associated with transmission cofactors. Perhaps more importantly, the particular value of 0001 (i.e., one infection per 1000 contacts between infected and uninfected individuals) that is commonly used seems to represent a lower bound. As such, this value substantially underestimates the infectivity of HIV-1 in many heterosexual contexts...heterosexual infectivity can exceed 01 (one transmission per 10 contacts) for penile-vaginal contact or even 03 (one transmission per three contacts) for penile-anal contact. Claims in both the popular media and the peer-reviewed literature that HIV is very difficult to transmit heterosexually are dangerous in any context where the possibility of HIV exposure exists," the review authors wrote.

"Improved infectivity estimates -- especially more detailed estimates that quantify the amplifying effects of biological cofactors -- will help us to grasp the magnitude of the HIV epidemic, accurately communicate the level of risk involved in heterosexual sex, and identify the best possible intervention strategies for slowing the epidemic's spread," they concluded.

"Infectivity studies are very difficult to conduct, and that few studies exist as a result. Many of the studies producing the published estimates suffered from at least one potential bias. Therefore, while our study documents the considerable heterogeneity of the heterosexual infectivity of HIV-1 and provides some explanations for this heterogeneity, considerable uncertainty remains."?

The findings were expected to be announced at the International AIDS Conference in Mexico City. The review was published online inThe Lancet Infectious Diseasesand was expected to be in the September print issue of the journal.

More information

The U.S. Centers for Disease Control and Prevention has more about HIV/AIDS.

SOURCE:The Lancet Infectious Diseases, news release, Aug. 5, 2008


This is a comment on one of the readers questions asking if you can get hiv by penetrating a woman who has hiv just ONE time when not wearing a condom, in other words not practising safe sex. One time. Yes you can, I did it one time and got it I didnt even come. I didnt ask her about this stuff, I assumed it was ok as there were no seemingly high risk categories, especially not from me, a normal everyday non promiscuous guy. Of course I only found out years later when in a relationship I infected the girl I was with, imagine that scenario, I didnt know I had it. Whenever I look for information on this bloody virus I have to pile through a load of gay stuff and cock sucking and arse fucking or dont share needles. Christ I dont even drink. I did it with a girl and got it, one time. I had no cuts no gashes no blood no spots or whatever else, I was perfectly I mean perfectly healthy and in brilliant shape, I still got it. I am still in mourning for my long gone self. So if you dont want to worry about it, wear a condom.

Response from Dr. Frascino


Thank you for writing in and sharing your story. It's amazing how many heterosexual guys do not believe they are at risk for HIV. Obviously our HIV awareness and prevention programs under the sex-phobic Bush Administration were woefully inadequate. As we turn back toward science and common sense, I look forward to finally getting the HIV message out in a clear, scientifically sound manner. Even though HIV remains 100% incurable, it is 100% preventable.

Good luck. I'm here if you need me. I do hope you'll soon stop "mourning your long gone self" and embrace the new you. You are "virally enhanced," but you are alive and "well" and have gained some valuable insights into life.

Dr. Bob

Insertive Oral Statistics Apr 23, 2009

Hi Dr. Bob, First let me say how much I admire your spirit, in dealing with a deadly viru as well as educating common people about the risks. I have a question about the risks of HIV transmission from insertive oral. The Vargehese paper from 2002 quoted by the CDC (and subsequently Wikipedia and you and more sources) states that the aquisition risk is 0.5/10,000 episodes. This is just an assumption, as even the paper states that there is no data to back up this number. From what I understand, there are no documented cases. You already know this, so why am I writing? The risk difference between insertive oral and vaginal is 10x. Someone might think that if they go for the former, then the latter is not all that more risky. Maybe you should change the nature of risk for insertive oral from 0.5/10,000 to extremely low? Just a suggestion. Anyway, my hat off to you for your efforts.

Response from Dr. Frascino


Most HIV specialists who have been in practice for a while have seen patients who claim insertive oral sex is their only HIV-risk exposure. These are anecdotal reports. There are no "documented cases," because that would require the sex police monitoring a couples' every sexual move to assure there was absolutely no other potential risk activity. The CDC estimated-risk statistics are very conservative and serve as an educational tool to show people the relative risk associated with various sexual practices. In that light, if vaginal sex is 10 times more risky than oral sex, it should make people think twice about taking that risk. The trouble with words like "low" is that no one really knows what that means. Our basic message should remain: Anal sex is more risky than vaginal sex which in turn is more risky than oral sex. The receptive partner is always at greater risk than the insertive partner for all types of penetrative sex. Use a latex or polyurethane condom for penetrative sex!

Dr. Bob

***Sorry,but what is CD4?Am I CRAZY?***
Put your money where your mouth is...

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