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Follow Up: Newly Out of the Closet (COMING OUT)
Dec 29, 2009

Happy New Year, Dr. Bob!

A year ago, I found these forums to write to you about a situation I had. I thought I had symptoms after being convinced I placed myself at risk. You correctly diagnosed my issues as feeling guilty about my behavior and my inability to accept who I am.

Since that experience, I've read your forums often, many times anticipating the answer before reading yours.

In this past year, I came out to my family who have been nothing but supportive. My mother is even asking about my dating life. I'm still seeing my therapist who is helping me navigate this new chapter in my life.

I'm dating, and it's been really interesting. There is someone that I met, whom I find deeply attractive. He's not a physical beauty, but there is something about him that I find myself just drawn to him.

I had not had a chance to talk to him about his HIV status, and we seem to be engaging in a "friends with benefits" kind of relationship. It's not my choice, but I can't seem to turn away from him. Unfortunately, I'm asking myself why am I putting myself at risk with someone I know I won't have a relationship with and is not exclusive with me. Sadly, I've suspected he's positive and I would be willing to accept that if we were to ever have a relationship (but I know that we won't).

I perform fellatio on him unprotected last week while fingering his anus. Unfortunately, I realized afterwards that I had a small sore on the tip of my tongue and a torn cuticle on the finger that I used. I tasted pre-cum several times. We then proceeded to protected anal sex (with me as the top).

I realize that these activities are low risk, but I also realize that sores and wounds increases that risk. I guess I thought I would try oral sex after reading on this forum about how it is low-risk and how studies show many magnet couple engaging in unprotected oral sex. I also read about the Swedish study that says men can build up an antibody resistance in their mouth when exposed to HIV. I thought I might be okay, but I'm second guessing that information a bit.

I admit: this is a bit confusing for me and I'm trying to sort out my risks and what behaviors are acceptable to me. I'm still talking with this guy and I could ask him status, but I honestly don't trust him. (I know, way to pick this guy, huh? It's like I'm a teenage girl in love with the bad boy.)

I suppose there's nothing I can do but wait 11 more weeks for an antibody test. As I begin my life as a gay man, what is the best way to sort out what is risky and what is acceptable? Do you have any advice for helping me navigate this?

I guess my letter to you is threefold: 1) I wanted to thank you for your help and guidance this past year. I would reread your assurances to me several times daily during my waiting period. You gave me hope; 2) I would appreciate any advice you have about oral sex and any good luck karma you could send my way; and 3) what advice do you have for those of us who are sorting this out and want to be responsible and take care of our bodies while also exploring our sexuality?

This was my situation a year ago and earlier this year: http://www.thebody.com/Forums/AIDS/SafeSex/Archive/Masturbation/Q200105.html

Thanks again for your help. I appreciate all that you do, and I hope and Dr. Steve have a wonderful holiday.

Rob

Response from Dr. Frascino

Hi Rob,

Welcome back to the forum. I'm delighted with the progress you've made over the past year! I'm hopeful your story will help others to come out and accept their sexual orientation. It really is the only road to (and hope for) physical and psychological well-being!

Turning now to your question:

1. You're welcome!

2. Good-luck/good-health karma has been signed, sealed and sent! I'm confident you'll test negative based on the activities you describe in your post. Protected sex is indeed protected, assuming the latex or polyurethane condoms are used properly and don't fail (break). Oral sex carries only a very small risk for HIV transmission. (See below.)

3. Continue to become more informed about the HIV risk associated with various sexual activities and the harm-reduction measures you can institute. Each of us needs to set our own boundaries for what we consider to be safe enough. For instance, some committed magnetic couples, in which the positively charged half has driven his HIV plasma viral load down to undetectable l levels with antiretroviral drugs for a considerable period of time, may feel comfortable having unprotected oral sex. Other magnetic couples in the identical situation may not feel the risk, however slight, is worth it. Each situation is unique, due to the level of comfort each of us has based on the information available and whom we are choosing to tumble with between the sheets. Knowledge is power and your comfort zone may change over time with experience and with how well you trust your mate.

Good luck.

Dr. Bob

The Results - Scared: ARS-like Symptoms After Mutual Masterbation Mar 16, 2009

Hi Dr. Bob,

I hope I haven't offended you. I just want to thank you for taking the time to answer my questions. Truly, I would reread your answers to me several times daily as I waited through the window period.

This was my situation: http://www.thebody.com/Forums/AIDS/SafeSex/Current/Q198643.html

These are the results after 12 weeks since exposure (86 days): - Negative HIV 1/2 antibody - Negative for Hepetitis A, B, C - Negative for Syphilis - Negative throat culture for gonorrhea - Negative urine analysis for gonorrhea and chlamydia

My questions: 1) Are there any other STD tests that I should have?

2) Do I need to repeat any of these tests at 6 months?

3) How realistic are the risks for HIV O or N?

4) How did you find a great guy like Dr. Steve? I clearly need to stay out of the bathhouses and meet real partners in real places. Got any advice for a young gay puppy such as myself on how to meet guys?

Finally about five weeks ago, I shook hands with an HIV+ man who had lots of moisturizer on his hands. At first, I told myself that I could wipe my hands on my pants and that there was no risk for transmission. My fear/anxiety/OCD got the better of me - I freaked out.

5) Do I need to get tested following this experience?

6) Is a 12-week test good even though this individual is confirmed to be positive?

I realize these last few questions are insulting to those with the disease, and I truly do not mean to offend you. You are a very kind, clever, and supportive individual. I ask because I'm trying to counter my fears with logic and reason, and I know that you can provide that.

I promise I will make another donation to your organization. Hope you and Dr. Steve are doing well.

Thank you once again.

Response from Dr. Frascino

Hi,

How could you have offended me? Did you vote for Palin or something like that?

1. Assuming you have no symptoms that require specialized testing, your results to date cover the major STDs and I do not feel additional tests would be warranted.

2. No.

3. Not realistic at all. You have a greater chance of being struck by lightening than contracting an O or N strain.

4. We met at work. Bathhouses may be convenient places to get off, but I doubt you'll find your Mr. Right in the orgy room. Try meeting guys with similar interests (other than bathhouses), such as hobbies, mutual friends, guys with similar jobs, etc.

5. No, absolutely not.

6. Testing is not warranted.

Dr. Bob

Follow Up - Scared, ARS-like Symptoms After Mutual Masterbation Jan 11, 2009

Doctor,

I hope you are having a Happy New Year. I'm in a bit of a crisis and I need your help.

On Dec. 3, I went to a bathhouse. There were a few risk incidents: 1) Sucked unknown partner for 30 seconds, don't think there was pre-cum, 2) used said partners precum as lube on raw penis, later noticed red open sore near the head and frenulum, 3) said partner fingered my anus while sucking me off, and 4) made out with a seperate guy who was biting my lips, tongue, and neck aggressively before I put an end to it.

Two weeks later, I had ARS-like symptoms (fever, sore throat, diarrhea, night chills, 16-pound weight loss).

On Day 20 after exposure, I saw an HIV specialist who ordered a viral load test (Roche COBAS Ampliprep Taqman) that came back undetectable.

Since then, my lymp nodes have gotten swollen. I saw the doctor again who refused to order anymore tests.

Is my undetectable HIV PCR RNA test (with 50ml sensitivity) really Whoo-Hoo-able? Should I find another doctor? Or do I need your good luck karma for a 3-month test?

I'm seeing a therapist to help me with the anxiety. I deeply regret going to that place.

Please respond, Doctor. I'm really scared and I'm afraid that maybe the HIV specialist is overlooking HIV-2, non B subclades, and other testing options because he wants me to come out of the closet (and I've started telling my friends who are helping through this - I'll tell my family as soon as I'm confirmed to be HIV- so they won't have to worry).

I'll send a donation to your fund, Doctor.

Please help me.

Response from Dr. Frascino

Hello,

Your HIV-acquisition risk from the activities you describe are extremely low. Your negative HIV PCR RNA at day 20 is extremely encouraging and I have no reason to question your HIV specialist's opinion. He has much more information about the specifics of your particular situation than I do. Certainly the option to take a three-month HIV-antibody is open to you. The odds are astronomically in your favor the results will be negative.

My advice is to continue working with your therapist to cope with your anxiety, fears of HIV infection, sexual orientation issues and your coming out process. Remember closets are health hazards!

Your fears of missing an HIV-2, non-B subclade, etc. are unwarranted.

Thank you for your tax-deductible donation to the Robert James Frascino AIDS Foundation (www.concertedeffort.org). I'm sending you my good-luck/good-health karma that you'll come out and learn to cope better with your sexual orientation, your HIV fears and that you'll remain HIV negative as an out and proud healthy gay man.

Good luck. Be well.

Dr. Bob

Positive through oral sex (TRANSMISSION VIA ORAL SEX 2009) Dec 29, 2009

Dr,

You strongly say that HIV is not transmitted through oral sex on your other posts. Then y did you not raise any concerns on the below post where the person claims of having caught HIV through oral sex.

http://www.thebody.com/Forums/AIDS/SafeSex/Current/Q205768.html

Response from Dr. Frascino

Hello,

OK, let's set the record straight once again! I have never said, let alone "strongly said," that HIV is not transmitted through oral sex! If you read my comments carefully, you will quickly see that I consistently say that the HIV acquisition/transmission risk from oral sex is very low.

Please see below for a more detailed discussion and review of my very consistent comments on this topic. You should also review the chapter on oral sex in the archives of this forum.

Dr. Bob

HIV from Oral Sex Confirmed!!!!! Dec 25, 2009

Dr. Bob.

I read the post from earlier today from the man that wrote he got HIV from Oral Sex. Will you and the "experts" now retract your assurances that Oral Sex is a low to no risk exposure and take a more strident stance that Oral Sex is a significant risk. I am another example. I believe that I as a man was exposed as a result of receiving oral sex from a man. I haven't been tested yet but the symptoms I have are very indicative of HIV. I wish you would take a sterner stance and warm people of the great dangers of Oral Sex. There are probably hundreds if not thousands of us out here that have contracted HIV from Oral Sex. Your thoughts please.

Response from Dr. Frascino

Hello,

You want me to "warm" people??? How should I do that? Pop them in the microwave?

I'd be delighted to give my thoughts as you request, but I'll warn you in advance you won't like what I have to say.

You ask: "Will you and the 'experts' now retract your assurances that oral sex is a low-risk exposure and take a more strident stance that oral sex is a significant risk?" No, of course not, silly boy! Why would we do that if it is not supported by sound scientific facts? The scientific epidemiological evidence collected over the past quarter century is very consistent. Oral sex carries only a very small risk for HIV transmissions/acquisition. Please note, I never claimed oral sex is a "no risk" activity! That one person wrote in to the forum claiming to have contracted the virus via oral sex does not change the overall HIV risk! Please note the gazillions of others who have written in over the years who had oral sex with HIV-positive partners, but did not contract the virus! Science is science; fact is fact; no matter how freaked out you are about your blowjob incident. I'll reprint below some recent information from the archives.

Next, I must point out you also state: "I am another example. I believe that I as a man was exposed as a result of receiving oral sex from a man. I haven't been tested yet but the symptoms I have are very indicative of HIV." Hmm. That statement speaks volumes! I agree you are indeed "another example." However, not an example of oral sex HIV transmission, but rather another example of someone convinced he is HIV infected based on "symptoms," but who has never been tested. (Others have tested negative multiple times, but still remain convinced they are HIV infected, because of "symptoms." In reality, they are not!)

Your claim that there are "probably hundreds if not thousands of us out here that have contracted HIV from oral sex" is pure lunacy.

Dude, get tested. Then write back. I can just about guarantee your opening line will be: "Dr. Bob, I tested negative!"

Our assessment of the risk of HIV transmission/acquisition via oral sex remains unchanged.

Dr. Bob

HIV Risk From Oral Sex and Can RX's Increase Risk? (TRANSMISSION VIA ORAL SEX 2009) Dec 16, 2009

What is the true risk from oral sex? After looking at many other forums....some sources say there is low risk, some say no risk, some say that while HIV could transmit in theory, there has never been a recorded case of infection from only receiving oral sex - no other activity involved. Also, can being on RX's increase exposure risk - specifically sertraline, atorvastatin, valsartan hydrochlorothiazide or good old aspirin? 6 days ago a stripper went down on me, unprotected, and I ejaculated in her mouth. Is there a transmission chance of virus entering the penis through the tip (no sores here) and can the meds mentioned here make one more susceptible? No excuse as protection should have been used though alcohol was a definite factor here....and six days without a beverage is feeling pretty good right now. This was the first (and last) time this happened. Immediately I was filled with regret and outright fear. Thinking about the stupid thing has consumed me and I really can;t talk about it with anyone. Did a mail in anti-body test (neg) which I now know was a waste - too early. The first few days after this incident I was a basket case, hard to function, extremely down, convinced I'd ruined the future. Constantly checking for symptoms and only have a slightly stuffy nose, little tweak in the ears. I'm worried that the stuffiness is about to turn to a sore throat as some forums say sore throat can happen right after infection and is a symptom (in days???) other don't. So should I be obsessed with worry here, by the sertraline it's easy to tell I go anxiety ridden pretty easily and can be a hypochondriac or am I overreacting? what is the real risk? Thanks in advance.

Response from Dr. Frascino

Hello,

What is the true risk from oral sex? This is a somewhat difficult question to respond to, as there can be confounding variables. See below for some recent information from the archives. (By the way, we have an entire chapter in the archives devoted to oral sex. Check it out! My opinion that oral sex carries only a low risk for HIV transmission/acquisition hasn't changed.)

The medications you listed do not increase the HIV risk associated with oral sex.

Should you be obsessed with worry? No.

Dr. Bob

Oral sex/Magnetic Couple (TRANSMISSION VIA ORAL SEX) Jun 15, 2009

Dear Robert,

First of all, thank you very much for providing such great advice and information on this site. I am HIV-negative and have just recently started to date a guy who is HIV-positive. I am 29 years old and have only ever slept with one person, who was also negative. So as you can imagine, this has been a really emotional journey for me. I have not had sex with my current HIV positive boyfriend yet. I am waiting till I am informed on all of the risks involved, before preceding. I have been doing a ton of research online, and keep getting conflicting results. I really love him, and want to try to make this work. I also want to feel comfortable having sex with him. My question I had was regarding oral sex. How safe is oral sex without a condom and without the guy ejaculating in your mouth? I am trying to keep an open mind, but I cannot imagine not being able to have unprotected oral sex with my boyfriend. Using a condom for everything else is fine by me. Please shed some light on this situation for me. I am just trying to make good choices and have the knowledge before we start having sex. Thank you so much for your time.

Response from Dr. Frascino

Hi,

The HIV risk associated with oral sex is definitely a QTND (question that never dies). What we can say is that overall risk of HIV acquisition/transmission via oral sex is very low. An insertive partner has less risk than a receptive partner. Review the information in the archives. We have entire chapters devoted to oral sex, magnetic couples, HIV-sexual transmission, etc. Also, I'll post below a summary of recent information presented at medical conferences discussing the latest information on the HIV transmission risk related to oral sex. Many magnetic couples have decided the risks associated with oral sex are acceptably low and forego using condoms. Others try to adhere to an absolutely no-avoidable-risk policy and hence cover their penis popsicles before all oral action. Ultimately only you and your partner can decide how much risk is acceptable. Some risk-adverse folks never drive above the posted speed limit even if there isn't another car in sight for miles and miles. Others never wear their seatbelt and text while speeding on the freeway during rush hour. We all make calculated decisions about acceptable risk everyday. You need to do the same thing with HIV and oral sex.

Dr. Bob

TRANSMISSION VIA ORAL SEX

The risk of HIV transmission through oral sex has been a subject of debate since the early years of the epidemic. But the issue is difficult to resolve based on epidemiological studies, since most people do not limit themselves to a single sexual practice. As described in the December 2008 issue of the International Journal of Epidemiology, researchers from Imperial College in London undertook a systematic review to assess the risk of HIV transmission via "orogenital intercourse," both fellatio (on a man) and cunnilingus (on a woman).

The authors searched the PubMed database and bibliographies of relevant articles through July 2007. Out of the 56,214 titles searched, they identified ten potentially appropriate studies. Two additional studies were identified through bibliographies, and one was found through discussions with experts. Ten studies, all from North America or Europe, provided estimates of HIV transmission probabilities per partner, incidence per partner, incidence per study participant, and incidence per sex act. Only three were conducted after the advent of HAART, which suppresses viral load and therefore reduces transmission risk. Given the small number of studies, they did not consider a meta-analysis (in which data from all studies are pooled) appropriate.

Six studies reported no instances of transmission via oral sex. The four studies that reported non-zero estimates included per-partner estimates of 20% (in a small study with only ten participants) and 1%, one per-study-participant estimate of 0.37%, and one per-act estimate of 0.04%. "There are currently insufficient data to estimate precisely the risk from orogenital intercourse exposure," the investigators concluded. "The low risk of transmission evident from identified studies means that more and larger studies would be required to provide sufficient evidence to derive more precise estimates."

In a related study reported in the January 28, 2009, issue of AIDS, Swedish researchers sought to determine whether exposure to HIV via oral sex results in HIV-neutralizing antibody activity in the saliva. Saliva samples were collected from 25 HIV negative gay/bisexual men with positive male partners and from 22 low-risk HIV negative healthy male control subjects; 21 of the 25 HIV-exposed but uninfected individuals reported unprotected receptive oral sex and three reported unprotected receptive anal intercourse.

Saliva from both exposed uninfected individuals and low-risk control subjects exhibited HIV-neutralizing activity. However, a significant difference was seen for immunoglobulin A1 (IgA1), with 13 of 25 exposed uninfected individualsbut none of the 22 presumably unexposed control subjectsexhibiting HIV neutralization. Based on these findings, the researchers concluded, "Unprotected oral sex evokes a salivary IgA1-mediated HIV-neutralizing response that persists over time during continuous exposure in uninfected male partners of infected men."



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