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Oral sex from HIV positive. (TRANSMISSION VIA ORAL SEX 2010)
Jun 16, 2010

Dear Dr Bob,

I have posted a question before, but now as i have update on the situation i am posting again hoping it will not disturb.

I received a blowjob from a guy who after told me that he was HIV positive. I in the same night a few hours before had protected sex with a condom with a HIV -ve person. I did not notice any lesions, cuts or sores on my penis.

I came into communication with the guy again today who stated that he is on tritherapy and has an undetectable viral load. The guy might be lying just to reassure me and i cannot be certain of what he says.

I am very anxious about this whole situation and would like to know whether i am at risk. I see on various threads that it might be a low risk situation but some others say its a no risk situation. I have also seen on the san fransisco std chart and aids med that receiving oral does not contribute to hiv transmission.

I have taken combivir for 2 days but decided to stop today because i was feeling really bad while taking it. Was that a good idea ?

Thanks for your precious help.

Thanks for your help

Response from Dr. Frascino

Hi,

Unprotected insertive oral sex carries only a very low risk for HIV transmission. See below. If your partner was on effective combination antiretroviral therapy that had driven his HIV plasma viral load to undetectable levels for a considerable period of time, this would significantly decrease the risk of HIV transmission, but not completely eliminate it.

Most HIV physician specialists would not strongly recommend a course PEP for this type of scenario. Some might "offer" it without strongly recommending it if the patient was adamant about taking PEP and thoroughly understood the risks involved in taking HIV medications. I would agree with your decision to stop Combivir. You should get an HIV test at the three-month mark.

Good luck.

Dr. Bob

Straight Question (TRANSMISSION VIA ORAL SEX 2010) Jan 3, 2010

Hi Doctor Bob,

Is it in your view permissible to let a negative partner give you oral sex (without ejaculation) where precum is produced but where the recipient is on HAART and undetectable. If there are no recorded cases of transmission in this way and the risk is only theoretical and miniscule with it, then should anyone really be worried about a condom in this situation. Where is the line. Sometimes I wish there were a universal factsheet provided unanimously by healthworkers saying when and in what situation a condom should be used. Complicated medical articles, conflicting opinions and non-committal responses by professionals just add to the confusion & I think may put people in danger. What are your thoughts.

Thank you

A confused London Boy

Response from Dr. Frascino

Hello Confused London Boy,

Another "straight question" for the gay cyber-sexpert. Unfortunately, there is no straightforward answer! You're looking for a "line" when in reality what exists is more of a "zone." All reasonable HIV experts will agree the risk of oral sex is very low, but not completely nonexistent. There can also be a number of confounding variables, including: (1) concurrent STDs; (2) oral membrane trauma, bleeding gums, gingivitis; (3) differences in HIV plasma viral load and viral strains; etc., etc., etc. London Boy, read through the chapter on oral sex in the archives of this forum. Yes, the whole chapter! It'll give you a better understanding of the risks associated with oral sex. I'll also post below some recent information from the archives.

Happy New Year.

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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