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Very quick question about oral sex + piano (TRANSMISSION VIA ORAL SEX 2010)
Jul 23, 2010

hi! just want to ask you a very quick question, Dr Hansfield at Medhelp says insertive oral is essentially zero risk, but you say is NOT non-existent. . . . . it it because you know someone who got HIV that way? From what I have read there hasn't been a documented case. . . . is confusing for us lay people when experts don't give us the same answer :(

Would you recommend testing if insertive oral sex is the only exposure for medical rather then anxiety calming reason?

p.s. have you got any recording/ video of you playing the piano? I live in the UK can't get to your Concerted Efforts performance, is great to see someone so talented. . . . . . World Expert and a great musician!!!

Be grateful if you could clarify

Worried

Response from Dr. Frascino

Hi Worried,

Actually it's just a question of semantics. "Essentially zero risk" is not the same thing as absolutely no risk. Consequently my comments of "NOT nonexistent" could be consistent with "essentially zero risk."

As for my personal experience, yes, I've had patients who claim to have been infected via insertive oral sex. However, since the sex police weren't there to confirm that insertive oral sex was the only type of sexual contact, I cannot be certain these guys were being completely honest. I'll post some information below from the CDC and other sources supporting my "NOT nonexistent" rationale.

Regarding HIV testing, for guys who generally try to play safe but have unprotected oral sex with multiple partners, I recommend routine HIV-antibody testing every 6 to 12 months.

Regarding a recording/video of my musical exploits, we do have a promotional DVD that explains the genesis and mission of The Robert James Frascino AIDS Foundation, which has short clips from our Concerted Effort events. You can contact the foundation (www.concertedeffort.org) if you would like one. Generally they are sent out as token thank-you gifts for those who make donations to the foundation, but sometimes there are extra copies available on request.

Good luck. Be well.

Dr. Bob

Oral sex Published: 08 April 2010

How risky is oral sex?

When is oral sex more risky?

How can you reduce the risks?

Doctors and researchers aren't quite sure how many people have got HIV from oral sex. Some think hardly anybody has been infected with HIV from oral sex, but other people think that as many as 3% of infections are due to oral sex. In late 2008 researchers looked at all the available evidence and calculated that the risk of contracting HIV from oral sex was very low, but that it wasn't zero.

It is known that oral sex involves less of a risk than unprotected anal sex or unprotected vaginal sex.

How risky is oral sex?

The likelihood that HIV is transmitted from an HIV-positive person to an HIV-negative person depends on the type of contact involved. HIV is most easily transmitted by unprotected anal sex (that is, without condoms), unprotected vaginal sex, sharing injecting equipment, and from mother to baby. It also depends on the viral load of the person with HIV, and the dental health of the person performing oral sex.

Oral sex has been shown to be a less risky activity than these practices, but is definitely not risk free. It's also worth remembering that other sexually transmitted infections, such as syphilis, herpes and gonorrhoea, can be quite easily transmitted through oral sex.

A number of studies have been published on the risks of HIV transmission from oral sex. One American study reported that of 122 gay men with HIV, 8% reported oral sex as their only risk activity. But this study doens't have much credibility. The numbers were very small. Plus some of the men in this study who initially said oral sex was their only risk activity later said they'd had unprotected anal sex.

It's worth noting that a study didn't find any cases of oral transmission of HIV over a ten year period in over 100 couples where one partner was HIV-positive and the other HIV-negative.

Another study from the US found involving gay men found the risk to be effectively zero, but didn't exclude the possibility of there being a risk.

Researchers have looked at all the studies looking at the risk of HIV transmission from oral sex. They found that the risk was very low, but not zero.

When is oral sex more risky?

You are at more risk of passing on HIV through oral sex if you have an untreated sexually transmitted infection. You are at more risk of being infected with HIV from oral sex if you have cuts, sores or abrasions in the mouth or on the gums. There is also more of a risk if you have an infection, including sexually transmitted ones, in the throat or mouth which is causing inflammation.

Having high viral load in the blood may also mean that viral load is high in the semen. Although there is good evidence that men who have an undetectable viral load in their blood usually have an undetectable viral load in their semen, this isn't always the case. Factors like untreated sexually transmitted infections can cause viral load in semen to increase. Therefore most doctors believe that you cannot automatically assume that having an undetectable viral load means you're uninfectious. However, the risk of HIV transmission from oral sex if a person has an undetectable viral load are extremely low.

The levels of HIV in vaginal fluid vary. They are likely to be highest around the time of menstruation (having your period), when HIV-bearing cells shed from the cervix are most likely to be found in vaginal fluid, along with blood. Oral sex will therefore be more risky around the time of menstruation.

How can you reduce the risks?

There are several ways to reduce the risks of oral sex. Naturally, some will be more acceptable than others to different individuals, so you must make your own decisions about the level of risk you find acceptable. If you would like to discuss these issues, ask to see a health advisor, or other health professional, at your treatment centre or genitourinary clinic. Many of the strategies below will also provide protection against other sexually transmitted infections:

You may decide that the risks of oral sex are low enough for you to continue your regular behaviour. You may prefer not to have oral sex because you do not wish to take even a low risk of HIV transmission. You may decide to reduce the number of partners with whom you have oral sex. You may decide to have oral sex with barriers such as condoms for sucking men or 'dental dams' (latex squares) for sucking women. You may decide only to have insertive oral sex (being sucked) as this appears safer than receptive oral sex (sucking). You may decide not to ejaculate into your partner's mouth or not to have someone ejaculate into your mouth. You may decide to avoid oral sex with women during menstrual periods. Look after your mouth. The likelihood of oral HIV transmission increases if one has bleeding gums, ulcers, cuts or sores in the mouth. Don't brush your teeth or floss before oral sex. Take regular sexual health screening. This will identify if you have any sexually transmitted infections, which may increase the likelihood of you transmitting HIV to a negative partner, and reduce the likelihood of you contracting HIV if you are HIV-negative.

What You Should Know about Oral Sex June 2009 (from the CDC)

Oral Sex Is Not Risk Free

Like all sexual activity, oral sex carries some risk of HIV transmission when one partner is known to be infected with HIV, when either partner's HIV status is not known, and/or when one partner is not monogamous or injects drugs. Even though the risk of transmitting HIV through oral sex is much lower than that of anal or vaginal sex, numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted diseases (STDs). Abstaining from oral, anal, and vaginal sex altogether or having sex only with a mutually monogamous, uninfected partner are the only ways that individuals can be completely protected from the sexual transmission of HIV. However, by using condoms or other barriers between the mouth and genitals, individuals can reduce their risk of contracting HIV or another STD through oral sex.

Oral Sex is a Common Practice

Oral sex involves giving or receiving oral stimulation (i.e., sucking or licking) to the penis, the vagina, and/or the anus. Fellatio is the technical term used to describe oral contact with the penis. Cunnilingus is the technical term which describes oral contact with the vagina. Anilingus (sometimes called "rimming") refers to oral-anal contact. Studies indicate that oral sex is commonly practiced by sexually active male-female and same-gender couples of various ages, including adolescents. Although there are only limited national data about how often adolescents engage in oral sex, some data suggest that many adolescents who engage in oral sex do not consider it to be "sex;" therefore they may use oral sex as an option to experience sex while still, in their minds, remaining abstinent. Moreover, many consider oral sex to be a safe or no-risk sexual practice. In a national survey of teens conducted for The Kaiser Family Foundation, 26% of sexually active 15- to 17-year-olds surveyed responded that one "cannot become infected with HIV by having unprotected oral sex," and an additional 15% didn't know whether or not one could become infected in that manner.

Oral Sex and the Risk of HIV Transmission

The risk of HIV transmission from an infected partner through oral sex is much less than the risk of HIV transmission from anal or vaginal sex. Measuring the exact risk of HIV transmission as a result of oral sex is very difficult. Additionally, because most sexually active individuals practice oral sex in addition to other forms of sex, such as vaginal and/or anal sex, when transmission occurs, it is difficult to determine whether or not it occurred as a result of oral sex or other more risky sexual activities. Finally, several co-factors may increase the risk of HIV transmission through oral sex, including: oral ulcers, bleeding gums, genital sores, and the presence of other STDs. What is known is that HIV has been transmitted through fellatio, cunnilingus, and anilingus.

Other STDs Can Also Be Transmitted From Oral Sex

In addition to HIV, other STDs can be transmitted through oral sex with an infected partner. Examples of these STDs include herpes, syphilis, gonorrhea, genital warts (HPV), intestinal parasites (amebiasis), and hepatitis A.

Oral Sex and Reducing the Risk of HIV Transmission

The consequences of HIV infection are life-long. If treatment is not initiated in a timely manner, HIV can be extremely serious and life threatening. However, there are steps you can take to lower the risk of getting HIV from oral sex.

Generally, the use of a physical barrier during oral sex can reduce the risk of transmission of HIV and other STDs. A latex or plastic condom may be used on the penis to reduce the risk of oral-penile transmission. If your partner is a female, a cut-open condom or a dental dam can be used between your mouth and the vagina. Similarly, regardless of the sex of your partner, if your mouth will come in contact with your partner's anus, a cut-open condom or dental dam can be used between your mouth and the anus.

At least one scientific article has suggested that plastic food wrap may be used as a barrier to protect against herpes simplex virus during oral-vaginal or oral-anal sex. However, there are no data regarding the effectiveness of plastic food wrap in decreasing transmission of HIV and other STDs in this manner and it is not manufactured or approved by the FDA for this purpose.

This article was provided by U.S. Centers for Disease Control and Prevention.

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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