Who to believe (TRANSMISSION VIA ORAL SEX, 2010) (BAREBACKING, 2010) (HOW DOES THE TOP GET INFECTED DURING ANAL SEX, 2010)
Sep 21, 2010
Years back I read an article where a doctor did a study on oral sex. Her findings were that it was absolutely not possible to become HIV+ from giving oral sex.
The very next day an article I had read years before was released and said: "It is absolutely possible to become HIV positive from giving oral sex."
It made me so angry because I did not know who to believe.
I went to my doctor and talked about it all. His belief is that oral sex is completely safe and if you are topping you are likely safe as well.
Yet...everyone is screaming: "topping is not safe."
Then I just saw a "BB" video that ended with "Stop the condom Nazis." This actually scared me too. Although I know there is a strong push for BB-ing, I want to know who to believe.
What are my real chances of catching HIV from being a top?
I might add that I have been out for 28 years and have topped a lot of guys BB. However, I don't want these your kids that did not experience all their friends dying to have to face another epidemic.
I know this is very conflicted, but if you have any answers I would appreciate it.
Response from Dr. Frascino
Yes, it's possible to acquire HIV from oral sex. See below.
The physician who "believes" you are "likely safe" if you are topping (presumably bareback) is a total idiot. I'd fire him immediately and find a more competent physician! (See below.) Barebacking is risky business. There is absolutely no controversy on this point. By way of analogy certainly it's possible, if I'm lucky, for me to close my eyes and walk across a busy intersection during rush hour traffic and manage to get to the other side unharmed. However, if I continue to do this over and over again, eventually I'll get squished to smithereens by a bus. Think of barebacking as equivalent to sexual Russian Roulette. Sure, you may be lucky enough to pull the trigger (bareback) a number of times, but eventually you blow your brains out (get infected with HIV). Only you can decide what level of risk you're willing to take.
Please post this (TRANSMISSION VIA ORAL SEX, 2010) Sep 15, 2010
because it is rarely asked (actually often asked but rarely posted). I gave a BJ and got cum in my mouth (all other posts claim no cum in mouth). No straight guy question about lap dances, but a real risk. What are my risks of HIV?
Response from Dr. Frascino
Actually it's been asked and answered numerous times. We have an entire chapter devoted to oral sex in the archives. Check it out!
The CDC's estimated per-act statistical risk for acquiring HIV from unprotected receptive oral sex (including getting a mouthful of high-protein baby-batter) with a partner confirmed to be HIV positive is 1 per 10,000 exposures. Also see below.
Oral Sex: What's the Real Risk? July 2010
The chances of HIV being transmitted from an HIV+ person to an HIV-negative person depends on the type of contact. HIV is most easily transmitted through unprotected (no condoms) anal sex, unprotected vaginal sex, and sharing injection drug equipment.
Oral sex has been shown to be less risky than these activities, but it is not risk-free. It is also possible to get other sexually-transmitted diseases (STDs), such as syphilis, herpes, and gonorrhea through oral sex.
Studies on the Risks of Oral Sex
Even though oral sex is a lower-risk activity, people have reportedly become infected with HIV in this way. A number of studies have tried to determine the exact level of risk of oral sex, but it can be difficult to get accurate information from study participants. Since oral sex is not the only sexual activity for most people, it is also difficult to single out oral sex as the definite way HIV was transmitted. Because of these issues, different studies have reported different levels of risk ranging from less than 1% to about 8%.
The take home message of these studies is that oral sex carries a small but real risk.
Tips for Safer Oral Sex
Oral sex is more risky if you or your partner have an untreated STD, bad oral hygiene (bleeding gums, ulcers, gum disease), or take ejaculate (cum) in the mouth. There are things you can do to reduce the risk associated with oral sex:
Don't have oral sex if you or your partner have mouth sores (such as oral herpes lesions). Look at your partner's genitals for lesions (cuts or scrapes). If you find something, don't believe your partner if he or she tells you it was caused by the heat, the weather, or clothes. You should avoid any contact with the area until a health care worker has examined it. Don't floss, brush your teeth, or do anything that would create abrasions or cuts in your mouth before performing oral sex. Use mouthwash or a breath mint instead. Avoid swallowing pre-cum, semen, or vaginal fluids. Use latex condoms for oral sex on a man (try the unlubricated, flavored ones). If you perform oral sex without a condom, finish up with your hand, or spit semen out and rinse with a mouthwash rather than swallowing. Use a dental dam or cut-open condom for oral sex on a woman or for rimming (licking the anus). Dental dams are squares made from latex. Put some water-based lube on one side of the dental dam or a condom that has been cut open. Then stretch the dam or condom over the vagina or anus with the lubed side facing down. This gives you a thin barrier between your mouth and the vagina or anus. (Some people use plastic food wrap as a barrier. While plastic wrap has been shown to prevent the transmission of herpes infections, there is no proof that it will prevent the transmission of HIV.) Avoid vaginal oral sex during menstruation to prevent contact with blood. Take care of your mouth. The likelihood of oral HIV transmission increases if you have bleeding gums, ulcers, cuts, sores, or infections in the mouth. Find alternatives Try massage or mutual masturbation. Use a vibrator (use a condom when sharing). Avoid vigorous, prolonged oral sex ("deep-throating"). Avoid mouth or throat trauma caused by a large number of partners in a short period of time.
Taking Care of Yourself
Any type of sexual activity with an infected person carries a risk of HIV transmission. While the risk of becoming infected through unprotected oral sex is lower than that of unprotected anal or vaginal sex, bad oral hygiene and taking cum in your mouth makes oral sex more risky.
If you or your partner is HIV+, you should decide what steps to take to make all types of sex as safe as possible. If you would like to discuss these issues, see a sex educator or health care provider at your local AIDS service organization or treatment center.
This article was provided by The Well Project.
Sick of Oral Sex Questions (TRANSMISSION VIA ORAL SEX 2010) Jul 23, 2010
I am an Emergency Room doctor, last week I had someone asked me wither being the insertive partner of oral sex (getting sucked) is a risk for HIV, I said no. Some of my colleagues said yes, we decided to debate this out like academics (I can imagine you laughing and shaking your head at the screen right now). After some reading, I think the mixed opinion among doctors is pretty much same in the field of GU medicine.
How I see it, theoretical risk is possible, but after 25-30 years of HIV endemic (billions of blow jobs later) and no clear documented report of receptive to insertive oral sex HIV transmission, can't we just come to the consensus that there is no risk from insertive oral sex? When we tell HIV scared people there is a very low risk, they don't really hear the "very low" part they just hear the "risk" part, hence the mountains of questions and anxiety about oral sex.
One can imagine a lot of day to day scenarios as a "theoretical risk": what if I go to a bar, the barmen cut his finger served me a drink and I drank it immediately? What if someone has bleeding gum and his spit came into contact with my eye when he sneezed near me. Has anyone thought to caught HIV that way? No. . . . . I think we get the picture here right?
So whats the difference when the scenario is getting your willy sucked and HIV risk? Remember earlier in the epidemic people were worried about mosquito bites and HIV transmission? theoretically possible? Yes. Ever documented to have happened? No. and yet we confidently advice people that it is not a risk for HIV. Just like the hundreds of worried mums who bring their kids into the ER after their children got stuck with hypodermic needles found on the beach, any of them got HIV? Not that I have heard of.
Understandably, it is a difficult thing to study, I can see so many confounding factors reading a few papers out there on the subject, but from most of discordant couple data we got, if they used condom consistently for virginal or anal sex the HIV -ve partner stays HIV -ve. I wonder if they always used condom for oral sex, I think unlikely.
You have more experience then most experts in the field, I will be interested to hear your thoughts on the subject, if I am wrong then there is a learning point for me from a well respected World expert!
Response from Dr. Frascino
While I agree there is room for debate, I do not personally believe we can "just come to the consensus that there is no risk from insertive oral sex." See below. However, there is indeed consensus regarding some of your other scenarios: the barman with a cut on his finger, mosquitos, etc. These are indeed absolute no-risk situations.
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
Response from Dr. Frascino
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.
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
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.
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.
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.
Positive through oral sex (TRANSMISSION VIA ORAL SEX 2009) Dec 29, 2009
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.
Response from Dr. Frascino
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.
HIV from Oral Sex Confirmed!!!!! Dec 25, 2009
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
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.
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
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.
Oral sex/Magnetic Couple (TRANSMISSION VIA ORAL SEX) Jun 15, 2009
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
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.
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."
How does the top get infected in anal sex? Sep 14, 2010 (BAREBACKING, 2010) (HOW DOES THE TOP GET INFECTED DURING ANAL SEX, 2010)
I was reading your pages on amounts of HIV in body fluids and then read about top/active partner in anal sex getting infect but it did not say how. Obviously if it was vaginal sex the top would get infected by vaginal fluid. What is the body fluid for anal sex? I have heard people say it is blood-to-blood but where is the blood on the top? And I have never seen blood coming from the bottom. How come after all these years it is all a mystery?
Response from Dr. Frascino
Mystery? What mystery? See below.
About the Breeder's Question (RISK OF HIV AS A TOP, 2010) (ANAL MUCOUS, ANAL FLUIDS, RECTAL SECRETIONS, 2010) May 15, 2010
I'm glad you clarified something about the risk for tops. You stated the CDC says the risk of an unprotected, insertive partner with a bottom known to be HIV poz is 6.5 per 10,000 exposures. You said that was a very high relative risk. Whenever I've seen those numbers before, I always thought fairly low risk. It proves I need to do my homework.
The whole risk thing is interesting to me. I know tops get infected. However, every total top I know keeps testing negative after years of bareback sex. I guess they have just been lucky. It seems everyone I know who is poz got it by bottoming. If the risk is that high for total tops, I would think there would be more than one million HIVers in the U.S. I always thought straight guys got it because vaginal fluid carried HIV better than the anus.
I know you've probably talked about this before, but I'm always curious--
Would you mind explaining the difference between putting your penis in someone's mouth and their butt? What is happening in the butt? Does there have to be blood involved in the butt to infect the top? Or, is HIV just present in the anus in fluid? That fluid/blood would have to make its way up the uretha or a sore on the penis? If the top ejaculated, would that force everything out?
My negative partner keeps telling me he could top, because it is a very low risk. I don't even like the idea of letting him perform oral on me.
Response from Dr. Frascino
The CDC statistical estimate of risk provides information about relative risk rather than actual risk applicable to a specific encounter. Unprotected insertive anal sex with a poz partner (6.5 per 10,000 exposures) is, for example, much riskier than unprotected receptive oral sex with a poz partner (1 per 10,000 exposures), but not as risky as unprotected receptive anal sex with a poz partner (50 per 10,000 exposures). There are many confounding variables for a specific encounter, both viral (viral strain, viral load, etc.) and host (immune integrity, concurrent illness, trauma during sex, etc.).
As for knowing total tops who keep testing negative, even after barebacking, yes, they are lucky. Also, would you really expect HIVers who become infected from voluntarily putting themselves at risk (when they obviously should have known better) to broadcast the news they lost their game of sexual Russian Roulette? I can assure you after caring for a great many HIVers I've personally known many total tops who became infected. (See below for an example.)
Next, you want me to explain the difference between putting your penis in someone's mouth and in his butt? Dude, I've known guys who were a bit confused about anatomy, like not knowing which side their liver was on, but not knowing the difference between one's mouth and butt???? Now that's a bit worrisome!
As for HIV risk, saliva does contain components that inhibit HIV. Also, there is much less risk of local trauma from oral as compared to anal sex. Blood does not have to be present for a top to be infected during anal sex. (See below.) The urethra is lined with a mucous membrane. HIV can be absorbed across a mucous membrane without cuts, sores or trauma. Ejaculation does not "force everything out," as infected fluids merely need to come into contact with the mucous membrane; they don't have to travel all the way up the nine-plus inches (if you're Italian) of your Mr. Happy.
Regarding your negative top gun, I'd suggest you have him read the information on this site, in its archives and on the related links. We have an entire chapter on magnetic couples in the archives.
Re: risk of HIV as a TOP May 15, 2010
I've always been an exclusive top, a medical professional who couldn't believe you could get HIV from just topping. I figured the worst that could happen would be the usual STD's and I would self medicate
Well here I am HIV positive
Don't top with out protection. I've known others just like me.
Response from Dr. Frascino
Hello Medical Professional,
Thank-you for your honesty and taking the time to write in. I'm confident your testimonial will save lives. See below.
I'm here if you ever need me. Let's get through this together as positively charged medical professionals dedicated to helping others stay HIV free.
HIV transmission thru urethra Feb 16, 2010
about 4 weeks ago I had some contact with the anal fluids of another guy. I was going to top him, but decided I wouldn't. I just fingered him and sort of penetrated him without going all the way in. I doubt this guy is HIV+ but there's always that chance. A few weeks later, I got a urinary tract infection - the whole works, diarrhea and everything, and took antibiotics which cleared it up. I was really startled to learn that HIV can enter through the urethra. But it makes no sense to me how anal "fluids" (whatever they might be...sweat or just ordinary liquid secretions?) could have a sufficiently high concentration of HIV to infect someone? It seems like nowadays it's just better to avoid sex altogether...everyone just seems to be a germ farm nowadays. Last year I had a really nice session of kissing with a guy, which resulted in a 6 week long upper respiratory infection (which he came down with too, but he didn't know it while we were making out.) Anyhow, any light you can shed on my urethral contact with anal fluid would be appreciated. Thanks for your time, -Andy
Response from Dr. Frascino
The rectum is lined by a mucous membrane. Mucous membranes secrete mucous ("anal fluid"). Your nose and mouth also are lined with mucous membranes and they too are always "wet," right? HIV can permeate across mucous membranes (but not intact skin). As it turns out, the urethra is also lined with a mucous membrane. Consequently, if your unprotected tallywhacker's urethra comes into contact with infected anal fluid, HIV can be absorbed across the mucous membrane and result in HIV transmission/acquisition.
Why consider give up sex? Isn't it easier just to put a latex condom on your big bopper?
insertive issues (Rectal secretions from men who have sex with men contain more HIV than blood or semen) (ANAL MUCOUS, RECTAL SECRETIONS, 2010) Mar 30, 2010
I have a hard time believing as an exclusive TOP that I contracted this virus through anal juice sneaking up my urethra while servicing a bottom. I'll bet one way a top more likely gets infected and probably what happened to me was topping a guy who had just had sex with someone else (yes there are actually places where that might occurr!!) and had someone else's infected semen still in his rectum, and that's what snuck up my urethra, semen having a much higher viral load than anal secretions. Theoretically, therefore I could have been infected by some one I literally did not have sex with and the bottom might not have even been poz. What do you think? I'll bet this happens more often than believed.
Response from Dr. Frascino
What you choose to believe or "have a hard time believing" is, of course, totally up to you. However, it really doesn't change scientific fact. Do I think your hypothesis is correct? Nope. Sorry, Charlie, I don't. You can read a great deal about the biology of HIV transmission in the archives and related links if you so desire.
Hello Dr. Frascino, I was wondering if you could actually explain this post considering I am currently on PEP for having sex with a HIV negative bottom but who I think had an unknown person's ejaculate in his anus when I topped him. If this doesnt seem like a reasonable route for transmission, I will most likely stop the PEP, considering the bottom is negative. Could you please shed some light..thank you for your help.
Response from Dr. Frascino
Dude, it really doesn't matter what you personally believe or what wild notions you might concoct about your cock and acquisition of HIV. The reality of your situation is that you became infected with HIV because you unwisely decided to have unsafe sex with your Brokeback Mountain buddy. Top-gun or bottom-boy unprotected anal sex is risky business. I should also point out several studies have found very high levels of HIV in rectal mucosa secretions (anal mucous). (See below.) Heads up top guys! Shield your rocket or keep it in your pocket!
Rectal secretions from men who have sex with men contain more HIV than blood or semen Chris Gadd, Wednesday, June 16, 2004 Levels of HIV RNA in rectal mucosa secretions from men who have sex with men (MSM) are higher than those in blood and semen, according to a study presented in the July 1st edition of The Journal of Infectious Diseases. The results suggest that unprotected insertive anal intercourse may involve exposure to higher levels of free virus than previously believed, even where the receptive partner's plasma viral load is undetectable on HAART.
In contrast to previous studies, which have examined HIV levels in rectal biopsies (tissue samples) or swabs from the anus in men with suppressed viral loads, this study looked at secretions from the rectum in a group of men with varying degrees of viral suppression and antiretroviral drug exposure.
"HIV RNA was often found at high levels in rectal secretions, even in men receiving antiretroviral therapy, and paired HIV RNA levels in rectal secretions were greater than those in either the blood or seminal plasma among HIV-infected MSM," state the authors. Furthermore, "antiretroviral therapy had a greater direct effect on levels of HIV in seminal plasma than in rectal secretions."
The investigators recruited 64 HIV-positive MSM from sexually transmitted disease clinics in Seattle, USA, and Lima, Peru between December 1999 and January 2001. Twenty-seven (42%) of the men had been on a stable antiretroviral regimen for at least 30 days, and the remainder were drug-naive.
HIV viral loads were measured two to three times over four weeks in swabs taken from the rectum, and in the blood and semen. Because the samples were diluted at different ratios, the lower limit of detection was not equal in the three samples (rectal secretions: 8000 copies/ml; blood: 400 copies/ml; semen: 800 copies/ml). However, the authors used a mathematical correction to estimate the distribution of viral loads in samples below the limits of detection.
Overall, HIV viral loads were higher in rectal secretions (median 91,200 copies/ml) than in blood (median 17,400 copies/ml; p < 0.05) or semen (median 3550 copies/ml; p < 0.05). Nevertheless, HIV viral loads in the blood were correlated with those in the rectum (p < 0.001) and the semen (p < 0.001).
A similar pattern of viral loads was observed in the men who were taking antiretroviral therapy. Rectal secretions contained a median of 3980 copies/ml, compared with 200 copies/ml in blood (p < 0.05) and 1000 copies/ml in semen (p < 0.05). Ten (37%) of 27 rectal samples from these men had detectable viral loads, nine (35%) of 26 blood samples, and eleven (55%) of 20 semen samples, a much higher level than observed in most other studies, the authors note.
In the men who were not taking antiretroviral therapy, HIV viral loads differed significantly among all three samples, with rectal secretions containing the highest viral loads (median 316,000 copies/ml), compared with a median of 63,100 copies/ml in the blood and 12,600 copies/ml in semen (p < 0.05 for all comparisons). These men also had higher rates of detectable viral loads in the rectum (35 [95%] of 37 samples; p < 0.05), and blood (37 [100%] samples; p < 0.05), but not in the semen (28 [78%] of 36 samples; p = 0.08).
Using mixed-effects model analysis without controlling for blood viral loads, the authors demonstrated that the use of antiretroviral therapy caused a 1.3-log10 reduction in rectal viral loads (p < 0.001) and a 1.4-log10 reduction in seminal viral loads (p < 0.001). Lower CD4 cell counts were also associated with higher viral loads in both samples (p = 0.03 and 0.004 respectively).
When blood viral loads were included in the model, the authors found that a one-log10 reduction in blood viral loads caused a 0.5-log10 reduction in both rectal and seminal viral loads (p = 0.006 and 0.02 respectively). However, use of HAART was found to reduce viral loads in the semen, but not rectal secretions (p = 0.003 and 0.5 respectively).
This leads the authors to suggest that the effect of HAART on rectal viral load occurs as a result of viral load reductions in the blood. In contrast, antiretrovirals may affect viral levels in the semen directly. This "may be due to differential levels of antiretroviral drugs or to anatomic and immunologic differences in the male genital tract versus rectal mucosa."
Zuckerman R A et al. Higher concentrations of HIV RNA in rectal mucosa secretions than in blood and seminal plasma, among men who have sex with men, independent of antiretroviral therapy. J Infect Dis 189: 156-161, 2004.
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