[Question #1176] hpv and oral

49 months ago
This question is more for Dr Handsfield. Since I asked my first question, I have been doing a lot of research and  trying to understand how oral sex is safe sex. Every where else I looked, it says all the risks involved. With oral HPV infecting  people and herpes, the risks seem to be  risky.  I have read on this website that HPV oral is infecting half the population at a time and if is easily transmitted , wouldn't the  risks be greater. I understand that most of the population has HPV but what about a person who doesn't have it yet( like I believe i don't )having oral sex with a prostitute who probably has it. Even though it was protected, it seems to be very risky.  I really don't understand how oral sex is safe ?  I am not trying to contradict you or be negative, its just that I have been struggling ever since my episode and have talked with a lot of people and am very very concerned 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
49 months ago
Welcome back to the forum. I'm not sure why you are looking for my opinion in particular; Dr. Hook would have addressed this no differently than I will. I reviewed your previous thread and agree with all he advised.

Host-pathgen interactions are very complex -- why particular bacteria and viruses infect some sites but not others, immunity and effectiveness of the immune system, and much more. You're essentially asking about this in regard to STDs in general and HPV in particular -- i.t. the biologic, anatomical, and behavioral reasons that oral sex is lower risk for HPV than vaginal or anal intercourse. While the reasons are not completely known, here are some aspects. The STD bacteria and viruses, probably including HPV, evolved as genitally transmitted, probably because other forms of human contact were inefficient transmission mechanisms. This probably involves greater susceptibility of speciallized tissues and cells in some sites but not others. The immune system may be more effective eliminating infection at one site versus another. Also, the different mechanics of oral versus vaginal sex may be important.

Regardless of the biological reasons, it works out that oral sex can indeed be viewed as safe sex: much lower transmission chance for all STDs than vaginal or anal sex, and virtually zero risk for some. HIV and chlamydia are rarely if ever transmitted by oral sex, so much so that if vaginal and anal sex could be eliminated in humans, both of these would rapidly disappear; oral sex is not efficient enough to sustain transmission.

Turning to HPV, the most comprehensive research finds that at any point in time, HPV can be recovered from the oral cavity or throat one seventh (about 15%) of the frequency as genital, even when 80+% of the population has had frequent oral sex. And in STD clinics (in which genital warts and other HPV problems are the most common of all diagnoses), we almost never see people with genital HPV whose only possible exposure was a partner's oral cavity. That's not to say oral sex doesn't occasionally transmit the virus, but it's obviously uncommon compared with genital intercourse.

It is also true that most educational resources don't make these distinctions. Much of what is said implies or states that if there is any STD risk at all, it's a risk, period, without distinguishing different types of sexual contact. 

Your statement that you "believe you don't have HPV" probably isn't justified. At least 90% of all people get genital HPV at one time or another, and most research indicate that it happens in over half of all people after they have had 3 different lifetime partners -- regardless of the risk profiles of those partners. Getting and having HPV should be viewed as a normal, expected consequence of human sexual activity:  not desirable, but anything that happens to 90% of people has to be considered normal. The goal for HPV is to avoid the most consequential infections to the extent practical, i.e. immunization (which prevents infection with the 9 HPV types that cause 90% of cancers and 90% of warts); for women to have pap smears to detect the most common pre-cancerous lesions many years before they become serious; and for others to be on the alert for symptoms (warts, genital sores, etc) that should be medically evaluated. But beyond these, to just not worry about it.

Sorry for such a long reply. Sometimes I take the opportunity to write a blog-like reply to which I can refer future questioners. Anyway, I hope it has helped. But let me know if anything isn't clear.

HHH, MD



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49 months ago
Thank you for the detailed answer  , It answered a lot of questions . The only clarification  I need is that you said you have seen some  Hpv transmission in oral only interactions , have you seen oral interactions  transmit Hpv using a condom ?  Thanks  . And is it true most 1 time sexual encounters don't transmit stds and it takes multiple exposures ? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
49 months ago
I don't know that I ever personally saw a patient with genital HPV acquired by oral exposure and didn't say that. For sure it happens extremely rarely if a condom is used, if ever. There would have to be substantial contact of the oral partner's lips above the condom, which is obviously unlikely -- and even that usually wouldn't result in transmission. And of course the oral partner would have to have oral HPV, which is uncommon.

Most STDs are transmitted inefficiently -- that is, even when one partner is infected, infection isn't transmitted. Therefore, risk obviously rises with increased frequency of exposure. So yes it is true that infection with any STD is relatively uncommon for any one exposure and more common in people with multiple exposures.

Most experts consider condoms optional advice for non-monogamous oral sex, but strongly promote unvarying condom use for such contacts with vaginal or anal sex.


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49 months ago
I have been doing some research and would like to get your opinion on this and if you agree with this info. 

Transmission rates from men to women and women to men are about equal and about 20% per person during a 6-month relationship period.[8] At an average of 4 sexual encounters a week,

the per-sex-act transmission rate was roughly 0.2%..  

Also I read that one of the reasons Hpv from oral is low is because the viral loads are much lower in the mouth 

Is .2% accurate for chances during a one time encounter 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
49 months ago
Caclucating per-exposure transmission risks is very dicey, and probably depends on all sorts of factors that are difficult to analyze or control for. Examples might include how recently the source partner was infected (probably higher transmission risk for new rather than longer lasting infections); other inflammatory conditions that might increase transmission risk; details of the sexual exposure (duration, vigor and hence chance of micro trauma to genital tissues); exactly where the source partner is infected (vaginal opening: labia? cervix?); and undoubtedly others. Accordingly, I cannot vouch for the transmission rates you have quoted. However, I agree that lower viral loads in the oral cavity is a logical reason why oral HPV may be inefficiently transmitted. Also, as noted above, oral infection is a lot less common than genital.

I would advise you to re-read the concluding paragraph of my main reply above. And stop worrying so much about this! It's simply not a big deal.

That compeltes the two follow-up comments and replies included with each question and hence ends this thread. I hope the discussion has been helpful. Please note that repeated questions on the same issue are not permitted. You've had replies to two questions, so let's make this the last one. Thanks.
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