[Question #3716] test
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87 months ago
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test
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87 months ago
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I had unprotected mutual oral sex with another man 4 days ago. Neither of us ejaculated and I didn’t sense pre-ejaculate in my mouth.
Foolishly, earlier in the day I carried out hydrogen peroxide teeth whitening (causing my gums to be very sensitive/sore; although there was no bleeding as far as I know). I also used mouthwash immediately before the oral.
The day after the exposure the tip of my penis stung. I thought this may be because of washing with soap; however, it is still sensitive now, 4 days later. I have no other symptoms (no discharge, no pain when urinating, although my urine stream does seem to be “spraying” more than usual).
1) what is the HIV risk from this exposure, particularly given the preceding hydrogen peroxide treatment, sore gums and use of mouthwash?
2) could the stinging penis tip be indicative of any STD?
3) Many websites say tests for gon/chly won’t be effective for 2 weeks: is that correct or can I rely on a test taken now?
3) I have type 1 diabetes and since the encounter my blood sugars have been uncharacteristicaly high. I usually have very tight control. I nearly had a break down the night after the exposure when my blood sugar was sky high (this never happens), as I was scared it was HIV causing it. I know that viruses / infections cause high blood sugars and I am worried this could be my body mounting defence to new HIV infection. Does this, medically, make sense? Could I have contracted HIV and it’s impacting my blood sugar control?
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H. Hunter Handsfield, MD
87 months ago
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Welcome to the forum. Thanks for your confidence in your services.
We get many questions about oral sex and its risks for HIV and other STDs. You can use the search function to read others, or just scan any 10-20 threads at random. As you will see, our response is always consistent: oral sex is safe sex. It's not completely free of HIV/STD risk, but the chance of infection is far lower than for vaginal or anal sex, virtually zero for some STDs (including HIV) and low risk for all. The three main STDs from oral sex are gonorrhea, herpes due to HSV1 (the main cause of oral herpes), and nongonococcal urethritis (NGU), perhaps often due to entirely normal oral bacteria that are likely harmless for both affected men and their sex partners.
In theory, stinging of the penile tip could be a urethritis symptom. But probably not: all three of the likely causes generally result in discharge as the main symptom. And indeed soap is very irritating to the urethra and can cause pain, especially with the next couple of urinations.
To your specific questions:
1) There has never been a proved case of HIV transmitted oral to penis, and only very rare cases penis to mouth. Based on some infected persons' beliefs (not proof) of how they were infected, CDC once calculated the chance of HIV infection to be 1 in 10,000 for an oral partner if the penile partner were infected, or 1 in 20,000 in the opposite direction. Those numbers are equivalent to giving or receiving BJs by infected partners once daily for 27 years and 55 years, respectively, before transmission might be likely. And of course your risk is lower than this, since you don't know that your partner has HIV (and probably does not). Sore gums, peroxide, tooth brushing, etc make no known difference in HIV transmission risk.
2) As implied above, I doubt the stinging is caused by any STD. However, you could have a urine gonorrhea test if the expected negative result would add to your confidence you don't have it. (Gonorrhea testing more or less automatically includes chlamydia, but that's one of the STD rarely transmitted by oral sex.)
3) Many sites indeed recommend waiting 2 weeks, but it makes no sense and I don't know where it comes from. Probably one or another test used by various labs restricted their initial research to people who had been exposed at least 2 weeks earlier. If so, FDA will not allow a claim of accuracy earlier than that. But that doesn't mean it's actually necessary to wait so long, and all STD clinics and other experts pay little or no attention to time since exposure. For sure testing for gonorrhea will pick up virtually all infections within 2-3 days and for sure within a week.
4) I am unaware of reports of acute HIV infection, or any other STD, altering diabetes control or otherwise affecting blood glucose, A1C, insulin activity, or insulin requirements. I imagine it could happen, but only in the presence of a systemic inflammatory response, i.e. all the main symptoms of acute HIV like fever, muscle aching, sore throat, lymph node inflammation, skin rash, etc. I cannot imagine that a change in tight blood glucose control could be the only manifestation of a new HIV infection. OTOH, certainly stress and anxiety -- through their physiologic "flight and fright" hormones (corticoids, adrenaline, etc). That seems a much more likely explanation. In any case, if control remains more brittle than normal, you probably should discuss it with your diabetes doc.
I hope these comments are helpful. Let me know if anything isn't clear.
HHH, MD
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87 months ago
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Thank you very much for your reassuring and explanatory reply. Very helpful indeed.
Just a few clarifications:
1) I am reassured to hear your view that sore gums and teeth brushing etc does not affect HIV risk from receptive oral. However, I am still extremely concerned that there have been reports of HIV being transmitted in this way and I can’t help but worry that my sore gums could have provided a large surface area for infection to take hold. How reassuring is it that he did not ejaculte in my mouth? Do most/all reports of HIV transmission resultant from giving oral sex involve ejaculation in the mouth?
2) Would a urine chlamydia test also be reliable at 5-6 days post-exposure?
3) I am assuming that it would be highly unusual for gonorrhoea or chlamydia to present with a sensitive penis tip as the sole symptom: correct?
4) Would the urine tests for gonorrhoea and chlamydia pick up NGU or does that necessitate a separate test?
5) If we assume that acute HIV infection or any other STD could actually affect insulin sensitivity / blood sugar levels, am I right in thinking that it likely wouldn’t have had an impact so soon (I noticed the high levels literally hours after / the evening of the exposure)?
Thanks again for the service you offer here.
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87 months ago
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Also, please can you confirm your professional view of window period for conclusive HIV testing using an antigen/antibody 4th gen test? I always thought you said 4 weeks was conclusive but your recent advice seems to be 6 weeks?
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H. Hunter Handsfield, MD
87 months ago
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1) I'm not aware of scientifically validated reports of enhanced risk of HIV transmission because of tooth brushing etc, only opinions that such things in theory could raise the risk. Anyway, if you think about it, there must have been billiions of oral-genital HIV exposure following tooth brushing, and the number of known transmissions can be counted on 1-2 hands.
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2) Yes, but chlamydia uncommonly infects the throat and hence transmission to penis by oral sex is very rare. There has never been a documented case. OTOH, chlamydia testing is usually done automatically with gonorrhea testing. If you do it, I am confident it will be negative.
3) Correct about gonorrhea symptoms. Possible for this to be the only symptom, but in 40+ years in this business, I don't think I've ever seen such a case.
4) NGU is a clinical diagnosis, based on symptoms, examination, and sometimes checking for WBC in the urethra. But usually harmless anyway (see my opening paragraph above).
5) It seems a reasonable assumption that any effect of acute HIV on glucose control could not come into effect until onset of the systemic inflammatory response responsible for ARS symptoms.
Almost a year ago, an authoritative review of the currently available HIV tests was published, which supported 6 weeks rather than 4 weeks as conclusive for the AgAb tests. At that time we modified our advice on this forum accordingly. However, a negative test remains highly reliable at 4 weeks, which often is a sufficient delay for confidence in the results.
If you remain concerned, I suggest you see an expert, such as an STD/GUM clinic, roughly a week after the exposure, then follow their advice about all indicated evaluation and testing. That is, don't just arrange your own lab testing.
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87 months ago
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Thank you again; your wisdom is very gratefully received!
(1) I tested negative for both chlamydia and gonorrhoea (both throat and penis). These tests were carried out at 6 days post-exposure so I trust can be conclusively relied upon without the need for me to retest?
(2) Thanks for the update on the window period for HIV testing. I really don’t know if I’ll cope waiting 6 weeks given the stress and anxiety this exposure has caused me. I am intending to test at 3-4 weeks; are you able to provide an estimate for how reliable a test would be if taken at this time?
(3) my “tip of penis stinging” has gotten slightly better but is still there at some times even now, over one week later (although mainly when I think about it, so perhaps it’s anxiety driven). Given that I can strike out gonorrhoea and chlamydia does that leave only NGU or is there anything else I should be worried about (e.g. what about herpes?) and should, for peace of mind and before resuming sex with my partner, should I consider testing for:
(A) mycoplasma;
(B) trichomoniasis;
(C) gardnerella;
(D) non specific urea plasma?
Thanks once again.
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H. Hunter Handsfield, MD
87 months ago
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I would recommend against testing for any of those organisms in this setting. If you were seen in our clinic, we would examine you carefully for visible evidence of urethral discharge, ideally at a time when you had not urinated several hours; would collect a swab specimen to check microscopically for WBC. Most likely these would be unrevealing and no treatment would be recommended nor additional testing done. Without evidence of urethritis (discharge and/or urethral WBC), there is simply no evidence symptoms like yours ever are due to any known infection, and so we don't test for them. Depending on still other symptoms that might suggest a prostate gland problem, which you have not mentioned, we might refer you to a urologist for further evaluation. But the large majority of men in similar situations -- we deal with them daily -- haves gradual improvement in symptoms and never show up with partners with evidence of any STD or other health problem. The declining frequency of your discomfort suggests you are on a pathway to this same outcome.
Once in a while, in patients with such symptoms that are particularly severe or bothersome, and with exposures other than oral (vaginal, anal) we might try a round of antibiotic, such as doxycycline. But NGU following oral exposure is never due to any STD pathogens known to be important, such as chlamydia, Mycoplasma genitalium, or trichomonas; often appears to be caused by entirely normal oral bacteria to which the urethra might have to adjust, but causing no harm; and has never been known to cause any health problem in any additional sex partners, male or female, going forward. In other words, even with NGU in this situation, treatment is a low priority and probably unnecessary.
So based on the nature of the exposure, your symptoms, and all the rest we have discussed, I really think you shouldn't be worried at all.
---That concludes this thread. I hope the discussion has been helpful. Best wishes and stay safe.