[Question #4035] Oral Sex HIV Risk

32 months ago
I am a 70 year old man with a bipolar condition that makes me susceptible to risky behavior.  Recently, I gave oral sex (provided a blow job) to a man of similar age at a video arcade.  It is the only time I have had any type of sex with a man.  He ejaculated what seemed like a small amount of semen in my mouth (against my wishes).  I had no apparent sores, lesions, cuts, or blood in my mouth.  I reviewed your former medhelp.org website, which now is dated, and believe it indicated that this type of activity under these circumstances had almost no risk.  However, I notice that other sources (including CDC) seem to suggest the risk is not insignificant.  Could you please give me a risk assessment based upon current research and understanding and let me know to what extent (if any) I should be concerned?  Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
Welcome to the forum. Thanks for your question and your confidence in our services.

First, I would point out that it's very uncommon to see STDs in men your age, at least in public STD clinics. Of course there are exceptions the risk isn't zero, and could be quite high in someone who frequently has anonymous sex in video stores or similar settings. OTOH, one reason STDs are uncommon in older persons probably has to do with partial immunity due to numerous past infections or exposures. Whatever the reasons, infections in men your age are uncommon.

Second, your online research has come to the right conclusion about STD risk from oral sex. While not entirely risk free, the chance of infection is low enough that oral sex is considered quite safe, if not perfectly safe. Having performed fellatio, especially with receive the ejaculate in your mouth, you could be at risk for gonorrhea, syphiis, and an extremely low risk of HIV. (The last has been estimated at 1 chance in 20,000, if the penile partner has HIV. That's equivalent to giving BJs to infected men once daily for 27 years before transmission might be likely.) As for advice from CDC and other sources, many (most?) make no distinction between risk levels -- if there is any risk at all, they simply describe various sexual practices as risky or not. (Sometimes the people writing the advice truly don't understand the differences. In other cases, including CDC, there is an over-abundance of conservative caution, driven in part by medicolegal concerns.)

What to do now? Probably nothing. However, if you would like (or emotionally feel the need) for greater certainty, see a doctor or clinic for testing. A throat swab to check for gonorrhea would be valid any time more than a few days after exposure, and conclusive blood tests for HIV and syphilis can be done at 6 weeks (and nearly conclusively at 4 weeks). Better still, if you are able to contact your partner, it sounds like he would benefit from STD/HIV testing. Perhaps he would be willing to accompany you for mutual, simultaneous testing. If negative, you could be 100% confident you weren't exposed.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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32 months ago
Thanks for such a comprehensive and educational response.  Its value far exceeds its cost.  Three questions:

1.  Am I safe in assuming that the 20,000 incidents (of which one resulted in HIV) probably included persons with sores, lesions, or bleeding gums that provided an easy transmission route?   
2.  If so, would it be likely that the 1 in 20,000 actual transmissions would have been someone with such a problem? 
3.  Please correct me if I am wrong, but I think I read on your former website that a cut, sore, or lesion in the mouth would have to be rather substantial or noticeable to create a transmission risk?

Thanks for your advice to test for other STDs. I had presence of mind to do so and also took 2000 mg of Zithromycin as a prophylactic.  I see no reason to test at this point — focusing mainly on trying to manage my manic episodes.   Thanks Dr. Handsfield.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
1) Yes, correct.

2) Such conditions might somewhat elevate the risk. But so what it the risk were doubled, for example. Would 1 in 10,000 be significantly worrisome?

3) Yes, it is generally believed that such lesions would have to be fairly prominent. In other words, it you noticed nothing along these lines, you can be confident they were not present.
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32 months ago
Thanks again.  One thing I just thought of is that I contracted genital herpes about 45 years ago.  Breakouts have been infrequent, and I do not recall any in the recent past.  They only have occurred on my penis, and  there was no contact there.  Am I safe in assuming this is not a material factor?  This puts me at the end of my sesssion.  I appreciate your helpful counsel via this process.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
32 months ago
Most likely your genital herpes is caused by type 2 herpes simplex virus (HSV2). Having HSV2 roughly doubles the risk of HIV if exposed. Whether or not you have an outbreak at the time, or the frequency of outbreaks, makes little or no difference; just having it (with or without symptoms) doubles the risk. Once again double risk might sound like a big deal -- but as described above, double risk for oral sex still means only 1 chance in 10,000, and only if your partner has HIV, which isn't necessarily the case.

That completes the two follow-up comments and replies included with each question. I hope the discussion has been helpful. Best wishes.

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