[Question #4109] ORAL SEX

30 months ago
I am a little worried. I have a friend who recently told me he is positive but has been taking descovy since May, 2018. He showed me his most recent report, July 5, 2018, which was negative sign 20, undetected. He also tested negative for std's.

We wrestle a few times a month, great exercise and I know the only way to be infected in this case would be if we both have gaping, bleeding wounds. However, recently, four times in the past three months, we have been having oral and I am the one giving the oral. It has been unprotected. The most that has ever happened has been some pre-cum on his part. However, I do have gums that bleed when I brush. When they do bleed (not all the time) it is always less than 2-3 minutes then it's over. By the time I reach his place, it is well over an hour later so I'm reasonable sure there is no bleeding, of course, not 100%. But, if they are bleeding, am I at risk for hiv? I went to the health clinic the other day and they gave me a rapid test that they said was valid through June 25th, negative. They also gave me a blood test, results came back this morning, all negative. They would not give PEP as they said the risk was too small. One last thing, there is a major discrepancy on the internet regarding how much blood is needed for an infection to occur.  Some say a small amount of blood would result in transmission while others say that it needs to be gushing.  Which one is correct?  Please advise.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
30 months ago
Welcome to the forum. Thanks for your confidence in our services.

Two parts of your question are by far the most important, probably the only important parts of your question. First and most important, being on HIV treatment with undetectable virus in the blood prevents transmission of the virus. Period, no known exceptions. To a point that some experts recommend that even with spouses or other loved ones, condoms are unnecessary for vaginal or anal sex. There has never been a known HIV transmission from someone on such effective treatment. Second, oral sex is zero risk for HIV or close to it. Even if your partner had a high viral load, the average risk from performing oral sex (i.e. for transmission from penis to mouth if the penile partner is infected) is 1 chance in 10,000. That's equivalent to giving BJs to infected men once daily for 27 years before transmission might be likely. The risk in the other direction, i.e mouth to penis, is even lower, around 1 in 20,000 (55 years). Indeed, there has never been a proved case of HIV transmission mouth to penis.

What about wrestling, blood exposure, etc? There have been no studies, but all the evidence is that if HIV cannot be detected in the blood, there is no transmission risk from blood exposure. So I also would not worry about those evetns.

"How much blood exposure to be a risk?" The reason there is conflicting information is that there are no conclusive research studies or data. However, from all we known a large exposure (a "gush" as you put it) probably is necessary. What we know for sure is that even the busiest HIV/AIDS clinics have no patients whose only apparent risk was minor blood exposure. Whenever someone says otherwise, i.e. denies a traditional exposure, it always turns out they were wrong. Some were lying about risks, and others had risks they didn't recognize (e.g. the woman whose husband, unknown to her, had sex with men or was an injection drug user). Also, many public health agencies and other experts make conservative statements: that is, they don't distinguish between theoretical risks (e.g. scant blood exposure) and major, documented risks (e.g. large blood exposure). Sometimes this is driven by medicolegal considerations -- their lawyers advise them to bend over backwards in how they warn people. However, we and similar forums have the luxury of relying on documented cases and data -- and these support the "gushing" conclusion.

The standard medical advice is that the regular sex partners of HIV infected persons should be tested from time to time, and this applies to you. Assuming no changes in the effectiveness of your partner's treatment, and with the kinds of contact you describe, the chance you'll ever catch HIV from his is near zero. OTOH. the advice for occasional testing, like once a year, still makes sense and I suggest you follow it. But this really shouldn't be a major worry for you.

Final comment:  if any doubt about any of this, I recommend you accompany your partner to his next appointment with his HIV doctor or clinic, assuming he agrees. I'm confident they will confirm what I have said above.

I hope this has been helpful. Let me know if anything isn't clear.

HHH, MD

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
30 months ago
I forgot to add that I agree 100% with the doctor who declined to give you PEP.  I also would have refused that request, for all the reasons above.

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30 months ago
Thank you, doctor.  I did my research and I can say that I have come to really trust you and Dr. Hook.  Please keep up the good work, people need you.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
30 months ago
Thanks for the kind words.---
30 months ago
I do have one follow up question, if the person is on medicine and they are undetectable, why do they say to wait for 6 months of being undetectable before you engage in activities without a condom/other protection?  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
30 months ago
This just provides a safety margin. A newly treated person's viral load may vary during the first few weeks or months of treatment. If s/he were tested, say, once a month with low or undetectable levels, it is still possible to have periods of higher viral load not detected by testing. After a few months, the viral load is more predictable. In addition. many people who start anti-HIV treatment don't stick with the program. After 6 months, most people still on treatment are likely to continue.---
30 months ago
May I ask you one more question?  In regards to frottage, I know that the tip of my penis did touch the other guys anus (and vice-versa) but there was no penetration.  Is this something to worry about?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
30 months ago
Sexual transmission of HIV and other STDs is extremely rare, if it occurs at all, without actual penetration. While nobody can say the risk is zero, I am unaware of any reported cases after such contact.

Have safe sex only, or be mutually monogamous with a committed partner; in sex potentially HIV infected partners, especially other men, assure that those partners are getting effective anti-HIV treatment and have low or undetectable amounts of virus in their blood; and never share drug injection equipment. If you follow these guidelines, you need never worry about getting HIV. Common sense says it would also be reasonable to limit your wrestling with your HIV infected friend in a way that prevents bleeding injuries. 

We're beyond the two follow-up comments and replies included with each thread, so that ends this discussion. I hope it has been helpful. Best wishes and stay safe.

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