[Question #5019] HIV risk from oral sex

25 months ago

Thank you for this amazing service.

I am concerned about an encounter I had 3 days ago with an escort in Canada. I am a 26 year old male. I have been diagnosed with HSV2 from a blood test,  no outbreaks yet. I can’t remember the number on the test but after showing it to my PCP, she confirmed it was high enough to be a true positive.

The encounter involved only oral sex. She had just started to lick the base of the shaft of my penis when I requested a condom. With the condom on we engaged in oral sex which involved deep throating, hence it was on the rougher side. She also aggressively licked and sucked my scrotum (apologies for the graphics). I also I inserted my finger in her mouth quite a bit (I bit my nails and skin so there could have been cuts).

After about 20 mins I took the Condom off and used her breasts to ejaculate.

Here are my concerns:

1. Did using the Condom help?
2. I’ve read that saliva cannot transmit hiv but sores in the mouth and other infections can make it risky. I know she smoked and she also had other customers whose semen could be in her mouth (remnants). How does that affect my risk?
3. While I had no sores on my genitals, I’ve read that having HSV2 can increase the risk of getting hiv even without sores. I’m worried, specially about the licking and sucking of my scrotum that could have other cuts and dry skin
4. I know blood is a risk to transmit hiv, what if she had some in her mouth from sores and from the aggressive oral sex we had?
5. I also have a fungal infection in that area that I am treating. Does that affect my risk?
6. Do I need to test? If yes when should that be done?
7. I have a wife, it’s a long distance situation for now. But if we meet, should I abstain from sex?

Thank you for help!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
25 months ago
Welcome to the forum. Thanks for your question and your confidence in our services.

Perhaps the first thing to remember is that escorts -- by which I mean high-priced female sex workers by appointment, as opposed to street walkers, brothel workers, bar pick-ups, etc -- generally are considered to have low rates of STD. Most know the score, select their clients with care (mostly low risk men -- guys like you!), use condoms, and get tested regularly. That's not to say your particular escort partner is especially low risk, but that's usually the case. And in general, Canada is a low risk country in terms of heterosexually transmitted HIV, and Canadian sex workers in general have low rates of HIV.

Second, oral sex is safe sex, even without condoms. I don't mean totally risk free, but the frequency of all STDs is far lower than for vaginal or anal sex, and it's essentially zero risk for some (such as HIV and chlamydia).

To your specific questions:

1) The risk would have been low even without the condom. And there was zero risk from oral contact with skin of the scrotum, penile shaft, etc. Genital skin is no more susceptible to STDs than skin anywhere on the body. Risk from oral sex comes entirely from oral exposure of the urethral opening and head of the penis.

2) There has never been a proved, scientifically well documented case of HIV transmission mouth to penis. And of course there have been billions of oral sex exposures between HIV infected and uninfected persons. The factors you mention -- oral hygiene, sores in the mouth, etc -- are extremely common, so millions if not billions of those exposure had these compoenents, yet still no proved cases. Based on stories of infected men who believe they were infected by receiving oral sex, CDC calculated the risk at 1 in 20,000, if the oral partner had HIV. That's equivalent to receiving BJs by infected partners once daily for 55 years before transmission might be expected. You risk is much lower than this, given both the nature of your partner and the condom.

3) HSV2 roughly doubles the risk of sexual acquisition of HIV, but first one has to be expsosed. And "doubling" actually is a pretty small increased risk. Would my statistics above be more alarming if the chance of transmission were 1 in 10,000 instead of 20,000?

4) What if she did? No proved cases -- and obviously some of the billions of events mentioned above must have involved blood in the mouth. Anyway, if you didn't see enough blood to be obvious, this is irrelevant.

5) No, a fungal skin infection in the genital area would not significantly elevate the risk.

6,7) There is no hard and fast rule about either testing or continuing sex at home in this sort of situation. From a strictly medical/risk assessment, no testing is needed for any STD, and it is safe to continue sex with your wife. That's what I would do if somehow I were in your situation. OTOH, many people are more reassured by negative test results than by scientific data and opinions, no matter how expert. (I don't take it personally!) Also, I suspect most people nervous enough to come to this forum are in the latter category. (The vast majority of men in your situation probably would never give it a second thought.) So it's up to you. You could have a valid urine gonorrhea/chlamydia test at any time (valid 4+ days after exposure; and an HIV antigen-antibody (4th generation) blood test and a syphilis blood test, both at 6 weeks.

I hope this information is helpful. Let me know if anything isn't clear.


25 months ago
Thank you very much for those answers. Those have definitely made me feel much better.

However I do have some follow up questions.

1. You mentioned that HSV double the risk roughly but one has to be exposed. I’m confused, I thought I was exposed in this scenario.

2. I’m actually beginning to understand more about how HIV is transmitted so I understand how the condom protected my urethral opening and the head. What my major concern was after reading a study related to HSV increasing transmission risks. What really worried my was that while the condom covered my penis, my scrotum was completely exposed and hence it could have had many micro tears, lesions or sores that I was not aware of etc that could be a route for HIV, no?

3. I forgot to ask about having the escort suck my finger which as I mentioned I bite out of nervousness and stress. There is not bleeding but it does have visible damage around the nails.

4. I did do a full STD panel 3 months ago as part of my annual checkup. All negative. In fact for more than an year after getting married I have had no sexual relations. So in light of your assessment if this was my only encounter and there was none in the future I should not have to test at all?
25 months ago
Also I forgot to mention. I am circumcised, not sure if that affects my risk in a negative way or not.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
25 months ago
You're seriously overthinking all this. 

1) "Exposed" means a partner with HIV, which almost certainly your escort partner did not have; and via a sexual practice that can transmit the infection, which you also did not have. Re-read my comments above.

2) Exposure of skin, even with cuts, nicks, etc, is little or no risk of HIV. Oral exposure of any kind carries little or no risk. (Saliva kills HIV.)

3) No risk.

4) No sex a year after getting married? You have a serious problem, and it is not HIV or anything related to it. Professional counseling would seem to be in order. This isn't normal.

5) Being circumcised lowers the risk of HIV if exposed. But you weren't exposed, so it doesn't matter.
25 months ago
Thank you for those answers doctor! I feel much better now! I’m just still a little concerned about the scrotum licking and how my HSV2 and fungal infection could have put me at risk. I am definitely overthinking this, I agree! I might have read things on other websites that scared me a lot. But what I am reading now is that I did not have an exposure in the first place and HSB2 and fungal infections cannot covert that into an exposure.

As for the marriage part, my bad, I was exclusively having sex with my wife. This was the only encounter (and only for the rest of my life, slip of judgement) apart from that.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
25 months ago
Your summary is accurate:  glad you understand. And sorry I misunderstood your comment about sex at home -- glad to know the happier truth!

Going back to your HSV2:  The wording above implies you might have had a relatively low numerical result. Even if technically in the positive range, many such results are false. Since you have had no symptoms, additional testing may be warranted to confirm your HSV2 diagnosis. Normally threads are closed after two follow-up comments and replies, but I'll leave this open for another round in case you want to dig out and post the details of your HSV test, i.e. the numerical values for both HSV1 and HSV2 and, ideally, control values (they'll be on the lab report, if you have it).
25 months ago
Thank you for your kind words.

The following is the extract from the report for HSV1 and 2.

AB <0.90
AB 2.81 H
Value Interpretation
----- --------------
<0.90 Negative
0.90-1.10 Equivocal
>1.10 Positive
This assay utilizes recombinant type-specific antigens
to differentiate HSV-1 from HSV-2 infections. A
positive result cannot distinguish between recent and
past infection. If recent HSV infection is suspected
but the results are negative or equivocal, the assay
should be repeated in 4-6 weeks. The performance
characteristics of the assay have not been established
for pediatric populations, immunocompromised patients,
or neonatal screening.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
25 months ago
That's a positive result for HSV2, but not quite at the level of certainty. With the HerpeSelect test, only values over 3.5 are unequivocally positive. At 2.81, it's around 80% certain. If you had reported symptoms typical of genital herpes, it would be solid, but in the absence of symptoms, you should consider retesting. You could repeat the same test (HerpeSelect). Alternatively, there are other tests on the market, and sometimes the quickest resolution comes with a different test, such as the Captia® test by Trinity Biotech, or the Biokit USA test. You could check your local labs or ask your doctor's office find a nearby lab that offers one of these. If either of these is definitely positive, HSV2 would be confirmed. If negative, probably not. If things remain uncertain, final resolution might require an HSV Western blot test.

That concludes this thread. If you are retested for herpes and would like advice about interpretation or next steps, feel free to post a new question on the forum, choosing the Herpes category, for Terri Warren's advice.

I hope the discussion has been helpful. Best wishes.