Hello Dear Experts,

thank you for the great job you are doing with this forum. 

Here is my issue, would be thankful if you could help.

I am a bisexual male. For the last 15 years, my only sexual activity with other men was strictly limited to giving oral sex. I have had around 1 encounter per month, which means the rough estimation number of partners is around 180-200. I have had all kinds of encounters, in clubs, saunas, through apps, web sites, almost always with strangers and never having recurring partners. Great deal of my partners were escorts. So, you could say my partners were more or less in a high risk category - i had no information of their status etc. With that being said, i have never contracted any STD based on my sexual activity. Nothing. (I hope this small statistical information will help other people start worry less).  But i am the exact anxiety-driven type of person, that is likely to flood forums and search for symptoms on internet. This resulted in more than 100 HIV tests over the years, many sleepless nights and tones of wasted nerve cells. So, i decided, that since my activity does so much psychological harm, the only right thing to do is to stop. Which i did. I haven't had any encounters in a while and just moved on with my life. 

But now we have a new card on the table, meaning PrEp. It could be a game changer for people like me, and i was thinking of going on PrEP and restoring my sexual activity, as described above. I intend to go straight to the safest option - the daily PrEP, taking the pill every day, not “on demand”. 

So, here are my question in three parts:

1. Most of the information about how PrEP works refer to the protection offered to the receiving partner in anal and vaginal sex. All discussions are about the relative level of deposition of these drugs in anal and vaginal tissues, I haven’t seen any data about drug levels in other tissue sites. So, what does it mean for the mouth and digest tissues  and what does it means for someone explicitly engaged in giving oral sex?

2. The generic PrEP drug i have access to is called RICOVIR EM and consists of Emtricitabine and Tenofovir. It’s not Truvada. Can i still consider the level of protection as high as it should be for a regular PrEP drug?

3. Would it be true to state, that if someone is on PrEP (be it Truvada or a generic one), he is completely on the safe side giving oral sex to other males? Would swallowing change the answer?

Thank you!

Welcome to the Forum and thanks for your thoughtful question  Congratulations as well on your approach to reducing your risk for STIs and HIV.  Before I address your specific questions, I'll make a few background comments regarding your risk for HIV and STIs.  Among sexual acts occurring between men, different sex acts vary in their risk for HIV.  When exposed to a sex partner with HIV, receptive rectal intercourse is the highest risk activity with HIV being acquired on average about once in every 200 sex acts.  The risk for insertive partners is lower, about 1 infection per 1200 exposures on average.  When it comes to oral sex, there certainly have been cases of HIV acquired as a consequence of performing oral sex on infected partners but they are rare, estimated to occur about once in every 10,000 sex acts, on average.  To our knowledge, no one has ever acquired HIV from receipt of oral sex from an infected partners. 

Other STIs, particularly gonorrhea although sometime chlamydia and rarely syphilis can be acquired by performing oral sex on infected partners.  I trust that when you have been checked for STIs, you have had throat swabs performed.

Finally, it is always a good idea to ask partners if they have HIV or are on PrEP, as well as when they were last checked.  It sounds like you do this- good work!.

As for your specific questions:

1.  Great question  The studies of PrEP have focuses on rectal and penile infections because they are the most common infections.  HIV from oral sex is so rare that it is hard to measure the effect in well conducted studies- you'd have to study a huge number of persons who only performed oral sex on partners.   That said, although little is known about tissue levels of PrEP medications in the throat, I would guess that it may have some effect.

2.  Yes, as long as the doses of Emtricitabine and Tenofovir  are the same as are found in Truvada, the generic should be fine.

3.  I think I follow the question but if I get things wrong, please ask again.  If a partner is on PrEP then they should not have HIV and since you do not have HIV there should be no risk.  OTOH, if a partner has HIV and is on treatment, IF the person's treatment has completely suppressed his HIV to undetectable levels he should not be able to transmit his infection to others. 

I hope that I have addressed your questions.  If portions of my answer are unclear, don't hesitate to use your up to 2 follow-up questions for clarification.

---

Hello Dr. Hook,

thank you for your answer, it was helpful to read.

There is a slight misunderstanding in the third question. I was asking if i stick to oral sex only (being the receptive part, not the insertive) would going on PrEP render the risk of getting HIV to zero, given the fact that oral sex is in general a low risk activity. Would PrEP offer any additional protection. Would it be safe to quote the same numbers (99% protection) for oral sex, as quoted by PrEP producers for other sexual activities. You have partly answered the question previously, by saying " little is known about tissue levels of PrEP medications in the throat", but still i would like to know how what is your opinion in general on this situation. Can one relax and feel that he has done everything medically possible to be fully protected or we still have a statistical and scientifically uncertain possibility of getting infected.

Thank you

Thanks for your follow-up.  As I think I’ve already pointed out, results of studies of PrEP  likely reflect reduction in HIV infections due to rectal (insertive and receptive) intercourse among MSM.  OTOH, I presume that even in the absence of data it is reasonable to presume the PrEP would further reduce the already very low risk, at least as long as there aren’t other barriers such as insurance or allergy.   I wish there were better data but since there aren't I have to say that were I in your situation, I would go with PrEP.  Further, as you've already indicated would be your preference, I would go with daily PrEP rather than PrEP on demand.  This would likely lead to somewhat higher drug levels in the tissues of the throat, maximizing the protective effect.

Hope this clarification is helpful.  EWH

---

Thank you,

your answer is clear now and i find it very helpful.