[Question #704] HIV transmission

45 months ago
Hi Doctors, having read your responses to many questions on Std and HIV transmission, would it be accurate to say that unless you have had unprotected anal or vaginal sex, and don't inject drugs,  that you effectively have no risk of HIV transmission? I ask because in response to many questions on oral sex,  performed on you by male and/or female partners you consider there to be no risk. Similarly for fingering/fisting and other practices where there is no subsequent anal/vaginal sex you also consider this safe sex. I am not questioning your expertise noting your decades of expertise but many public health websites state that oral, and fingering/fisting with cuts present a low/very low risk particularly if you have gum problems (for oral sex risk) and you/your partner has small wounds/cuts on their fingers hands for finger/fisting risk.  Finally, is HIV testing recommended if your only risk has been oral/fingering or fisting both giving and receiving, (apart from regular annual checks)   PS I am only taking male/female interactions, generally with CSW, sometimes in Asia, but generally western countries. Thanks for your time.  
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago

Welcome to our Forum.  Your questions are good ones and certainly identify an area where there is a certain amount of disagreement between us and some of the recommendations by our friends and colleagues at the CDC.  Part if the basis of these differences related to the fact that at the CDC, Federal agencies are strongly influenced by the performance information provided by manufacturers in their package insert material.  Package insert materials, in turn tend to be conservative and often do not try to prove that their tests are better or get results more quickly than their competitors but just to prove that they are as good as their competitors - this tends to hinder identification of better tests.  Finally, as a Federal agency which provides general information, typically through printed or on-line documents, the CDC is not able to consider local factors to provide individualized recommendations in the same manner that we do.

 As for oral sex, there are a few cases in which HIV has been transmitted from an infected person to a partner who is performing oral sex (fellatio) on them but these occurrences are so rare as to be hard to quantify- certainly occurring on average less than 1 in 10,000 exposures (i.e. like performing oral sex on an infected partner once a day for more than 25 years).  As for receipt or oral sex or performing cunnilingus on an infected partners, neither of us is aware, either through our own patient care activities, through regular attendance at scientific meetings, or from colleagues or there ever being a proven case of HIV acquisition. 

Performance of fisting is an activity (unlike fingering) which is inherently traumatic and, when received along with other sexual activities is associated with increased risk for acquisition of HIV.  there is no evidence I am aware of that the insertion of a fist into another person's rectum carries a risk for getting HIV, with or without cuts on the hand.

Finally, remember that even is areas where HIV may be relatively common (such as parts of sub-Saharan Africa or Asia), most people still do not have HIV and if your partner does, risk becomes a "numbers game" in which most sexual activities carry a numerically low risk of acquisition, i.e. if the partner has HIV, receipt of insertive anal intercourse- 1 in 100, for vaginal intercourse 1 in 1000, and for performing oral (fellatio) substantially less than 1 in 10,000.) 

I hope these comments are helpful.  Please understand as well that these figures are meant to provide a realistic estimate of the low risk of HIV acquisition from most sexual activities,.  That said, there is no substitute for regular practice of safe sex, including condom use.  Just as some day someone may be struck be a meteor falling from space, rare sorts of HIV transmission may occur as well.  EWH

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45 months ago
Dear dr Hook, thanks for your prompt reply and for clarifying. I understand better know the differences between advice between institutions.  The advice/risks on oral is now much clearer. . Similarly for fingering/fisting.  But just to clarify, you say when receiving fisting, which is inherently traumatic (understandably) that there is increased risk when associated with other sexual activities there is increased risk of HIV does that mean if you then have receptive anal sex? Thus if you only received fisting but no anal sex there is no risk or only the 'struck by lightning' risk level? Finally, can gloves and condoms considered to be 100% effective, if they don't rupture?  Like the other issues, some websites again say they only provide 'safer sex' not safe sex, presume this is also the manufacturers insert issue? Many thanks 
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago

There are no studies on pure fisting with no other activity that I am aware of. that said, if not part of other sexual activity, it should be safe.

Condoms are gloves are the best way to reduce risk of HIV when engaged in sexual contact with a new partner of unknown status.  there is nothing in the world that is 100% but condoms and gloves which do not break are VERRY close. EWH

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45 months ago
Dr Hook. Thank you for your response. Final query relating to Ars and testing. I appreciate risk and testing is important not second guessing symptoms but a few queries if I may.  Again varying authoratative websites or cdc, the body etc state ARS occurs 2-4 weeks after infection and not after  after six weeks, and that symptoms whilst variable produce bad sore throat, fever over 100 degrees and a bad rash for 70% of people based on extensive studies.  Do you agree with this, and if you did experience ARS is 6 weeks too late? Leading question I know but, if I test annually, am not a MSM, received unprotected fellatio or perform cunning less, and insert fingers in a vagina or anus and have fingers inserted in my anus (using a glove) or almost the whole hand, and then suffer major flu like symptoms six weeks later, should I consider HIV testing or am I just being paranoid?  And just stick to my annul test? Many thanks for time, expertise and patience? 
Edward W. Hook M.D.
Edward W. Hook M.D.
45 months ago

Final answer (as you know, we are permitted only three replies per question).

Annual testing is the way you go.  The ARS does not occur in all persons who get HIV.  As for timing, once again, the CDC is being conservative and while a very few cases of the ARS may occur as late as 4 weeks after contact, most occur at 2-3 weeks.  Further, I think the 70% figure for persons  getting classic ARS is too high a figure- I would estimate it to be closer to 50%, hence the need for periodic testing even in the absence of ARS symptoms.  A flu-like illness at six weeks after an exposure is almost certainly NOT the ARS, irrespective of the sort of contact and, in your specific case with the sorts of exposures you mention, I would not be worried at all.  The activities you describe are close to no risk and the timing at six weeks would be off.  Annual testing should be sufficient.

Congratulations on your commitment to safe sex.  Stay safe and take care.,  EWH

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45 months ago
Thank you very much for your time and considered advice.