[Question #8264] Follow up question #8200

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46 months ago
I know that Dr. Handsfield believes my exposure was “virtually no risk” but I wanted to follow up on some other symptoms and ask a question pertaining the true risk of oral sex:In my last post, I spoke about my sore throat that started at day 7 post exposure that would come and go and Dr. HHH said that an ARS sore throat would not come and go. A week later at day 14, I had sore muscles and joint pain and noticed what may be swollen lymph nodes under both armpits, along with the tiny one on my neck. I only feel them in my armpit from certain angles so not sure if they are tendons that feel differently when moved around but they feel like hard beans that move around. One side definitely feels ball like. Other than that I haven’t had a rash or temperature so maybe that’s reassuring. The sore muscles subsided in about 4-5 days but the joint pain comes and goes and is a shooting pain. Do you think that may  be a concern or change your opinion on the possibilities of having HIV? 

Lastly, I ran into this journal entry on medhelp: https://www.medhelp.org/user_journals/show/546013/HIV-and-ORAL-SEX-The-Facts 

It is 9 years old and basically says that performing oral sex is no risk at all and there has never been a convincing documented case of someone acquiring HIV this way and that the cdc and doctors will never say that it is absolutely no risk because of the theoretical risk but no doctor has ever seen it. Here on the forum, you say performing oral is low risk and that there have in fact been a handful of people that have acquired this way. It seems like receiving is the one that you outright say is not possible. I guess I’m trying to understand what “a handful” means and why the differing of opinion. Is there just new information that has been learned about the risk of performing oral sex in the past 9 years or is it this just the conservative approach? I guess my question is, have you personally treated or heard of any patient that has gotten hiv giving oral sex? 
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H. Hunter Handsfield, MD
46 months ago
I'm going to start with something from my closing comments in the first of your three questions:

My final advice is that you stop searching about all this online. It seems clear that's what is generating much of your partial knowledge, uncertainties and fears. Anybody can post anything, and the internet is not a friend to most anxious persons who look for information related to those anxieties. The famous statistician Nate Silver (fivethirtyeight.com) wrote a book about public understanding of statistics, "The Signal and the Noise". In it he writes (approximate quote) "Give an anxious person a computer with an internet connection in a dark room, and soon he'll believe his cold is the bubonic plague." Sound familiar?

This includes the business about oral sex and HIV risk and the old comment on our MedHelp forum. We have always said that oral sex DOES transmit HIV, penis to oral:  that is, performing fellatio on infected males can transmit HIV to the oral partner. However, the average risk has been calculated (by CDC) as 1 chance in 10,000. That's equivalent to giving BJs to infected men once daily for 27 years before virus transmission may be likely.  There still has never been a scientifically validated case of HIV transmitted oral to penis, or by cunnilingus (oral-vaginal contact). We won't be changing our advice or the words we use in answering forum questions.

As for your current symptoms, the answer is no:  they do not change my judgment or my advice to you as discussed in your previous two threads. You do not have HIV.

HHH, MD
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46 months ago
Thank you for your prompt reply. I was just confused since it seems that that journal entry was written by a nurse that has worked very closely with ID doctors for years and hadn’t encountered or met doctors that have encountered this and she stated stats on a forum you were previously affiliated with and other moderators unanimously agreed. 

I guess my next question is why is the suggestion to not to be tested at all if it is an actual possible route for infection even if tiny? After all it could just take one time for something to occur no matter how tiny the risk. I get the risk is so small that it is not worth looking into but not impossible. How many people have you encountered in your career? 
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H. Hunter Handsfield, MD
46 months ago
The nurse's advice sounds normal. I often tell folks they are not at risk when in fact there is a theoretical possibility of HIV transmission. The exact message should and does depend on personality, the level of worry, and other factors. For this reason, anyone reviewing our advice on this or the MedHelp forum needs to be careful about applying the message to their own situation and psychology. I also have never had a patient who apparently acquired HIV by performing oral sex on a male partner. That doesn't mean it never happens, only that it's uncommon. I also have never cared for anyone struck by lightning, but it happens.

Testing when the risk is exceedingly low is of course a personal decision, and it can help some people move on and sleep better, especially those particularly anxious or worried. On the other hand, it's a waste of health care resources. It's almost like someone who doesn't own a car purchasing auto insurance "just in case". Or a better medical analogy might be mammograms in males:  breast cancer in men is rare, but it happens, and male mammography probably would save a few lives each year through early detection. But it's not a valid or recommended prevention strategy. A much smarter approach for HIV and STI is for persons with low but repeated risk (e.g., a handful of new low-risk partners each year) to be tested periodically, like once a year, but not after each new low-risk event. This is what's done by most sexually active singles (at least among those who test at all -- of course some people are oblivious to any danger and never test).---
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46 months ago
That makes sense. I guess most of my apprehension comes from the symptoms I’ve been having. If I didn’t have weird symptoms I wouldn’t be quick to jump like getting a sore throat exactly 7 days after and the swollen lymph nodes. I know symptoms are nonspecific but I go back and forth in my head if they are a coincidence or not or if I’m being hyper aware of everything. 

I also think back to the day of the exposure and having been sick with a bad cough and taking a million lozenges that day and if they could somehow damage my tongue  barrier and make it possible. Then on the other hand I flip in that there was no ejaculation in my mouth but there was precum and it that has any effect. I know they are ridiculous to think about but I get in my head and think of the probabilities. The swollen lymph nodes are my biggest concern although it seems like even if I had every ARS symptom in the book, you still would say I don’t have HIV which is reassuring. 

Thank you again. 
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46 months ago
Also what are swollen lymph nodes in ARS like? Are they usually visible? The ones I feel are deep in the armpit. If I hold my arm up  straight I don’t feel them but if it’s 90 degrees I do but they aren’t visible on the surface or anything. 
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H. Hunter Handsfield, MD
46 months ago
Symptoms are exceedingly poor in either judging possible HIV or excluding it:  they almost never help in a meaningful way and should be disregarded, whether present or absent. The blood test results always overrule all other considerations, i.e. no matter how high the risk at the time of exposure and no matter what symptoms are present, the test results is the gold standard and the only standard by which to judge whether or not someone has HIV. Scanning your previous two threads, these exact issues were discussed then. You might want to go back and re-read those discussions. I also will add (which I may also have said previously) that self-assessment of enlarged lymph nodes by non medical professionals is exceedingly unreliable --- and your description suggest you do not have any lymph node problem at all. And if in fact enlarged or inflamed, HIV isn't the cause. (HIV nodes are body wide, never in a single location like a single armpit.)

That completes the two follow-up exchanges included with each question and, as you know, ends this thread. This will have to be your last one; repeated questions on the same topic are not permitted and are subject to being deleted without reply, and without refund of the posting fee. This policy is intended to reduce the temptation to ask questions with obvious answers, and because repeated answers to anxiety related concerns often simply prolong anxiety rather than relieving it (there's often a "yes but" or "could I be the exception" sort of thinking). And in our experience, many or most questions are restatements of previous ones, using different words. Such questions have little value for other users, one of the forum's main goals. Thanks for your understanding of the policy. But I do hope the discussions have been helpful and you're able to move on with lessened worry about HIV. Good luck.

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