I wanted to ask very general questions about the HepB transmission risk for gay men specifically. In many other HepB questions, I have noticed you making the caveat that heterosexual intercourse is generally low risk for HepB. As a gay man, I would be interested in knowing what your thoughts are specific to MSM? For what it's worth, I am HIV negative and HSV2 positive. 

1) Does deep (French) kissing carry a risk for HBV transmission among the MSM population?

2) What about oral? I'm guessing like with anything else giving oral is riskier than receiving but not sure if the risk is enough to be concerned. 

Also, am I right that people who have cleared prior acute HepB are generally considered good to go in terms of being physical with partners? I know a few such people in my life. 

I know from my research that there is such a thing as occult hepatitis B (OBI) My very layman understanding is that occult Hep B is when sub-clinical traces of the virus remain in the body and can sometimes reactivate under various circumstances/on various immune-effecting meds (which I believe is why so many drug commercials say to 'tell your doctor if you've ever had hepatitis B') but I'm not sure if occult hep is passable in sexual ways. It seems to be more of a concern with blood transfusions, liver transplants, and the like. 

I am no liver expert so my casual reading about/understanding of occult HepB may be WAY off.

Thanks Doctors!

My first reaction is to ask if you have been immunized against hepatitis B virus (HBV). Depending partly on your age and where you were in your youth (most of the US, Western Europe, and many developing countries), it is likely you were immunized. HBV is now included in most childhood vaccination regimens and recommendations. If not, you should seek vaccination now:  all persons should be vaccinated, and it's obviously an especially high priority for those at highest risk, including MSM. If you indeed have been vaccinated, you can safely assume you are not at risk, regardless of your sexual practices and the HBV status of your partners.

As for sexual risks among non-vaccinated MSM, there actually have been very few studies; only educated guesses are available. Most experts agree that both scenarios you mention are zero to low risk, i.e. little chance of HBV transmission by either kissing or oral sex. To the extent there is risk from oral sex with men, most likely the orally exposed partner is at higher risk than the penile partner, perhaps especially if there is ejaculation in the mouth. But still, this is believed to be very low risk. The main risk in MSM is believed to come from anal sex; and even there, blood exposure may be the most important aspect, i.e. transmission when anal sex is traumatic with bleeding. However, as I said, there has been little study of any of this.

I have not previously heard the term "occult hepatitis B". Your description suggests a term perhaps used by health educators to simply mean low levels of infectious virus in blood or other body fluids. 

In summary, my advice is that you determine whether you have been vaccinated. If unsure (e.g. no access to your childhood immunization history), a simple blood test can tell. If not immunized, I suggest you do that now. Within a month of the second vaccine dose (i.e. 2 months after starting), you'll be immune. Between now and then, I would advise you adhere to the standard safe sex practices among MSM -- ask your partners about their status (if vaccinated, no worries); if not or uncertain, of course use condoms for anal sex, either top or bottom; and for still more caution, perhaps condoms for oral sex. I trust you're using these practices routinely to prevent HIV and other STIs.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

Thank you so much for your response. I wanted to spare you the tale behind my vaccination status but I will tell you about it here:

In the summer 1999-after I had had oral exposure to other men but before I had any anal exposure-I developed sudden extreme fatigue. My Dad, who is an ENT, took me to see his Internal Medicine colleague. I was 19 at the time. I am very vague on what happened next because I was so out of it but my father remembers that my liver enzymes were slightly elevated but the culprit was good ole mono hepatitis NOT viral hep. My Dad swears up and down he would have remembered if I had tested positive for something as serious as HepB. 

In 2006, I got my hepatitis vaccine shots. 

About a year after getting my shots I developed a very strong OCD concern that, as a gay man, I had acquired hepB BEFORE getting vaccinated and wanted to make sure that I was negative and immune. I asked him to write me scripts for surface antigen and surface antibody tests. These were the results: 

HBSurfaceAntigen 0.24 (above 1.0 is reactive above 5.0 is positive)

HBSurfaceAntibody 12.01 (5.0 to 12.0 is indeterminate, above 12 is immune 

***Apparently the CDC now thinks that above 10.0 is considered immune) I was a smoker at the time which apparently might account for my low antibody number. It is my understanding that most people have antibody numbers in the hundreds. 

I didn't know enough at the time to ask my dad to order the Core Antibody test so I still don't know if my surface antibodies are the result of natural immunity from before the shots or actually the result of the shots. My psychologist has more or less insisted that I not get a core-antibody test which would be giving into my OCD around this issue but I am so worried that my barely passing antibody response (12.01) is a sign that I am vulnerable. I am also worried that if my antibody's are indeed the result of a cleared infection and not the shots, that I could be one of those people who are occult and that I might be potentially infectious to others. But I'm also assuming that you would have heard about occult hep if it were some big cause for concern. I obviously trust your expertise in this area. For what it's worth here is where I read about occult:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3082745/

Long story short my vague memories of the past, my barely 'over the line' Antibody number and my OCD are kinda crashing together and making me concerned about my ability to acquire or pass hepB

Keep working with your psychologist on your OCD. That's the only health problem in evidence here, it seem to me.