Dear Doctor,

In my younger days prior to getting married I had 5 encounters with CSWs.

I felt what I did was safe and protected (sex) but it now feels that the messaging around HR-HPV transmission and kissing has changed from "not possible" to "maybe possible", in fact some UK sources list it as a transmission risk. I deeply regret the incidents and feel I can never let the past go due to the possibility that HPV can reactivate in the future and that you maybe never truly clear it. So thoughts and overall perspective welcomed on above and questions below:

1 - What would you estimate is my transmission risk of HR HPV from deep kissing 5 CSWs for 10 minutes + each?

2 a) Could you explain biologically why this panel have said oral HR HPV does not take well in the oral cavity / tongue?

   b)  Is it because the tongue has a fully keratinized epithelium and hence someone is unlikely to have an infection at this site? And that    if they have a HR HPV infection anywhere it is more likely to be in the special epithelium of the base/back of the tongue and tonsilar crypts? 

   c) Or that saliva acts as a glide and reduces micro-abrasions? 

   d) If HPV can be detected in Saliva how is it not transmitted by it?

3 - What are the chances of an infection reactivating in the future?

Thank you for taking the time and I hope you can help me with the above as I am really struggling with this and would love to be able to move on.

There was modest risk of HPV from the events described, but it probably was greater from condom-protected vaginal sex than by kissing. Condoms only modestly reduce the risk of HPV, because of skin contact above the condom; on average, consistent condom users eventually have nearly the same chance of having genital HPV as non-condom users with otherwise similar sexual lifestyles. That said, with only 5 such contacts, I would guess there's under 10% chance you acquired HPV. However, I also realize that 10% risk may not be trivial. And since the HR HPV types are among the most common, there's at least some chance you were infected and now carry such an HPV. If so, it's more likely genital than oral.

However, even this should not be at all alarming. Virtually all sexually active persons (>90%) acquire one or more genital area HPV infections, and a minority (probably 10-20%) acquire oral infection as well. Happily, though, even with the HR types, the vast majority do not progress to cancer either in the infected person or his or her future sex partners.

Those comments cover question 1.

2a) True that HPV is less common orally than genitally, which is why there is expert consensus that the oral cavity must be less susceptible to HPV. But I am unaware of research that has determined the biological reasons for the apparent difference in susceptibility to HPV of different anatomic sites.

2b,c) I suppose these might be part of the explanation, but that is strictly speculation, as far as I know.

2d) HPV DNA can be detected in saliva, genital fluids, urine, under fingernails and, I imagine, elsewhere if research were done on other body fluids. But detection of DNA doesn't necessarily mean complete virus, capable initiating a new infection, is present. Most HPV infections probably require complete virus (not merely DNA) to be massaged into exposed tissues. This is the likely reason that genital warts typically appear at anatomic sites most subject to friction during sex:  e.g. penile head and shaft, vaginal or anal opening, labia minor in women -- and not so much on scrotum, groin, etc, even though these obviocsly have lots of contact with genital fluids or saliva.

3. Good data do not exist on the likelihood of future reactivation of silent/dormant HPV infection, or on ways to prevent it. Smoking is believed to have an adverse effect.

All in all, you are at low risk of having HIV currently, either oral or genital; and even if you do, you are at exceedingly low risk of having a serious health outcome as a result. Assuming you have not been vaccinated against HPV, that is far and away the main thing you should consider to eliminate your risk of infection with the 9 HPV types that cause 90% of warts and cancers. Some data also suggest that immunization probably reduces the frequency of reactivation, so there may be some protection even for HPV types you already might have acquired from the limited risks you describe.

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

HHH, MD

I fail to understand why you're so focused on kissing and oral HPV when the likelihood of genital infection is so much higher. But here you go:

2) Nobody ever needs to mention HPV exposures (without known infection), whether oral or genital, to new partners.

3) I am unaware of any studies of the sort you mention, i.e. analysis of oral HPV in CSWs and its relation to kissing. But yes, that scenario sounds reasonable. (In general it is true that rates of HPV at any anatomic site is not much higher in CSWs than in other sexually active women. This is to be expected and I have commented on this previously in the forum.)

4) Whether reactivation of HPV is described as "common" or "uncommon" is a matter of context and how a question might be asked. For most HPV infections, once cleared by the immune system, reactivation is relatively unlikely -- so for any particular person, it can be said to be uncommon. However, since HPV is exceedingly common (virtually universal in sexually active people), even infrequent reactivation means it will happen to millions of people. From that perspective, reactivation is common. In reviewing other questions and our responses, always consider the context, which also can include our assessment of the emotional status of the questioner.

5) I have nothing to add to my comments above. If there are scientific data on reasons for the difference in HPV frequency in the oral cavity versus anogenital, I am unaware of it.

There is no need to apologize for understanding HPV or other STDs as you look forward to new relationships. But you need to gain a proper perspective on HPV: having it is normal, expected, and a nearly universal aspect of human sex. Oral HPV is a lesser danger, both from the standpoint of overall frequency and the rarity of serious outcomes like warts or cancer. Everybody should be vaccinated to prevent 90% of those more serioius outcomes; get care if anything does appear, like visible warts or abnormal pap smear; and otherewise more or less ignore HPV as they plan their dating lives.---