Unprotected oral sex can transmit HIV
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7392.730 (Published 05 April 2003) Cite this as: BMJ 2003;326:730All rapid responses
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These two studies were both presented at the Barcelona AIDS Conf.,
and published last year in AIDS:
I) del Romero J, Marinocovich B, Castilla J et al. Evaluating the
risk of HIV transmission through unprotected orogential sex. AIDS
2002;16:1296-97.
Between 1990 and June 2000, in a STD and HIV testing clinic in
Madrid, the authors followed an open cohort of individuals who were
initially seronegative for HIV and whose heterosexual steady partner had
had a diagnosis of HIV infection confirmed. Each member of each couple was
followed in the same clinic with regular six monthly examinations.
Subjects were surveyed about each type of contact, whether protected or
unprotected, as well
as about ejaculations and accidents with condoms. Determination of
antibodies to HIV was carried out for the member of the couple who was not
initially infected. Individuals who showed any risk exposure to HIV other
than to sex with the mentioned partner were excluded from the study.
A total of 135 seronegative individuals (110 women and 25 men) whose
only risk exposure to HIV was unprotected orogenital sex with their
infected partner, participated in the study. For the 110 HIV-seronegative
women whose partner was an infected man, 179 person-years of follow-up
were taken into account. Of these women, 96 performed fellatio without a
condom, which gave an estimated total of 8,965 unprotected fellatios, of
which 3,060 (34 percent) were with ejaculation in the oral cavity. Ninety-
eight infected men carried out unprotected cunnilingus on the uninfected
woman with an estimate of 8,656 practices of this type. Among the HIV-
infected members of the couples, 8.1 percent
had been diagnosed with AIDS and 15.6 percent had a CD4 cell count lower
than 200 x 106/l. For 60 individuals an HIV-1-RNA quantification was
available, and six of them presented with greater than 10,000 copies/ml.
Of the 135 initially infected partners, 39 percent received antiretroviral
therapy during the follow-up. The authors reported registering 210 person-
years of follow-up with participants.
While a number of women presented with vaginal infections, the 135
individuals, "who had had over 19,000 unprotected orogential contacts with
their HIV-infected partner," presented without a single case of
seroconversion to HIV. According to the authors, "this seems to point to a
very low probability of HIV transmission related to this practice, when
other risk exposures are excluded."
II) Page-Shafer K, et al. Risk of HIV infection attributable to oral
sex among men who have sex with men and in the population of men who have
sex with men. AIDS 2002;16:2350-52.
From December 1999 to 2001, individuals seeking HIV testing at an
anonymous testing site in San Francisco were screened to identify those
who in the past 6 months reported no anal or vaginal sex, had not injected
drugs, and had performed fellatio on at least one male partner. Eligible
participants completed a pre-HIV test survey, measuring a 6-month history
of sexual practices. Post-interview HIV serology was conducted to
determine participants' HIV serology using enzyme immunoassays, Western
blot confirmation, and a sensitive/less sensitive enzyme immunoassay
strategy to identify recently acquired infection. Of 10,283 anonymous
testing site clients, 413 (4 percent) were eligible, and 243 (2.3 percent)
participated. Of those, 239 (98 percent) were men, whose median age was 39
years, and all were MSM. Four women were dropped from the analysis.
No recently acquired HIV infections were detected and the estimated
probability of orally acquired HIV was 0. The median number of fellatio
partners in the past 6 months was three, almost all (98 percent) were
unprotected. One-third (35 percent) reported getting semen in their mouth,
and of those, 70 percent swallowed it. Fellatio on a known HIV-positive
partner was reported by 28 percent; of those, 81 percent did not use a
condom, and 39 percent had swallowed ejaculate. The PAR% rises as the
number of partners increases: PAR% for one fellatio partner was estimated
at 0.18 percent, for two fellatio partners at 0.25 percent and for three
fellatio partners as 0.31 percent. The cumulative PAR% for one to three
fellatio partners could thus be 0.74 percent.
The authors' results are based on a modest sample size; therefore,
they cannot rule out the possibility that the probability of infection is
indeed greater than zero. The calculations showing very low PAR% are
consistent with the findings of extremely low individual risk. In
addition, if one considers that only a fraction of those who report
fellatio are actually exposed to semen (35 percent), the PAR% will be
considerably lower. "These data confirm that the risk of HIV infection
attributable to fellatio among MSM and in the MSM population is especially
low," the authors concluded. "It is important that health professionals,
including HIV counselors have valid information to impart to their
sexually active clients. If individuals believe that the risk of HIV from
fellatio is high or on a par with well-documented high-risk exposures such
as anogenital sex, they may not feel that sexual behavior choices make a
difference. Acquiring HIV through fellatio is significantly less risky
than from anal sex, and therefore one's choice of sexual practices do
matter."
Competing interests:
None declared
Competing interests: No competing interests
Dr Gottlieb pointed out clearly that HIV "can" find out its way "in"
via oral sex. But the millon dollars question is if we "put in" or "take
out" the semen of the equation: "unprotected oral sex". Cohort studies
don't show any relevant prevalence of transmision of HIV by oral sex.
May be cualitative research of sexual beheavior can answer this question
Competing interests:
None declared
Competing interests: No competing interests
It would seem logical to conclude from Dr Gottlieb's in vitro research that deep kissing may be just as risky as unprotected oral sex. And yet I have not seen any evidence suggesting HIV is spread in this manner.
Competing interests:
None declared
Competing interests: No competing interests
Options Project
There is an error in your citation for the Options Project
data (AIDS 1999;16:737-8). First, AIDS does not have a
volume 16 in 1999. In Vol 13 Issue 6 pages 737-8 there
is a letter from Robinson, et al discussing oral sex and
HIV transmission but it does not mention the Options
project data.
The Options Project data was first presented by Dillon,
et al at the 7th Conference on Retroviruses and
Opportunistic Infections in San Francisco in early 2000
(Abstract 473). While 8% infection rate from oral sex
was identified in this study, it was later determined that
at least half of these subjects had also engaged in
unprotected anal sex (Sex Transm Infect
2001;77(5):307-8). To my knowledge, this data has
never been formally published in a peer-reviewed
journal.
More recently Page-Shafer et al published data from the
Centre for AIDS Prevention Studies in San Francisco
(AIDS 2002;16(17):2350-2). They found zero risk of HIV
transmission in 239 homosexual men who practice
unprotected oral sex exclusively.
Thank- you
Robert Gair BSc (Pharm)
Vancouver, BC
Canada
Competing interests:
None declared
Competing interests: No competing interests