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Oral Sex: Risk Factors for HIV Infection

By: Paul O'Malley, Researcher San Francisco Department of Health

I certainly agree that what is called "safe" or "protected" sex does go against the natural order of things; it is natural for us to want to engage in sex that involves skin-to-skin contact and the exchange of body fluids. Nonetheless, we do have to deal with the reality of HIV statistics in the San Francisco Bay area in the middle of the second decade of the epidemic (in San Francisco, an estimated 42% of men who have sex with men are positive.) Although I will focus in this article on risk factors involved in oral sex, my underlying concern is of course safety in general and so I would first like to say something about the most well-documented and well-known risk factor for HIV transmission among gay men; eight out of ten of the new HIV infections in our study (see sidebar) most probably could have been prevented if HIV-infected precome and semen had been kept out of the men's rectums.

As a way into the discussion of risk factors associated with HIV transmission through oral sex among men who have sex with men, I will try to answer three general questions about oral sex and HIV commonly asked by our study participants.

1. How risky is oral sex as compared to anal sex?

Oral sex is considered less risky for several reasons. First, the mucus membrane lining the mouth is much tougher, thicker, and more resilient than the anal canal, so it is more difficult for HIV to break through. Also, it is easier to remove infectious fluids from the mouth than from the anal canal. To remove precome or semen from the mouth after oral sex, a person can spit out the semen precome and gargle with water, mouthwash, hydrogen peroxide, or alcohol. (We recommend spitting and/or gargling instead of swallowing, just in case the semen, precome, or penile fluids contain blood or other agents such as gonorrhea or chlamydia which can infect the throat.) Finally, recent reports in the scientific literature say that saliva in the mouth contains enzymes which can help neutralize the virus.

2. How risky is insertive oral sex as compared to receptive oral sex?

Receptive oral sex or "giving a blow job" is considered more risky because of the potential that more HIV-infected fluid will enter the body. When someone is giving a blow job, not only is there the potential exposure to semen and precome, there is also the potential exposure to blood from a penile cut, sore, or abrasion, or even from an irritated piercing.

Furthermore, if the man receiving the blow job has another infection in addition to HIV, he may have an unusually high level of HIV present in his body fluids. This is because his immune system may not be as efficient at controlling, HIV since it is also trying to contain the other virus or bacteria. An added problem is that if the additional infection is localized in the penis, then there will probably be urethra inflammation. If so, his penile fluids may contain high levels of 'infection-fighting" white blood cells, which unfortunately also contain HIV. All this could amount to increased infectiousness.

Getting a blow job is considered a very low risk sexual activity. In general, if someone is getting a blow job and has no cuts, scratches or sores on his penis, the possibility of his being exposed to HIV is lower. If the man giving the blow job has good oral hygiene and his mouth is free of infection, then the inserter's penis is primarily being exposed only to saliva. Getting a blow job might also be safer than giving one because ejaculating might flush out the virus. Urinating and washing the penis also reduce the chances of HIV infection and of additional infection.

All this notwithstanding, it is still possible that someone's penis might be exposed to blood or other HIV-infected fluids during a blow job. This might occur if someone has an abrasion or scrape in his mouth which might bleed or if for example, during multiple-partner sex (group sex), he carries in his mouth the remnants of another person's penile fluids or blood from one blow job to the next.

3. Is precome infectious? If so, is it as infectious as semen?

Two studies have isolated HIV from precome but the potential for HIV infection from precome is most likely minimal under normal circumstances. Exposure to precome probably poses less risk of HIV infection than exposure to semen for two reasons: it has fewer infectious particles of HIV per milliliter than semen and even if a lot of precome is discharged into the mouth during oral sex, it is still less than the amount of semen the mouth or throat is exposed to by an ejaculation.

Now, onto the main discussion. There are two sides to the phenomenon of how supposedly "low-risk" oral sex becomes a high-risk activity resulting in infection: the infectiousness of the HIV-positive partner, and the susceptibility of the HIV-negative partner. I would like to go through the important factors involved in each side of the general phenomenon of increased-risk oral sex, and then to report our study data specifically.


Anal Sex:

Barebacking–Unprotected Anal Intercourse

From Jerry Kennard


Barebacking is the term used to describe gay men who have unprotected anal intercourse. It is a practice that is on the increase. There are dangers, especially if you get involved in casual sex with someone you do not know.

HIV/AIDS has had a profound effect on attitudes and sexual behaviors within the gay community. Safe sex practices, especially within the gay community, were taken very seriously. Condom sales increased, STD's (sexually transmitted diseases) decreased. People understood the seriousness of the message. So why are more gay men reversing the trend and taking the risk of having unprotected anal intercourse?

Why Risk It?

There are a number of possible reasons. Since the early days of HIV/AIDS a new generation of gay men have grown up with an acceptance of the hazards of unprotected sex. The potency of the safe sex message has perhaps diminished over time and this has been helped by advances in AIDS treatments.

Another common issue is the condom. Condoms are generally viewed by men as less satisfactory and less pleasurable. There is a perceived lack of spontaneity involved and it can be expensive if you on a limited income.

There is, of course, no risk involved in barebacking if both men know that they are not infected with HIV. It can provide an incentive to remain monogamous when you are both committed to the relationship.

If you bareback with someone who is infected with HIV, some other STD, or hepatitis B and hepatitis C, you are risking your health and ultimately your life. Remember, infected people may appear symptom free so even if your sexual partner looks fit and healthy it can actually mean very little.

Many gay men involved in health-care believe that there are an increasing number of gay's who believe the treatments now available are so effective that HIV and AIDS no longer pose such a risk. The belief that even if you get AIDS it will be not really be that much of a problem to live with is simply not the case. It is true that treatments have improved a lot, but HIV claims the lives of many gay men each year.

People infected with HIV and AIDS are living longer if they have the right drugs and supportive treatments, but there is still no cure. HIV is not one disease. There are a number of different types, more than 10 subtypes in fact, which result in countless strains. If, for example, you catch a second or third strain, it causes what researchers are calling a "super infection". It dispels the myth that HIV positive partners can have unsafe sex without re-infecting each other.

Is it worth taking a chance with barebacking?

When you're having fun, drinking or clubbing, the reality of AIDS and the safe sex messages can seem a long way off. You can continue to ignore or dismiss advice and live for today. Maybe you have not had the experience of losing someone close to you, watching their suffering or their death from AIDS, a related disease or liver failure?

Unprotected sex is a form of gambling more akin to Russian roulette. There is really no measure of probability you can apply. You may get away it, but you may not and the price you pay is a very high one.


Drugs & Alcohol:

From the US Dept of Health and Human Services

What do drugs and alcohol have to do with HIV?

Drugs and alcohol use can lead to risky behavior that can increase your exposure to HIV/AIDS. For example, using or sharing needles or other drug materials, like rinse water or cotton, increases your chances of becoming infected with HIV.

What if I already have HIV?

There are different types of HIV, called strains. Even if you already have one strain, using drugs puts you at risk for being infected with a different one. If you are pregnant, you could even infect your unborn baby.

What if I can't stop using drugs or alcohol?

Don't be afraid or ashamed to ask for help. Call the Drug and Alcohol Treatment Hotline (1-800-662-HELP [4357]) for help in getting treatment. It can be your first step toward recovery.

If you decide to get drug or alcohol treatment in addition to HIV treatment, let your current doctor know. He or she can work with your drug or alcohol treatment provider to make sure the two types of treatment work together.

Did you know?

Drug abuse behavior plays the single largest role in the spread of HIV infection in the United States today.

Source: National Institute on Drug Abuse, March 2005.

Updated on January 28, 2013