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HIV Prevention (Expert Forum)
Actual receptive oral exposure to HIV source, PEP
Answered by
University of Washington
Seattle - WA
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No questions will be accepted on the treatment of HIV/AIDS or its complications, viral load, and similar topics. If you have questions about a specific STD other than HIV/AIDS, please visit the STD Forum. Questions that do not pertain to the above topics will be removed from the forum.
If you have not done so, please review other threads in our archives for questions similar to yours and Dr. Handsfield's replies. Questions that duplicate other frequent ones, for which abundant replies exist, and that have little educational value for other forum users, will be DELETED WITHOUT RESPONSE. YOUR PAYMENT WILL NOT BE REFUNDED. The most common examples of such questions are those about low risk exposures to HIV, such as oral sex, condom- protected intercourse hand-to-genital exposure, and nonsexual contact with possibly infected blood or body fluids as well as symptoms of early HIV infection.
Actual receptive oral exposure to HIV source, PEP
by strata, Jan 10, 2007 12:00AM
I'm a 30yo bi male. On 12/30/06, I was exposed to HIV through receptive oral sex with an HIV+ male. When I started, the man was flacid but had been previously aroused, so there was some pre-ejaculate (1 tsp?) on the outside of his penis. I gave him oral until he achieved an erection (1-2 minutes), at which point we told me he was poz (I should've asked beforehand!). He did not ejaculate.
I immediately rinsed repeatedly with alcohol-free mouthwash and water. Then I asked him his viral load. He seemed to think I was overreacting, but, after coaxing, he said his viral load "is less than 20,000, so you really don't have anything to worry about."
I panicked (more) because I thought 5,000 was a high VL, and there's a strong correlation between VL and transmission. I didn't think to ask if he was on any meds (possible resistance). But he appears to have unprotected anal sex with other HIV+ men, so infection with multiple strains is possible. He said he wasn't infected with any other STIs.
I also have an endocrine disorder (Addison's - I take 30mg hydrocortisone as replacement therapy) that makes me theoretically more prone to infection, and I have a couple of small abrasions in my cheek where it rubs my teeth (no bleeding though).
It took me 24 hours (I went to a clinic, an urgent care facility, and 2 ERs) before I found someone to prescribe PEP. I am currently on twice daily Combivir and twice daily Kaletra.
Questions:
1) I've read that the estimated per act transmission rate for receptive oral with ejaculation is 1/10,000. But is this based on a low (<1000) viral load?
2) Given the encounter, the source, my condition, and PEP, how would you rate my risk?
Here's my guesstimate:
1/10000(rec oral) * 20/1(VL) * 10/1(endocrine + oral abrasions) / 5(20% chance PEP fails) = 1/250!!! chance of infection.
3) I've seen several sites refer to cases where people have been infected through receptive oral, even when the insertive partner did not ejaculate, but I can't find any of the documented cases on the internet. Have you read any of these cases? Do you know where I could find more information on specific cases? Have you seen any cases in your practice?
4) Two days ago I developed a nasty, itchy rash all over, but it is worst on my thighs. It appears to be a side effect to the drugs. Will this reaction (or the antihistamine I'm taking to cope with the itch) weaken the effectiveness of PEP?
5) What's your take?
6) How long do I need to test HIV- for a definitive result?
The rash has been fading steadily since I started the antihistamines. The ID clinic I was referred to offered to prescribe a different drug, but I decided to tough it out and stay on the preferred/recommended regimen. I've had no fever or other symptoms (other than rash) suggestive of ARS.
I tested negative for HIV, Syphilis, Gonorrhea, and Chlamydia on 12/14/06. This oral exposure is the only potential exposure I've had since.
-Panic-stricken
I immediately rinsed repeatedly with alcohol-free mouthwash and water. Then I asked him his viral load. He seemed to think I was overreacting, but, after coaxing, he said his viral load "is less than 20,000, so you really don't have anything to worry about."
I panicked (more) because I thought 5,000 was a high VL, and there's a strong correlation between VL and transmission. I didn't think to ask if he was on any meds (possible resistance). But he appears to have unprotected anal sex with other HIV+ men, so infection with multiple strains is possible. He said he wasn't infected with any other STIs.
I also have an endocrine disorder (Addison's - I take 30mg hydrocortisone as replacement therapy) that makes me theoretically more prone to infection, and I have a couple of small abrasions in my cheek where it rubs my teeth (no bleeding though).
It took me 24 hours (I went to a clinic, an urgent care facility, and 2 ERs) before I found someone to prescribe PEP. I am currently on twice daily Combivir and twice daily Kaletra.
Questions:
1) I've read that the estimated per act transmission rate for receptive oral with ejaculation is 1/10,000. But is this based on a low (<1000) viral load?
2) Given the encounter, the source, my condition, and PEP, how would you rate my risk?
Here's my guesstimate:
1/10000(rec oral) * 20/1(VL) * 10/1(endocrine + oral abrasions) / 5(20% chance PEP fails) = 1/250!!! chance of infection.
3) I've seen several sites refer to cases where people have been infected through receptive oral, even when the insertive partner did not ejaculate, but I can't find any of the documented cases on the internet. Have you read any of these cases? Do you know where I could find more information on specific cases? Have you seen any cases in your practice?
4) Two days ago I developed a nasty, itchy rash all over, but it is worst on my thighs. It appears to be a side effect to the drugs. Will this reaction (or the antihistamine I'm taking to cope with the itch) weaken the effectiveness of PEP?
5) What's your take?
6) How long do I need to test HIV- for a definitive result?
The rash has been fading steadily since I started the antihistamines. The ID clinic I was referred to offered to prescribe a different drug, but I decided to tough it out and stay on the preferred/recommended regimen. I've had no fever or other symptoms (other than rash) suggestive of ARS.
I tested negative for HIV, Syphilis, Gonorrhea, and Chlamydia on 12/14/06. This oral exposure is the only potential exposure I've had since.
-Panic-stricken
Doctor's Answer
by H. Hunter Handsfield, M.D., Jan 10, 2007 12:00AM
, Jan 10, 2007 12:00AM
He should have told you his HIV status before you were exposed, but you shared equally in the responsibility: you should have asked. In any case, the risk you were infected is low and I would have recommended against PEP. However, now that you have started it, you should follow the guidance and advice of the provider who prescribed it. That person, and not this website, should also be the primary source of all advice and information at this point.
I am unaware of any data that steroid therapy, even in large doses, increases the risk of acquiring HIV; I never heard that. In any case, clearly there is no increased risk at physiologic replacement doses.
1) The data on exposure risk have not been calculated or estimated as a correlate of viral load.
2) I would guesstimate your baseline risk at 1 in 100,000; definitely not 1 in 10,000. Your drug therapy and/or oral lesions do not increase your risk tenfold; they have no measurable effect. Taking PEP is protective; I'll go along with 80% effectiveness. Thus 0.00001 x 0.2 = 0.000002, 2 in a million, 1 in 500,000. By contrast, your lifetime risk of dying by lighting (if you live in the US) is 1 in 27,000, or about 20 times higher than the chance you now are HIV infected.
3) I don't know where you might find individual persons' stories about infection by performing oral sex. But if I knew, I would advise staying away from them; such personal reports are the least reliable of all potential sources.
4) I haven't a clue whether a drug side effect or other skin rash would reduce the effectiveness of PEP. I see no reason why it should. But this is a question for the provider you inappropriately talked into prescribing PEP.
5) See reply no. 2.
6) I'm not sure what effect PEP has on delaying seroconversion. Not much, I believe--but again, speak with y our own provider.
Bottom line: Being panic stricken is an inappropriate response. Almost certainly you're home free. But maybe a silver lining: perhaps from here on you'll ask your partners about their HIV status before having sex.
Best wishes-- HHH, MD
I am unaware of any data that steroid therapy, even in large doses, increases the risk of acquiring HIV; I never heard that. In any case, clearly there is no increased risk at physiologic replacement doses.
1) The data on exposure risk have not been calculated or estimated as a correlate of viral load.
2) I would guesstimate your baseline risk at 1 in 100,000; definitely not 1 in 10,000. Your drug therapy and/or oral lesions do not increase your risk tenfold; they have no measurable effect. Taking PEP is protective; I'll go along with 80% effectiveness. Thus 0.00001 x 0.2 = 0.000002, 2 in a million, 1 in 500,000. By contrast, your lifetime risk of dying by lighting (if you live in the US) is 1 in 27,000, or about 20 times higher than the chance you now are HIV infected.
3) I don't know where you might find individual persons' stories about infection by performing oral sex. But if I knew, I would advise staying away from them; such personal reports are the least reliable of all potential sources.
4) I haven't a clue whether a drug side effect or other skin rash would reduce the effectiveness of PEP. I see no reason why it should. But this is a question for the provider you inappropriately talked into prescribing PEP.
5) See reply no. 2.
6) I'm not sure what effect PEP has on delaying seroconversion. Not much, I believe--but again, speak with y our own provider.
Bottom line: Being panic stricken is an inappropriate response. Almost certainly you're home free. But maybe a silver lining: perhaps from here on you'll ask your partners about their HIV status before having sex.
Best wishes-- HHH, MD
Anyway, giving oral, even to a known HIV positive partner, is VERY low risk. Think about it. Think about how many people give and get blowjobs every single day (millions!). If you can't find any documented cases, then just how common can it be? And I believe 5000 is actually a fairly low viral load anyway.
Your risk really is 1 in 10,000 (I'm guessing lower since he didn't ejaculate), and I personally think your doctor was wrong to put you on PEP.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm#tab1
And the resident cited the 'high viral load' of the HIV+ source (20,000).
FYI - Retail for 1 month of Combivir and Kaletra would have been $2200 at CVS. I bought 2 days retail $160 at a 24-hr CVS (so I could start PEP by 24th/25th hour), then bought the rest at my usual pharmacy the next day for a co-pay of $180.
The nausea was bad, but not intolerable. The rash is worse. But no side effect can hold a candle to the perpetual sense of dread. At least with PEP, I know that I've improved my odds somewhat.
The risk is very low, but do follow up with testing for peace of mind.