Advice Evolution

[MikeCA]

Hello Dr Hook,

Thank you for answering my personal concern back in September of 2010. I also appreciate reading the professional and nonjudgmental advice you give others with HIV-related questions.

I noticed that over time, and this is just my perception, that yours and the other physicians' opinions on certain issues have varied somewhat; i.e., several years ago you advised that oral sex was "low risk"(advising against engaging in oral sex with a known hiv-infected individual) but more recently referred to it as "no risk". Is this simply semantics, or as a medical professional, does your advice reflect the greater knowledge of the disease that becomes available as research progresses? Another example is a question you received a couple years ago from a guy who got an infectious bodily fluid in his eye; you recommended PEP. Would you make the same recommendation today?

Those are just some observations; I look forward to your comments.  Thanks for reading.

Thanks again for being an invaluable resource for people around the world.

Mike

[H. Hunter Handsfield, M.D.]

Welcome back to the forum and thanks for your question.  Dr. Hook and I take questions randomly, without regard to specific requests.  You got me this time.  Having worked very closely together for 3+ decades, and having both taught and learned from each other, our views never are significantly different from one another. although our writing styles differ.

Since the inception of the forum 8 years ago, we have periodically warned users to use care in extrapolating responses to specific questions to other situations.  Each answer is crafted in response to the situation at hand, often taking into account the user's emotional state, whether s/he has asked similar questions before, and so on.  And in the interest of efficiency, sometimes we are more expansive than otherss.  Also, it is impossible to prove a negative.  We often will use absolute terms like "HIV is not transmitted by kissing", when the truth is that there are no known cases, but I would certainly acknowledge the possibility it could occur and it may well have happened.  But sometimes an absolutist response is best for a frightened, anxious person, rather than a nuanced one that s/he might take the wrong way.

And as you suggest, often it is just semantics.  One time we might say "no riak" and the next time "no risk for practical purposes" oand yet again "very low risk with know known cases that it ever happened".  Nobody should perceive a significant difference beween such responses.  In addition, it's easy to read "zero chance you caught HIV" and think it applies to the test result alone, whereas the context (which might have occurred 3 days previously in an earlier reply, or even in an entirely separate thread) makes it clear it responds to a more complex scenario, taking into account the exposure history or other factors in addition to a test result.

I really don't think our answers are any more or less nuanced in recent years than earlier.  However, on reflection I think maybe there are more questions now from hyper-frigthened people with ridiculously low risk scenarios, in which we might take a more black and white stance.

As for the risk level for individual exposure events and our guidance about them -- testing or not, PEP or not, etc -- be careful to read each question very carefully.  Taking an eye exposure as the example, it's different if someone gets a splash of saliva (low risk) versus blood (higher risk) or genital secretions (somewhere in the middle); if the source is low risk for having HIV (e.g., a random person on the street, a sales clerk) versus high risk (e.g., a gay man in San Francisco) versus known infected; and in light of new research data (not available until a year ago), the last can be further modified according to whether and infected person is taking ART and his or her HIV viral load.

With those sorts of considerations in mind, both Dr. Hook and I have rarely recommended PEP when someone's healing skin wound has been exposed to blood or genital secretions, e.g. after fingering.  But 3-4 days ago I gave the opposite advice, that the user should see a specialist to consider PEP.  But in that case, the cut was only 3 hours old and there was heavy exposure to known HIV-infected blood.  I told him the risk was low, but that it was a reasonable consideration.  (As it happened, the doctor agreed with me and PEP was not prescribed.)

I'll close by repeating my opening comment:  all forum users should view our replies as specific to the situation describe in the question asked, including its entire context.  That answer may or may not be the one we would give in other, outwardly similar situations.

I hope that clarifies think a bit.  Thanks for your thanks about the forum.

Regards--  HHH, MD  

[MikeCA]

Thank you, Dr. Handsfield, for your prompt and comprehensive response. Take care. : )