Actual receptive oral exposure to HIV source, PEP

[strata]

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

[H. Hunter Handsfield, M.D.]

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

[monkeyflower]

I understand you were freaked at finding out he was HIV positive; I think most people would be. He really should have told you before you did anything sexual. However, what's done is done, and he did eventually tell you... and before you did anything risky. But next time ask first :-)

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.

[strata]

Thank you for the feedback. The Infectious Disease resident on-call made the decision about PEP, although I was adamant about wanting it anyway (public policy concerns about cost notwithstanding since I was willing to pay out-of-pocket). The CDC guidelines for nPEP indicate PEP in my circumstance:

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.

[monkeyflower]

Come on. After reading the table above, where it clearly states you have a 1 in 10,000 risk, can you *really* think that you were at a substantial risk? Yeah, I know it says that contact between mouth and semen falls in the "substantial risk" category, but it's pretty freaking vague. I mean, there's a huge difference between a blood transfusion or even receptive unprotected anal and a quick blowjob.  Relax. If you can't let this go, you might consider talking with a therapist.

[kekelow]

Strata my sister has hiv, and when i went to the doctor with her and spoke to her hiv specilist she showed me my sister's chart. Her viral load  is undectable and thats like 50 copies.Her CD4 i belive it was 725 i belive and she has had it about 19 years.I think that guys viral load is high, but what do i know, anyway, i'm sorry this has happed to you. God Bless You.

[kekelow]

The guys viral load he said  is 20,000 but viral loads can change during the day. I think that guy was lieing about his viral load.

[massguy]

The Doctor that gave you PEP was crazy!   If everyone who gave a BJ (even if their partner was HIV positive) was on PEP not only would there be a large sum of people on PEP, there would be resistant strains of the virus all over the place.

The risk is very low, but do follow up with testing for peace of mind.

[strata]

Dr,

Just to clarify why I am asking questions here and not of my provider:

I was prescribed PEP in the ER. For follow-up, I was told to schedule an appt at the hospital's ID clinic, which I have -- but it's not until next Wed, and I hoped to get some perspective from this site as a means to calm my nerves and regain some focus.

I did call the clinic to ask about the drug side effects and other concerns, but the doctor was pretty impatient and said that most of my questions could wait until my appointment. All he wanted to know at the time of the call (without knowing anything about me or my case) was: 1) Was I experiencing side effects that made me want to try different meds? and 2) If the side effects weren't so bad, why did I call? He has fantastic credentials for HIV and STDs, but his bedside manner was nonexistent.

I've read some articles correlating transmission risk (although not per-act) with viral load, which was the reason for my question and assumption that I was at higher risk:

http://findarticles.com/p/articles/mi_qa3876/is_200012/ai_n8904132
http://www.hopkins-aids.edu/publications/report/may00_1.html

Bottom line - the risk might be small, but so many sites and people (the ER docs looked at me like I was already dead) reinforce the fact that the risk from oral is REAL and that people have been infected by HIV. From a public health standpoint, oral transmission of HIV might not be a concern, but, for me, it's different, and only time (and HIV tests at 6, 12, and 24 weeks) will tell.

Yeah, I know, if I'm so concerned and risk-averse, what the hell was I doing having sex anyway? Or driving? Or playing golf in the rain?

Sorry to have bothered everyone with my nonsense.

[sgf12345]

i was a bit surprised to see that Dr HH estimated the baseline risk at 1/100,000 (before performing the other calculations.)  i had thought that the per episode risk from performing fellatio on an HIV + individual was 1/10,000.

[H. Hunter Handsfield, M.D.]

srata:  It's not nonsense at all.  I just want you to have a realistic understanding of the risks as I interpret them.  All in all, I think your risk of a dangerous health outcome from the PEP is greater than the chance you acquired HIV, which is why I would not have prescribed it.  And unfortunately, online consultation in a forum like this is not a proper substitute for personal care, and I cannot solve the communication and follow-up problems that often follow emergency department care.

sgf:  The 1 in 10,000 risk assumes more prolonged exposure, usually with ejaculation in the mouth.  Based on strata's description of the exposure event, I guesstimated the chance of transmission as about t one tenth the usual risk.

HHH, MD

[kekelow]

How you doing Strata i'm sorry you have yo go threw this.

[strata]

Thank you for the kind inquiry. Like many of us who have been concerned about an exposure or potential exposure, I vacillate frequently between debilitating anxiety and obsessing about work (or anything else that will get HIV off my mind). Now I just need to wait it out until I can have a definitive (and hopefully negative) HIV test.

If this thread remains open that long, I'll post my test results.

[kekelow]

Strata you can take this to the hiv surportive forum to get more surport. I obsess on everything to and it drives me nut.Hang in there and god bless you.

[strata]

FYI -

Many sites refer to a CDC report from December 2000 entitled: "Preventing the Sexual Transmission of HIV, the Virus that Causes AIDS - What You Should Know About Oral Sex"

This report is repeated several places on the net and mentions the following WITHOUT citation of any kind:

Documented: Although the risk is many timessmaller than anal or vaginal sex, HIV has been transmitted to receptive partners through fellatio, even in cases wheninsertive partners didn't ejaculate ("***").

This has been a source of significant concern and consternation, so I've tried to find some of the studies of oral transmission of HIV. Here are a few that have been interesting:

http://www.hivinsite.org/InSite?page=kb-07-02-02#S3.4X

-Provides several citations for risks associated with various types of sex, including oral. A great starting point.

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1405129&blobtype=pdf

-An NIH published study from 1990 that identified 2 MSM (from a cohort of 6705 in SF originally recruited in '78-'80 for a HepB study) who likely contracted HIV from oral sex. Both men had a history of gingival recession albeit without open oral lesions. In the period between the last HIV- test and the first HIV+ test (seroconversion), Man#1 reported 4 episodes of receptive oral with ejaculation (with at least one known HIV+ source) and 5 episodes of receptive oral w/o ejaculation over 4.5 months. Man#2 400 partners, 900 episodes of oral w/ ejac and 200 episodes of oral w/o ejac. One partner with whom #2 had receptive oral w/ ejac was confirmed HIV+ and reported AIDS-defining infections.

[ScaredUKGirl]

I also read that so many times about documented cases of HIV being transmitted without ejaculation!

If these documented cases refer to people who had very poor oral hygiene/bleeding gums I don't know but you can read that HIV can be transmitted through the tiniest cut in your mouth (I had a cut in my gums from wisdom teeth cutting through) but it seems that there is not a reliable source to back up any evidence of this at all which is why like me you are so confused at the subject! The doctor here says it is theoretical but I'm not so sure??

[strata]

FYI

Brief update. Went to ID clinic for follow-up after having been prescribed nPEP. The Attending had the same charming personality I mentioned in a previous post. We basically looked through me for 8-10 seconds while he talked to his resident. The main concern was the rash I had experienced, but the conclusion was that "any rash that is fading is OK".

I was instructed to stay on PEP for the remaining 2 weeks, with follow-up scheduled in 4 weeks. The ID clinic took blood for HIV antibody and PCR DNA/RNA. PCR seemed counterintuitive, especially since I'm on PEP, but my guess is that they are using it to rule out other early HIV infection (from before the oral incident I reported on 12/30 after the negative HIV test I had on 12/14).

No other STD tests were done (I don't have any symptoms indicative of STDs either).

For peace of mind, after I left the hospital ID clinic, I went to WWC (the awesome Whitman Walker Clinic, for those in DC area) for a rapid HIV test. Since it's been only 18-19 days since exposure, the clinician chose to use finger stick versus oral swab (99.6% vs 99.3% sensitivity). The test came back negative. Far from definitive, but it helps my nerves since roughly 50% of people would seroconvert by now.

If the tests run by the ID clinic come back negative next week(ELISA and PCR), I'll likely get another rapid test at WWC at week 4 and 6, along with follow-up ELISA and PCR from the hospital ID clinic at week 6.

[strata]

Just a testing update...

On 1/17/07 (18 days post-exposure), I had an ELISA and PCR/RNA at the hospital ID clinic where I was receiving follow-up care since I was precribed PEP in the ER.

Both the ELISA and PCR came back negative.

Today, 2/13/07 (approx 6.5 weeks post-exposure, 2 weeks post PEP), I had a rapid OraQuick Advance HIV-1/2 test by finger stick at WWC. It was negative.