Help needed

I'm just going to explain all the risks I have taken since I have become sexually active. I just want a doctor's opinion and some answers to questions I have.

I have NEVER had anal sex.
Risks (all unprotected)
1) Insertive oral (June 2010)
2) Receptive oral (July 2010)
3) Receptive oral (August 2010)
4) Receptive/Insertive oral (September 2010)
5) Receptive/Insertive oral (October 2010)
6) Receptive/Insertive oral (October 2010)
7) Receptive/Insertive oral (November 2010)
8) Receptive/Insertive oral (November 2010)
9) Receptive/Insertive oral (December 2010)
10) Insertive oral (February 2011 - same partner as number 6)

A total of 9 partners. All who said they were HIV negative by the way but I'm taking that with a grain of salt.

Tests (All INSTI - Finger prick 1 minute Anti-Body Test)
Jan. 6th - Negative
Jan 28th - Negative
Feb 14th - Negative (7.5 weeks past december encounter)

Questions:
1) Do my tests eliminate all encounters besides my most recent february insertive oral encounter?
2) Is a 4th generation test available in Canada?
3) Do I need to continue to test?
4) How accurate is a standard antibody test at 7.5 weeks?
5) Is it true that the risk from insertive oral only arises when there is blood present in the receptive partner's mouth? I was reading the transmission equation on AIDSvancouver.com and since saliva is not infectious and no blood was seen. I don't believe this last encounter was a risk at all.

Basically, I just want to hear what the professional has to say about my own personal experience. I totally understand there is a hundred topics relating to this out there and this was probably a waste of $20 when I could just read a similar question. I just need to hear what the doctor has to say about me in particular in order to move on.  

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  I'll try to help.

You don't say it, but I gather your partners are men.  As a man having sex with other men, you are inherently at higher risk of HIV than most straight men.  However, you are pursuing entirely safe sex practices.  HIV is rarely transmitted by oral sex.  Some experts believe it never happens, and others have calculated an average risk of once for every 20,000 events, if the oral partner has HIV.  That's equivalent to receiving oral sex by infected partners once daily for 55 years before infection might be expected.

You also are asking your partners about their HIV status, which is excellent.  You need not take that with "a grain of salt".  Infected people rarely lie about their HIV status when asked directly.

For those reasons, you have been seriously overtested for HIV based on your exposures.  If your sexual lifestyle does not change, it would be reasonable for you to have a routine HIV test from time to time, like once a year -- and to stop worrying about individual exposure events, unless much higher risk, like anal sex with a partner who is positive or doesn't know his status.  To your specific questions:

1,4) Your test results prove you weren't infected.  The antibody-only HIV tests are nearly 100% reliable 6 or more weeks after the last exposure.

2) I'm assume one or more combination tests ("4th generation") for HIV antibody and p24 antigen are available in Canada, but do not know for sure.

3) You are not currently at sufficient risk to have been tested at all and do not need any further testing at this time.

5) There are no data on risk of oral sex with versus without blood exposure.  Logically the risk might be higher if blood were present, but still undoubtedly very low.

I hope this helps reassure you.  Best wishes--  HHH, MD

[bloorguy1]

Also two more questions...

Is the seroconversion illness the body's reaction to the creation of antibodies?
If HIV is truly making you ill with the ARS then won't your antibody tests come back positive?

[bloorguy1]

Keep forgetting stuff -- incase it's not obvious.

I'm gay and all my partners are male.

[H. Hunter Handsfield, M.D.]

Yes, the symptoms of ARS are largely due to the body's immune response to infection.  The HIV antibody tests are almost always positive within 10 days of onset of symptoms.   Thanks for clarifying your sexual lifestyle.

Initially I thought your exposures were only insertive oral sex, but they also are receptive.  The only difference is a slightly higher risk, but still extremely low -- estimated one transmission for every 10,000 events with HIV infected male partners (equivalent to giving oral to infected men once daily for 27 years instead of 55).  So my opinion and advice above are unchanged.

[bloorguy1]

I just have a question regarding the biology behind the risk of the insertive partner in oral sex.

I don't know if this still covered by my $20 fee, I think it should be but not 100% sure.

Anyways,

Saliva is not infectious correct? Thus how is the insertive partner at any risk when receiving oral? In this case, the penis would enter the mouth but wouldn't be exposed to any of the 5 infectious fluids so how could it be biologically possible for an infection to occur? I totally get that there is a theoretical concern for the person performing but when you are receiving and your own semen/precum gets into the partners mouth how does that put you at risk? Where does this 1/20000 come from?

[H. Hunter Handsfield, M.D.]

The 1 in 20,000 estimate comes from a CDC report, based on interviews of infected people, their judgment how how and when they were infected, and what kind of exposures they had:  http://www.cdc.gov./mmwr/PDF/rr/rr5402.pdf

Data of this sort are imprecise, and many experts believe there is zero risk of transmission from mouth to penis.  The biological reasons are not clear; because such transmission is rare or may never happen, there is no point in doing research on it.  Maybe it is laregely because of the reason you state, i.e. saliva inactivates HIV, but we really don't know and probably never will.  If there is any risk, I doubt it has anything to do with whether or not the insertive partner ejaculates or is producing pre-ejaculate fluid.

We can go only so far with follow-up questions.  This will have to end this thread.  Take care.

[bluebulldog89]

Thanks for posting the link about CDC and oral sex risk. You are a great man Dr. Handsfield, thanks for doing what you do.