Theoretical Risk or Actual Risk?

Hello Doctor,

I am having some questions about theoretical vs. actual risk.  I was told theoretical risk is when there has never been a reported case but does exist in theory (ie - semen on a cut hand) while actual risk is when a risk does exist and cases have been reported to the CDC/Health Department.  The reason why I ask is because there I received conflicting advise from other message boards.
1.  I read on a Yahoo! message board that giving a hickey is possible transmission of HIV.  I want to know, plain and simple, are you aware of any documented cases of HIV of someone being infected with HIV through giving a hickey?
2.  Plain and simple, are yo aware of HIV documented cases from someone receiving a hickey?
3.  I was told that receiving oral sex for both a man and a woman remains a theoretical risk, as there are no actual reported cases but a risk exists in theiry.  Plane and simple, are you aware of any documented HIV cases of someone being infected with HIV via oral sex?
4.  Another website I was on gives mixed information of mutual masturbation, saying this too is a risk in theory as no cases have ever been documented.  Is this statement true?
5.  Also, what's to explain for the fact that the CDC estimates that the cause of HIV transmission in 8% of all cases is unknown (and not Anal Sex, Oral Sex, Vaginal Sex, Health Care Setting)?  I find this to be confusing.
6.  Does theoretical risk mean very low to no risk while documented risk means a risk exists?

Thank you doctor, for clearing these issues up.  It seems as if your the guy to go to with answering questions and i look forward to seeing your answer.

[H. Hunter Handsfield, M.D.]

There is no formal definition of "theoretical" versus "actual" risk.  In answer to question 6, my own interpretation is exactly as you say, i.e. whether or not transmission has actually been documented to occur.

1,2) Theoretical; to my knowledge, no documented (or even suspected) transmission by hickey.

3) There are reports of people acquiring HIV by receiving oral sex (fellatio, not cunnilingus).  However, many (most? all?) such reports were by people who might have denied or forgotten other exposures, and some experts do not consider them validated cases.  My view is that such transmissions probably occur, but too rare to worry about for practical purposes.

4) Hand-genital contact isn't even a theoretical risk, in my opinion.  Maybe some excrutiatingly small chance if there are open lesions on hands or genitals.

5) Some people with HIV deny all known routes of transmission.  Most of those are either not being truthful, or simply don't recall risky events, perhaps because they were exposed when drunk or on drugs.  The most common situation probably occurs in monogamous/faithful women who are oblivious about their male partners' risks.

Bottom line:  Safe sex means selecting partners carefully, asking new partners (before having sex) whether they have HIV or not, and using condoms for vaginal or anal intercourse.  That's it.  Do those things and you could go a lifetime with a new partner every day and never expect to catch HIV.  Other kinds of exposure basically don't matter much.

Good luck--  HHH, MD

[collegeboy18]

By the way, to clarify, my question in 3 is asking if you know of any documented cases of someone getting HIV via being the reciepitant of oral sex.  I know a low risk exists by giving oral sex.  Sorry for the confusion.

Thanks.

[Ermanno]

Hi,
Sorry If I say something.
Hope the doc will clarify the 8% thing.
He would not be so straight in saying sex with condom is safe and that certain people are only paranoid if the interpretation you give to this number is that 8 person out of 100 infected had it in one of the ways the doc describes as "nearly impossible".
My feelings is that 8% don't remember or don'y want to say what they did.
Is this the correct interpretation doctor?
Ermanno

[H. Hunter Handsfield, M.D.]

ermanno has it right.

[Ermanno]

Hi Doc,
so why do they put the news down so badly.
Us, not doctors but normal people, may believe that in 8% of infected people safe sex did not work.
That would mean it the less safe thing on heart, not the meteorite paradox...
These numbers and % scare people, as well as many other people that still want to tell everybody that there is a risk somewhere, no matter how they tried to protect themselves.
What do you think?
Ermanno

[H. Hunter Handsfield, M.D.]

I'm not sure CDC is responsible for some persons' overreactions or inaccurate assumptions about the data.  There are plenty of CDC publications and websites that state that the no-known-risk category doesn't mean people are getting HIV through casual transmission or atypical exposures.  In any case, most of the public probably does not have the sort of reaction you describe.  Most people seem to naturally assume that lack of a risk category doesn't mean casual or atypical transmission.

[collegeboy18]

Hi Doc.

Thank you for answering my questions, and clearing things up.  I read an interesting piece of advise from the University of California when I was researching actual v. theoretical recommending someone to get an HIV test because of a hand shack exposure (they had a cut on their had, as did the other person who was HIV+).

Are you aware of a docummented case from something as simple as a hand shake?  What are your thoughts on this?

Thanks

[collegeboy18]

I know my last question may sound a bit silly, something that has been done billions of times as a hand shake, but I find it odd that a hospital as reputable as the University of California would be recommended HIV tests on what they referred to as a "cut to cut" handshake.  I may not  be a doctor, but I am in business/economics, and it seems like that would be a waste of resources and money.  I wonder if any such things have been documented though to lead the University of California to give such advise.

[peekawho]

You will have to copy and paste the article you are referring too.  Or give a link.  I think you misunderstood something.

[collegeboy18]

Two Articles I wanted to point out to you doc and your thoughts on them:

1. http://hivinsite.ucsf.edu/insite?page=ask-01-09-07

That one is about the hand shakes

2.  http://www.hivinsite.org/hiv?page=basics-00-08

That is a two year old article that says HIV isn't transmitted by being the receipitant of oral sex.  I find this all to be confusing.  The article isn't too old, september of 2004.

[monkeyflower]

I think you misunderstood. The first article is 8 years old, and it clearly states there is no risk of infection from what the questioner described, but s/he can test if it makes him/her feel better.

[collegeboy18]

I see what you are saying.  My last question, posted to the doctor, is if the documented cases with regards to receiving oral sex have been in the past 2.5 years?  The article at  http://www.hivinsite.org/hiv?page=basics-00-08 just gives different advise, and I just wonder if its because of the age.  It says no one has gotten HIV from receiving oral sex, and it dates from September 2004.  It was that article that prompted me to ask in the first place.  

I suppose you are right about the hand shake.  I suppose its just the oral sex issue where I receive conflicting reports - with the Doc saying rare cases have been documented, with HIVInsite and a page from Ask Alice (though Ask Alice's advise is decade old) saying no cases have  been documented, but the Doctor knowing of cases documented.  I think it would be easier for the public if the CDC made up some guidelines listing which activities have a proven HIV risk and what the risk is (ie 1/10,000).

Thank you for your help doc.  I suppose this sparked interesting discussion and I hope you can settle the confusion that I have with regards to what you, Ask Alice, and HIV insite say.

I look forward to your response.

[monkeyflower]

The CDC has said that the risk from giving a blowjob to someone who is KNOWN to be HIV positive is 1 in 10,000. The risk from receiving a blowjob from a known HIV positive partner is 1 in 20,000, although the latter is purely theoretical...

So either way, the risks are really pretty astronomical.

[collegeboy18]

All these back and forth articles and comments, wow, I am now confused about the actual risk of receiving oral sex.  I know memphis and the others have all had their input, but I hope the Doctor will respond because I am curious to about the documented cases of HIV by receiving fellatio (given the HIVInsite article and I too found some articles that said there weren't via a google search and have yet to find one that substantially said there was, but a handful that said there weren't any documented cases - though like memphis they are all fairly dated being 96, 2001, 2004).

Also, are the CDC facts true?

And, what was that nonsense about hand to hand contact?  I read that article, and I agree it was probably misinterpreted by memphis.  No risk there.

Hopefully we can all stop responding and let the doc settle these final issues when he signs on in the morning.  He's the expert, after all.  I agree with everyone adding in their input, but lets have him settle everything in the AM.


Take Care everyone!

[H. Hunter Handsfield, M.D.]

The very fact that there are conflicting reports and debate among the experts proves the point:  acquiring HIV by receiving oral sex either doesn't occur or it occurs with sufficient rarity that it doesn't much matter.  End of story.  There will never be more precise data than we now have.

It's time to end this thread.  Those who remain interested can take it to the HIV Support forum.

HHH, MD