blood exposure in mouth

[justonce]

Doc,

My story, I had an hiv + male partner. We engaged in protected sex once (vaginal intercourse) and had protected
oral sex once. That was several months ago and I since
tested neg. We have agreed not to engage in any further
sexual activities but on 1/2/07 we were in bed just holding
each other when I bit his nipple just playing around and
drew blood into my mouth, I swallowed without thinking,
several minutes later rinsed with water. He probably
bled from the nipple for a few seconds (several drops).
He is pos x 12 years and tends to be well controlled with meds.
at his last blood test he was at 159 viral load which was a
couple weeks before this incident. After I bit him I tasted
a small amount of blood on the very back of the tounge. I have
good oral hygiene, no open cuts or sores. I did brush my teeth
about 1.5 hours prior to this. We have no other risks, no
other std's and general good health. I went to the ER the following day out of fear and was prescribed a 28 day expanded 3 drug nPEP. The ER doc looked at me like I was already a goner.... so Doc, what are my chances? I read it's 1/1000 for
a blood splash to a mucous membrane. If so, should I expect
some reduction due to the pep (it was started within 36 hours of exposure). The relationship tanked due to the stress of all this. Also, when do you think I should follow up with my pcp?

Thanks for your help.  

[H. Hunter Handsfield, M.D.]

Your risk is low from this event.  The indications for PEP are borderline; many providers would not recommend it, or would leave the decision up to the patient.  Swallowing blood is no higher risk than mucous membrane exposure, maybe lower; in general, swallowing HIV in any fluid is pretty low risk.  And with your partner's very low viral load, the chance you were infected certainly was much lower than 1 in 1000.

I cannnot give direct personal advice for your care in this situation.  Presumably the ER referred you to a provider experienced in HIV infections and in PEP.  If not, they should have.  Follow up with that provider, or find one yourself.  (You could phone the local health department or medical society to find someone, such as an infectious diseases specialist or other provider skilled in HIV care and PEP.)  In the meantime, continue your PEP until advised otherwise--but mellow out, knowing your risk of HIV was very low even without PEP.

Good luck--  HHH, MD

[notAnExpert1]

I think your chances of getting infected is zero or close to it. That much blood probably can not get you infected.

[justonce]

The PAC I saw in the ER stated it was a "significant exposure"
and I have been exposed. He placed a call to the powers that be
in infection control (assumed to be an infectious disease
specialist) and loaded me with Combivar (SP) and another drug
I think is AZT (which my guy is allergic to).

I just want to know if I have the 1/1000 chance that is
cited in all the studies published or if I have better odds.

These drugs are tough to take but I'm 1/2 way home. If indeed
they do reduce transmission by some 80% I'll stick with them.

I was also wondering when I should follow up with a test.

[justonce]

Thanks Doc, I didnt read your comment before my last post.

I will follow up. However, if you'd
please.. Are you saying that swallowing *** or any other
body fluid is about the same risk as swallowing blood?

Is it true that saliva inhibits the HIV virus?

Is an exposure in the mouth less than unprotected vaginal sex?

When should I follow up? I was refered to my Primary Doc not
a disease specialist. Is it imperitive that I see her now or
can I wait until I finish the meds ( I already have an appt in
a couple weeks). I understand if you can not answer questions
regarding treatment.

Thanks Doc, your words are reassuring to me. You have provided
some relief to a lot of people ...thanks again...

[H. Hunter Handsfield, M.D.]

In general, swallowing infected secretions is low risk.  I am unaware of comparative data for blood versus other secretions.  But to put the risk in context, HIV is present in the breast milk of infected, nursing women.  Yet over 1-2 years, only about 10-20% of babies nursed by infected women become infected.

Saliva inhibits HIV.  Mouth exposure or swallowing is much lower risk than unprotected vaginal sex.

People on PEP should be seen at least once during treatment, usually a couple of times, to check for side effects and general assessment.  Ask your provider what s/he recommends; or if s/he isn't up to speed on PEP, ask for referral to someone who is.

Glad to help.  Take care--  HHH, MD

[massguy]

10-20% of infected babies that got infected from their mother's were receiving breast milk for weeks and months!  

Good luck - I hope your a-ok, I think you will be!

[shouldknowbetter]

I am really not exactly sure what the following study says
but it appears that there is a different make up of the
virus in milk vs blood. I just hope we are not comparing
apples to oranges. Doc, this is not a challenge to what
you posted, I'm just frightened.

Conf Retrovir Opportunistic Infect 2004 Feb 8-11; 11:(abstract no. 93)

Edwards B, Ghosh M, Sabbaj S, Rhodes A, Decker D, Goepfert P, Aldrovandi G; Univ. of Alabama at Birmingham, USA and 2Childrens' Hosp. Los Angeles, CA, USA

BACKGROUND:
Transmission of HIV via breast milk is a significant source of pediatric infection, yet the majority of infants do not acquire infection through this route. This latter finding may be due to the low levels of HIV RNA in breast milk compared with plasma. We therefore hypothesized that the magnitude and quality of T cells in breast milk are different than the peripheral blood compartment as an explanation for the lower viral load in the former compartment.

CONCLUSIONS: T cells found in the breast milk compartment express a highly activated/effector phenotype that preferentially migrate to this area. These findings may not be specific for HIV, as other antigen responses also appear increased in breast milk. Nevertheless, our data are consistent with the hypothesis that increased numbers of activated HIV-specific CD8+ T cells result in lower viral RNA levels in the breast milk than peripheral blood compartments

[H. Hunter Handsfield, M.D.]

Of course the reason for the low transmission rate in nursing is multifactorial, and low levels of infecious HIV in breast milk is one of the reasons.  But the low susceptibility of the mouth and gastrointestinal tract also contributes, and the data remain reassuring in relation to oral exposure in general.

[sgf12345]

what if the shoe was on the other foot, and the hiv + partner bit the neg persons nipple and either drew blood or cbraded the nipple?  since the amount of HIV in saliva is apparently quite low, i would think that would be very low risk, but one does read anecdotal stories of someone getting infected by being bitten.  or are those urban myth?

Thanks.

[justonce]

I read something about one case where it was transmitted
as you stated but I think the bite was extensive and
there was tremendous tissue damage.

[Should have used my head]

Any feedback on cunnilingus during menstruation (high risk candidate).

I understand that 'theoretical' risk exisits and that there are few/no WSW cases of oral transmission. But assuming an action of very short duration and not...overly enthusiastic and engaging (not close to the opening - only in clitoral area. She showered prior this), what would the actual risks of transmission be.

Had I known she were menstruating I would never have done such a thing, but such is life.

BTW Dr., I love your site. It is a welcome relief to the fire and brimstone I read on other sites. I would respectfully suggest that some improvement could be made in the subject headings of each question: ie 'Yikes!!' or 'I am so unlucky!' could be changed to subject heading more indicative of what they addressed. I only say this as I have noticed a fair amount of duplication in the questions asked and I understand your time is limited.

I thank you for any reply I might receive.