Aa
Why the Variance on Risk Analysis?
After a great deal of research on the risk of becoming infected with HIV after being felated for a few seconds, I've become alarmed at the variance in the opinions of experts. It seems to range from "small risk" to "no risk". Very different answers. Based on reading many export forums, articles, case-studies, etc and applying my own logic, I think I've settled on that it is a "theoretical risk". The one study I haven't been able to figure out yet is the reference cited by the CDC for their estimate of 0.5 in 10,000 for insertive oral with an infected partner. They cite the study, "Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use." by Varghese B, Maher JE, et al. Based on the abstract I found, I believe this risk level is based on a statistical extrapolation in comparing to insertive anal sex. I can't see if this study uses any medical science of transmission paths via this oral route, or is it just some number they pulled out of their butts (so to speak) to derive this risk level. Are you familiar with this study and can you shed any light? If this study does not contain proof of this transmission possibility, then I can not find any resources online to prove that transmission to the insertive partner during oral is possible. Your thoughts?
Secondly, due to the anxiety I've experienced I believe I do need to get a "peace of mind" test. I'm coming up on three months since my possible exposure now, but I'm very fearful of possible positive result. If my risk of infection from this exposure is very low, then what I'm really afraid of is a false positive, or an initial inconclusive and having to wait for a confirmatory test. Can you advise if there are any tests available that do not pose a risk for a false positive, or if not what the test with the lowest risk is? Cost is not a concern, but peace of mind is. Any instant tests with perfect specificity?
Secondly, due to the anxiety I've experienced I believe I do need to get a "peace of mind" test. I'm coming up on three months since my possible exposure now, but I'm very fearful of possible positive result. If my risk of infection from this exposure is very low, then what I'm really afraid of is a false positive, or an initial inconclusive and having to wait for a confirmatory test. Can you advise if there are any tests available that do not pose a risk for a false positive, or if not what the test with the lowest risk is? Cost is not a concern, but peace of mind is. Any instant tests with perfect specificity?
MEDICAL PROFESSIONAL
This is an excellent discussion; I'm going to bookmark it and refer selected users to it, if concerned and confused by conflicting risk estimates and advice. joggen's, eagleeyes', and BeSafe2010's comments, and sciencepls's last comment, all make excellent points and are very articulate.
In response to sciencepls: You are right, of course. However, people crafting prevention messages have a more difficult task than you may realize. The large majority of people at risk for HIV have nowhere near the insight, understanding, and probably inherent intelligence that you all have displayed. Remember that education/prevention messages have to reach the uneducated, people with poor English language skills, people strung out on meth, and people who don't even know what a condom is. Some may be new to the very idea of HIV as sexually transmitted. The level of discussion here, and the sort of truly accurate prevention information you would like, would go way over the heads of many at highest risk. The more sophisticated information is available -- you just have to dig for it, and work to distinguish the BS from the good stuff. (You have found it here. It's the main reason MedHelp runs this forum.)
So if you were in charge of getting the most basic messages to those at highest risk, how would you craft the messages? I'm not saying it's right to tell people that all sex and all potential partners are equally risky for HIV; as discussed above the legal, CYA perspective is a problem. But you get the idea: the maximum effect in prevention may in fact be the simplistic message and not the sophisticated, insightful one.
That will have to end this thread. Feel free to continue among yourselves on the community forum.
HHH, MD
In response to sciencepls: You are right, of course. However, people crafting prevention messages have a more difficult task than you may realize. The large majority of people at risk for HIV have nowhere near the insight, understanding, and probably inherent intelligence that you all have displayed. Remember that education/prevention messages have to reach the uneducated, people with poor English language skills, people strung out on meth, and people who don't even know what a condom is. Some may be new to the very idea of HIV as sexually transmitted. The level of discussion here, and the sort of truly accurate prevention information you would like, would go way over the heads of many at highest risk. The more sophisticated information is available -- you just have to dig for it, and work to distinguish the BS from the good stuff. (You have found it here. It's the main reason MedHelp runs this forum.)
So if you were in charge of getting the most basic messages to those at highest risk, how would you craft the messages? I'm not saying it's right to tell people that all sex and all potential partners are equally risky for HIV; as discussed above the legal, CYA perspective is a problem. But you get the idea: the maximum effect in prevention may in fact be the simplistic message and not the sophisticated, insightful one.
That will have to end this thread. Feel free to continue among yourselves on the community forum.
HHH, MD
By this logic, we can't say that kissing (which we all know is no risk) is "no risk" either, because blood could "theoretically" leak or be lapped up from one person's lips to inside the other's mouth, causing infection. But that's just theory: 30 years of data--not to mention the ~125+ years combined clinical experience of the 5 HIV doctors on these forums (Hook, HHH, Dr. Sean, Dr. Jose, Dr. Mervyn)--will attest to the fact that infection just doesn't happen this way. I think this is why doctors say "no risk." They're not going to say, "Well, in theory a little blood could blah blah blah..." because what's the point? It just leads to heightened anxiety and unnecessary testing.
Unless a person's mouth is actively bleeding and is full of blood for some reason (in which case why would that person even be giving any oral sex?), then non-infectious saliva touching one's bare penis cannot constitute any real risk. I have seen the Freedomhealth doctors make comments along these lines and in addition to never seeing infections occur like this in decades of clinical experience, that must be part of why they say it's no risk and no testing is required.
Of course, our minds don't always follow logic and reason and so we're liable to freak out for no reason anyway.
Unless a person's mouth is actively bleeding and is full of blood for some reason (in which case why would that person even be giving any oral sex?), then non-infectious saliva touching one's bare penis cannot constitute any real risk. I have seen the Freedomhealth doctors make comments along these lines and in addition to never seeing infections occur like this in decades of clinical experience, that must be part of why they say it's no risk and no testing is required.
Of course, our minds don't always follow logic and reason and so we're liable to freak out for no reason anyway.
Hi,
I normally reserve my comments on the doctors side of the forum. It is after all, for the experts. But I just could'nt resist this one. Sciencepls, the answer you are looking for probably does not exist. But I understand exactly where you are coming from. In a state of anxiety (and maybe guilt), any odds other than an absolute zero can cause immense worry. unfortunately, for multiple reasons (biology, medico-legality and plain lack of sufficient data) no doctor can say with 100% certainty that the receipt of oral sex does not pose ANY risk. The fact is, biologically speaking, the urethra is a mucous membrane, a cut in the mouth with blood is possible and hence a 'theoretical' risk. The point is, we are so mortified of HIV that other daily routines like driving or travelling by air or even crossing the road which have higher statistical possibility of mortality does not even cross our mind. The doctors are trying to tell you precisely that. The doctors believe you must look at epidemiology rather than biology as far as risk analysis is concerned (which means, what 'can' happen, vs reported, documented transmission cases since the past 25 odd years of this epidemic). Mellow out pal, the risk you are referring to is way to small given the anxiety you are facing. My best advice to you and folks like you is to stay as clear of even remote HIV scenarios (and that includes deep kissing, mutual masturbation, handjobs - not because they pose any risk, but because your mind will put a spin on them anyway)
I normally reserve my comments on the doctors side of the forum. It is after all, for the experts. But I just could'nt resist this one. Sciencepls, the answer you are looking for probably does not exist. But I understand exactly where you are coming from. In a state of anxiety (and maybe guilt), any odds other than an absolute zero can cause immense worry. unfortunately, for multiple reasons (biology, medico-legality and plain lack of sufficient data) no doctor can say with 100% certainty that the receipt of oral sex does not pose ANY risk. The fact is, biologically speaking, the urethra is a mucous membrane, a cut in the mouth with blood is possible and hence a 'theoretical' risk. The point is, we are so mortified of HIV that other daily routines like driving or travelling by air or even crossing the road which have higher statistical possibility of mortality does not even cross our mind. The doctors are trying to tell you precisely that. The doctors believe you must look at epidemiology rather than biology as far as risk analysis is concerned (which means, what 'can' happen, vs reported, documented transmission cases since the past 25 odd years of this epidemic). Mellow out pal, the risk you are referring to is way to small given the anxiety you are facing. My best advice to you and folks like you is to stay as clear of even remote HIV scenarios (and that includes deep kissing, mutual masturbation, handjobs - not because they pose any risk, but because your mind will put a spin on them anyway)
Hi-
We share some of the same thoughts on the 1 in 20,000 figure. I even wrote a short journal about it because I often see people in your situation who fixate on it.
The full Varghese paper can be downloaded here:
http://www.aegis.com/files/AskDoc_refs/varghese2002-29-1.pdf
However, I've seen people on HIV forums experience HIV anxiety over situations such as kissing, lap dances, handjobs, non-sexual massage, and touching underwear. My point being that HIV anxiety can still occur in people who've had encounters that they regret regardless of whether the form of sexuality that they are feeling guilty about has a statistic attached to it or not.
We share some of the same thoughts on the 1 in 20,000 figure. I even wrote a short journal about it because I often see people in your situation who fixate on it.
The full Varghese paper can be downloaded here:
http://www.aegis.com/files/AskDoc_refs/varghese2002-29-1.pdf
However, I've seen people on HIV forums experience HIV anxiety over situations such as kissing, lap dances, handjobs, non-sexual massage, and touching underwear. My point being that HIV anxiety can still occur in people who've had encounters that they regret regardless of whether the form of sexuality that they are feeling guilty about has a statistic attached to it or not.
MEDICAL PROFESSIONAL
Welcome to the forum. Good questions.
However, I disagree with the premise. Most people probably would not describe "small risk", "zero risk", and "theoretical risk" as significantly different from one another. For intellectual honesty, I often remember to qualify zero risk with something like "virtually", "for all practical purposes", etc. The problem is that so many hyper-anxious forum users glom onto anything other than "absolutely zero risk" and conclude they are doomed.
The Vergehese paper is indeed the one most cited, with CDC's estimated transmission risks. It isn't sufficient to read the abstract; you need to read the entire paper to fully understand it. But in essense, it is as you state -- calculations based on patients' sexual histories in the weeks or months leading up to their first positive HIV test. The results are rough at best. However, most likely the stated transmission risks are not radically wrong. And would it really matter if the oral to penile transmission rate were actually 10 times higher than calculated? That would be 1 in 2,000 instead of 1 in 20,000 -- equivalent to receiving BJs once daily by infected partners for 5.5 years before infection might be predicted, instead of 55 years. Does it really make any difference? The risk is really, really low, and that's all the reassurance most people want or need. For those who need more -- well, so be it. They'll just be doomed to a bit more worry until tested and perhaps more frequent HIV testing. C'est la vie.
Another aspect, of course, is that because the data are imprecise, many experts interpret the numbers differently. So some equally qualified experts will give different estimates from one another. On top of all that, many government agencies -- CDC, health departments, etc -- get legal advice to avoid the least chance of false reassurance. So if you call CDC's national STD/HIV prevention hotline, you may hear that oral sex is just as risky as unprotected anal sex. Still worse, some websites give advice based on political or religious spin -- the worst situation of all.
Question 2: False positive results are an occasional problem with the rapid tests, both the blood and oral fluids antibody tests that give results in 15-20 minutes. False positives are virtually unheard-of (there's that qualifier!) with the lab based tests. My advice is to just suck it up and be tested. You don't describe the nature of your exposure 3 months ago, but based on the comments above, I assume it was low risk and you can expect a negative result.
By the way, did you read the blog on "Today's Pulse" about HIV treatment preventing transmission? (Upper right of this page.) It has comments about HIV transmission risk estimates and the likelihood of better estimates in the future, at least for some types of sexual exposure.
I hope this helps. Best wishes-- HHH, MD
However, I disagree with the premise. Most people probably would not describe "small risk", "zero risk", and "theoretical risk" as significantly different from one another. For intellectual honesty, I often remember to qualify zero risk with something like "virtually", "for all practical purposes", etc. The problem is that so many hyper-anxious forum users glom onto anything other than "absolutely zero risk" and conclude they are doomed.
The Vergehese paper is indeed the one most cited, with CDC's estimated transmission risks. It isn't sufficient to read the abstract; you need to read the entire paper to fully understand it. But in essense, it is as you state -- calculations based on patients' sexual histories in the weeks or months leading up to their first positive HIV test. The results are rough at best. However, most likely the stated transmission risks are not radically wrong. And would it really matter if the oral to penile transmission rate were actually 10 times higher than calculated? That would be 1 in 2,000 instead of 1 in 20,000 -- equivalent to receiving BJs once daily by infected partners for 5.5 years before infection might be predicted, instead of 55 years. Does it really make any difference? The risk is really, really low, and that's all the reassurance most people want or need. For those who need more -- well, so be it. They'll just be doomed to a bit more worry until tested and perhaps more frequent HIV testing. C'est la vie.
Another aspect, of course, is that because the data are imprecise, many experts interpret the numbers differently. So some equally qualified experts will give different estimates from one another. On top of all that, many government agencies -- CDC, health departments, etc -- get legal advice to avoid the least chance of false reassurance. So if you call CDC's national STD/HIV prevention hotline, you may hear that oral sex is just as risky as unprotected anal sex. Still worse, some websites give advice based on political or religious spin -- the worst situation of all.
Question 2: False positive results are an occasional problem with the rapid tests, both the blood and oral fluids antibody tests that give results in 15-20 minutes. False positives are virtually unheard-of (there's that qualifier!) with the lab based tests. My advice is to just suck it up and be tested. You don't describe the nature of your exposure 3 months ago, but based on the comments above, I assume it was low risk and you can expect a negative result.
By the way, did you read the blog on "Today's Pulse" about HIV treatment preventing transmission? (Upper right of this page.) It has comments about HIV transmission risk estimates and the likelihood of better estimates in the future, at least for some types of sexual exposure.
I hope this helps. Best wishes-- HHH, MD
Understood. Indeed it would be a challenging task to tailor the message to such a broad group as sexually active earthlings.
I would like to add that I did get a rapid blood test last week that turned out negative! While I suppose my single-participant study doesn't provide definitive proof that it is biologically impossible to transmit HIV via Oral, I can testify that a negative test does provide great relief. Despite the tech at the for profit testing center suggesting I get tested again in a couple of months, I consider my results at 12+ weeks to be definitive. It is much more relaxing to return my health worries back where they belong...with my triglycerides.
I would like to add that I did get a rapid blood test last week that turned out negative! While I suppose my single-participant study doesn't provide definitive proof that it is biologically impossible to transmit HIV via Oral, I can testify that a negative test does provide great relief. Despite the tech at the for profit testing center suggesting I get tested again in a couple of months, I consider my results at 12+ weeks to be definitive. It is much more relaxing to return my health worries back where they belong...with my triglycerides.
Thank you joggen for the link. It was helpful to see the full study report and confirmed my suspicion that the premise for the original risk used in the comparison was "best guess estimate" which means there have been no examples of verified (I know difficult to verify a report would be true or false) reports of infection via insertive felatio. I still need to look of the references they cite, but as of today still have not seen any reports of confirmed infection this way.
Thank you Eagleyes and BeSafe for your keen insights and helpful comments. Indeed I know logically that the anxiety which has effected various aspects of my daily life is not merited from real scientific probability but rather an irrational mind wandering. So I will suffer through my false-positive worries and get the peace of mind testing, then seek counseling if that does not do the trick (hopefully it will).
During the course of this experience I am really dissappointed in most of the resources published online that causes unnecessary worry. I understand the motivation to encourage people to reduce risky behavior and to get tested, but at the end of the day truth is most important and deviations from the truth or misleading/incomplete publications do a great disservice to society. E.g. "Risk of protected vaginal sex is n%" is published to consider the chance of infection when using a condom. The risk is there because condoms can break or slip. But to a reader who had sex with no problems with their condom the HIV risk should be stated as 0.00%. And if the condom failed then the risk should be stated as the same as unprotected sex. They should not present "a risk of protected sex." This is really misleading.
Thank you Eagleyes and BeSafe for your keen insights and helpful comments. Indeed I know logically that the anxiety which has effected various aspects of my daily life is not merited from real scientific probability but rather an irrational mind wandering. So I will suffer through my false-positive worries and get the peace of mind testing, then seek counseling if that does not do the trick (hopefully it will).
During the course of this experience I am really dissappointed in most of the resources published online that causes unnecessary worry. I understand the motivation to encourage people to reduce risky behavior and to get tested, but at the end of the day truth is most important and deviations from the truth or misleading/incomplete publications do a great disservice to society. E.g. "Risk of protected vaginal sex is n%" is published to consider the chance of infection when using a condom. The risk is there because condoms can break or slip. But to a reader who had sex with no problems with their condom the HIV risk should be stated as 0.00%. And if the condom failed then the risk should be stated as the same as unprotected sex. They should not present "a risk of protected sex." This is really misleading.
Thank you for your kind response.
I think you are correct that I would need to read the entire Vergehese paper to understand it, but all I see online is the abstract. Do you know if it is available to the public online somewhere? What confuses me is how they can come up with any risk level or risk relationship to other activities, if they can not confirm an instance of oral to penile transmission. If there is no certain instance of this I question the resulting number.
Your statement that agencies get legal advice suggesting "the least chance of false reassurance" is undoubtedly true, but given the source of severe anxiety this topic produces it is a tremendous disservice to the public. These agencies should put information accuracy, regardless of how it may impact society's behavior, as the top objective. I respect the work you and the team due on this site to combat the information that is disseminated in a style to reduce legal risk and improve morals. Truth is important.
Regarding the importance of one extreme set of odds verses another, actually I think it is important. Something that is a 1 in 2,000 chance is ten times more likely to occur on the first attempt than something that is 1 in 20,000. And it is no less likely to occur on the first attempt than the last.
At risk of you referring me straight to the anxiety shrink, I will tell you that my exposure was based on a masseuse that surprised me with unexpected oral for a few seconds. Based on the CDC estimate of 1:20,000 and the fact that this occurred in a country with a lower HIV rate than the US (and the agency advised she tested HIV neg a week later) I estimated my risk at less than 1 in 2 million. But when the result could be losing and exposing your family (wife is breastfeeding) even the smallest risk is an emotional burden. If it wasn’t human nature to believe in 1 in a million odds the lines to buy lottery tickets would be much smaller.
Keep up the good work of speading unskewed information.
I think you are correct that I would need to read the entire Vergehese paper to understand it, but all I see online is the abstract. Do you know if it is available to the public online somewhere? What confuses me is how they can come up with any risk level or risk relationship to other activities, if they can not confirm an instance of oral to penile transmission. If there is no certain instance of this I question the resulting number.
Your statement that agencies get legal advice suggesting "the least chance of false reassurance" is undoubtedly true, but given the source of severe anxiety this topic produces it is a tremendous disservice to the public. These agencies should put information accuracy, regardless of how it may impact society's behavior, as the top objective. I respect the work you and the team due on this site to combat the information that is disseminated in a style to reduce legal risk and improve morals. Truth is important.
Regarding the importance of one extreme set of odds verses another, actually I think it is important. Something that is a 1 in 2,000 chance is ten times more likely to occur on the first attempt than something that is 1 in 20,000. And it is no less likely to occur on the first attempt than the last.
At risk of you referring me straight to the anxiety shrink, I will tell you that my exposure was based on a masseuse that surprised me with unexpected oral for a few seconds. Based on the CDC estimate of 1:20,000 and the fact that this occurred in a country with a lower HIV rate than the US (and the agency advised she tested HIV neg a week later) I estimated my risk at less than 1 in 2 million. But when the result could be losing and exposing your family (wife is breastfeeding) even the smallest risk is an emotional burden. If it wasn’t human nature to believe in 1 in a million odds the lines to buy lottery tickets would be much smaller.
Keep up the good work of speading unskewed information.
You are reading content posted in the HIV - Prevention Forum
Condoms are the most effective way to prevent HIV and STDs.
PrEP is used by people with high risk to prevent HIV infection.
Can I get HIV from surfaces, like toilet seats?
Can you get HIV from casual contact, like hugging?
Frequency of HIV testing depends on your risk.
Post-exposure prophylaxis (PEP) may help prevent HIV infection.
