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HIV FAQ: Can you be infected with HIV via oral sex?
Given the importance of sexual transmission in the HIV epidemic, many HIV prevention strategies have focused on identifying and promoting safer-sex practices. As the name implies, these practices are thought to be "safer" than other sexual practices in that they help reduce but do not necessarily eliminate the risk of transmitting HIV from one sexual partner to another. Clinicians and health educators often have the unique opportunity to discuss topics of an intimate nature in a professional setting. With this privilege comes the responsibility to be respectful and nonjudgmental. In some cases, the goal of safer-sex education may be to help someone minimize risk to him- or herself; in others, it may be to help someone minimize risk to others. The goal of teaching safer sex is to provide not only information, but also counseling to help individuals or groups to make the most appropriate choices for risk reduction. Not everyone will open a discussion about safer sex with a health care provider. For example, some people may not ask about safer sex because they do not perceive themselves to be at risk. Others may be too embarrassed to open the discussion. It is incumbent on health care providers to perform HIV risk assessment as an integral part of the medical history, and to provide HIV prevention counseling as an integral part of patient education and anticipatory guidance. Risk assessments and appropriate counseling should be performed periodically to facilitate not only initiation, but also ongoing maintenance, of risk-reduction behaviors. As efforts to develop even more effective treatments and preventive vaccines continue, it is critical to continue aggressive prevention efforts as a vital component of the battle against HIV. In addition, although theoretical models have suggested that ART may combat the HIV epidemic on a population level, models that assumed steady or increased levels of safer-sex practices were more likely to predict reduction in new HIV infections than models that assumed decreased levels of safer sex. Thus, prevention remains the main line of defense for these individuals. This chapter reviews the evidence that has led to the development of safer-sex guidelines, and concludes with specific recommendations for safer-sex practices. Infectious HIV exists in saliva, tears, 14 and urine 15 ; however, it has only been recovered from these fluids at extremely low titers. In addition, no report has documented cases of HIV transmission by these fluids. Hence, saliva, tears, and urine are highly unlikely sources of HIV transmission. Infectious HIV has also been isolated in breast milk, and transmission from HIV-infected mothers to nursing infants has been well documented. However, should individuals accidentally or intentionally come in contact with HIV-infected breast milk during sex, care should be taken to avoid mucosal contact. Epidemiologic Studies and Case Reports Epidemiologic evidence in support of male-to-male, male-to-female, and female-to-male 31,33,36,39,40, sexual transmission of HIV infection is abundant. The risk of HIV infection among women who have sex with women appears to be largely attributable to other risk factors sex with men, injection drug use. The model shows that individuals can reduce their risk by choosing a partner who has tested HIV negative, choosing a safer-sex act, using a condom, or some combination of these factors. It is therefore important in high-prevalence settings to continue to encourage risk reduction behaviors that include both safer sex practices and HIV testing. When both sexual partners are HIV positive, it is still reasonable to consider safer-sex practices to reduce the likelihood of infection from other sexually transmitted diseases, such as herpes, gonorrhea, chlamydia, syphilis, and hepatitis B and C viruses. Case reports have confirmed that HIV-positive individuals can acquire different strains of HIV through sexual exposure. There is not yet a clear understanding of the probability of superinfection at the individual or population level, nor do we fully understand its impact on the long-term health of HIV-infected individuals. Superinfection may cause acute viral syndrome, and transmission of drug-resistant strains may reduce options for future ART, 59,60 suggesting a role for continued vigilance and safer-sex decision making by HIV-infected individuals even when both partners are infected. Studies of male-to-female and female-to-male transmission provide strong epidemiologic evidence that heterosexual transmission of HIV does occur via penile-vaginal intercourse. Early epidemiologic studies on heterosexual transmission in Western countries established that male-to-female transmission in the vagina was significantly more likely than female-to-male transmission from the vagina, 39,40,43,61,62 with estimates in three studies ranging from 1. Per-act infectivity in two studies 62,63 was found to be low: However, studies conducted in developing countries have estimated that per-act transmission probabilities are greater by a factor of 10 44,64 for both male-to-female and female-to-male transmission. The ratio of male-to-female summary mean transmission rates in the developing world compared to the rate in Western countries was 2. Women in some developing countries may be more infectious due to higher prevalence of sexually transmitted infections STIs and untreated HIV disease, although the authors state that evidence for the relative importance of these factors is unclear. The greater susceptibility of men in developing countries is also difficult explain, and may include a low prevalence of male circumcision, poor genital hygiene, a high prevalence of genital ulcer disease, and a high prevalence of unprotected sex with women having a high probability of being HIV infected. Transmission of HIV to the receptive partner probably occurs as a result of the deposition of HIV-infected semen on traumatized rectal mucosa. More recently, studies have suggested that exposure to infected pre-ejaculate through anal intercourse may also carry a high risk of transmission. Whether being the inserting partner in unprotected penile-anal sex is an independent risk factor for HIV infection is not well understood. Most early studies did not demonstrate a statistically significant association between this practice and HIV infection among MSM. The lack of more complete information on the risk of unprotected insertive anal sex reflects the research community's attention to the riskier activity URAI, rather than any consensus that unprotected anal sex has been determined to be of low risk to the insertive partner. In a large multicenter cohort study of MSM, the investigators devised a composite variable called "rectal trauma," composed of enema usage, receptive fisting, report of blood around the rectum, and evidence of scarring, fissure, or fistula on examination. Estimating precise per-act risk is difficult because so few people practice oral sex to the exclusion of other, higher-risk sexual activities. Nonetheless, the risk of infection from oral sex is believed to be extremely low. Early male-to-male transmission studies consistently failed to demonstrate an increased risk of HIV infection associated with the practice of oral-penile sex. Although these are low probabilities, the authors suggest that oral-penile sex may play a larger role in the epidemic among MSM as more men adopt these behaviors as risk reduction measures. Only one study was able to do this 68 ; another examined monogamous serodiscordant couples whose only unprotected sexual activity was oral sex. Despite the case reports, the epidemiologic evidence suggests that unprotected oral-penile sex is a low-risk activity. Oral-genital sex, both oral-penile and oral-vaginal, can transmit STIs other than HIV with varying degrees of efficiency. Receptive oral-penile sex carries the risk of pharyngeal gonorrheal infection for both men and women, and insertive oral-penile sex, although carrying only extremely low, hypothetical risk of HIV infection to the insertive partner, carries a demonstrable risk of urethral gonorrheal infection. Other risks of receptive oral-genital sex include small probabilities of human papillomavirus and hepatitis C transmission. Insertive oral-penile sex is an efficient route for the transmission of herpes simplex virus HSV. Oral-Vaginal Sex The risk of HIV transmission through oral-vaginal sex cunnilingus has received less attention than oral-penile sex. There have been case reports of female-to-male 74 and female-to-female 52 transmission of HIV infection via oral-vaginal sex. One study found an association between oral-vaginal sex and female-to-male transmission of HIV, although competing risks also showed significant associations in this study. However, all studies that have controlled for competing risk behaviors 35,36,38,40,69,70 have concluded that oral-vaginal sex is extremely low risk. Oral-Anal Sex Although oral-anal contact is not an independent risk factor for HIV infection based on data from male-to-male transmission studies, ,22,23, it may be a marker for other high-risk sexual practices. Univariate analysis showed an increased risk of HIV infection associated with oral-anal sex. This association was no longer statistically significant once the authors controlled for other high-risk behaviors. Permeability to Viruses Several laboratory experiments were conducted to test the ability of latex condoms to provide an effective physical barrier against HIV. Condoms were tested by placing a solution containing HIV inside the condoms, and culture medium free of HIV outside the condoms. No leakage of HIV across latex condoms was demonstrable. Latex condoms are impermeable to HSV 79,80 and hepatitis B virus. Leakage of HIV occurred across lambskin condoms in one 75 of two studies. In the s, polyurethane condoms were introduced in both "male" and "female" varieties the female condom will be discussed below. Polyurethane condoms, like those made of latex, effectively contain viruses in vitro. Epidemiologic Evidence for Condom Efficacy Several transmission studies demonstrated a statistically significant negative association between condom use and risk of HIV infection, 28,31,34,41,43 whereas others did not. Condoms are therefore recommended as an important HIV prevention measure. Reasons for Condom Failure As the results of HIV transmission studies indicate, being made of material impermeable to HIV in a laboratory ie, latex or polyurethane is not sufficient to ensure that condoms will provide complete protection during real-life usage. Condoms can fail to provide complete protection for a variety of reasons, including failure to use them consistently, failure to use them properly, condom breakage, and condom slippage. Studies of latex condom performance during human use reported breakage and slippage rates varying from 1. In addition, laboratory evidence suggests that improper use of latex condoms eg, applying an oil-based lubricant can make condoms more susceptible to breakage. In general, it was asserted that polyurethane condoms were more prone to breakage and slippage, and this delayed the approval by the U. Although the FDA eventually determined that the polyurethane condom was safe for consumer use in , 96 six epidemiologic studies have since addressed this question. All studies on condom efficacy in the United States were conducted with heterosexual couples performing vaginal sex. It is believed that condom failure rates may be higher for anal sex. Condoms designed for specifically for anal intercourse are available in Europe, but there is little data on their performance versus commonly available latex or polyurethane male condoms. The female condom prevents leakage of HIV in laboratory testing. Researchers have explored whether polyurethane female condoms can be reused. Given their much higher per-unit costs versus male condoms, this question is particularly relevant for women in resource-poor environments. One study has shown that the structural integrity of female condoms is not significantly damaged in up to five uses if disinfected in diluted household bleach and water 1 part bleach to 4 parts water for not more than 30 minutes, washed in diluted dishwashing liquid or bar soap and water, and air dried or dried carefully by hand. The condoms should always be inspected for holes and tears before reuse, and discarded if any are observed. Although female condoms are not approved for anal use, some MSM have nonetheless begun to use them for anal sex. The large size and polyurethane composition have been reported anecdotally by MSM to increase sensitivity for the insertive partner compared with latex male condoms. As with vaginal use, care should be taken that the outer ring of the condom does not enter the rectum. It is important to keep in mind that safety and efficacy have not been demonstrated in anal use, and that female condoms are neither recommended nor approved for this purpose. Dental Dams Latex dental dams can be placed over the labia and genitalia, or over the anal area, for protection during cunnilingus oral-vaginal sex and anilingus oral-anal sex. These latex squares can be purchased at condom specialty stores and some drugstores available in different flavors , or similar barriers can be made by cutting a latex condom or a latex glove. The efficacy of these methods has not been studied. Table 1 summarizes practical instructions for the use of barrier methods. Vaginal Microbicides Effective topical anti-HIV agents that women could use with or without their sexual partner's knowledge would be of great benefit. Nonoxynol-9 N-9 , a detergentlike molecule once thought to be a leading candidate in the search for vaginal microbicides against HIV, is no longer recommended. Studies of the in vivo efficacy of N-9 have shown that N-9 reduces the risk of HIV transmission in some cases but not in others. Public health officials and health care workers should actively discourage MSM from using Ncontaining lubricants for anal sex and promote awareness of the many Nfree, water-based alternatives available to facilitate condom use. The reasons may include disempowerment of one sexual partner particularly women in some heterosexual relationships , sexual assault, depression, or alcohol or drug abuse. In addition, condom breakage or failure may occur. The use of postexposure prophylaxis PEP using antiretroviral medications appears to reduce the risk of HIV infection in health care workers following occupational exposure to HIV eg, needlesticks or other contact with infected blood. The use of antiretroviral medication administered prior to sexual exposure pre-exposure prophylaxis, PREP to reduce the risk of HIV infection is under study in high-risk populations. Safer-Sex Recommendations General Risk-Reduction Strategies On the basis of the evidence just summarized, the following subjects should be incorporated into education and counseling intended to reduce sexual transmission of HIV. Decisions About Sexual Activity Because sexual contact is the major transmission route for HIV infection, eliminating sexual contact eliminates risk of transmission by this route.
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