The Washington Blade - February 4, 2000
Lisa Keen

The poster, from the University of California-San Francisco and the U.S. Centers for Disease Control and Prevention, indicated that 8 percent of 102 cases of HIV infection among Gay and bisexual men were "likely" due to receptive oral sex without a condom.

Previous studies have identified cases of HIV transmission between men through oral sex, but this report is the "most definitive study to date," noted Helene Gayle, head of the CDC's National Center for HIV, STD, and TB Prevention.

A CDC press release stated that "researchers have found evidence that a significant percentage of new HIV infections in some groups of men who have sex with men are due to oral sex, a mode of transmission too often regarded as posing little or no risk."

The poster noted that "most" of the eight men who apparently contracted HIV through oral sex indicated that they "believed oral sex represented either no or minimal risk."

"For some," stated Gayle in a press release, "oral sex is equated with safe sex. However, for the individuals in this study, and for countless others, this false assumption has led to tragic lifelong consequences."

A previous CDC study calculated the risk of oral transmission, for the receptive partner when the top does not use a condom, as .04 percent per contact ù a risk that was the lowest for all sexual practices but "not without risk." By comparison, the riskiest form of sex, being the receptive partner in anal intercourse when the top partner does not use a condom, was calculated to be 0.82.

The risk was considered so low for unprotected oral sex that, in 1996, the national Gay and Lesbian Medical Association urged AIDS prevention educators to ease up on pounding in the message that Gay men must wear a condom even when engaging in oral sex. While acknowledging that "a few documented cases of HIV transmission through oral sex" had been reported, the association said then that the risk of transmitting HIV through unprotected oral sex was not "statistically identifiable."

"Unprotected oral-genital sex (fellatio)," said the GLMA in a statement released in March 1996, "should be considered a low-risk (not a zero-risk) practice for HIV transmission." A press release explained that the group was taking the position because too many AIDS prevention efforts attempt "to impose an unrealistic zero-risk standard on all people."

GLMA President Don Abrams said this week that the report would not necessarily change the organization's position.

"If you restrict people to the point where they feel like they can't do anything, they're going to say, æTo hell with it,' and throw their hands up in dismay," said Abrams. "I've been telling people since 1983 that they should not be seminal receptacles. We hope people will be sensible in their sexual practices."

Abrams referred the Blade to GLMA board member Ken Mayer, who serves as medical research director of the Boston Gay community's Fenway Community Center, for further comment on behalf of the organization. Mayer, who is a professor of medicine at Brown University in Providence, said he expects GLMA will "carefully re-evaluate" its 1996 message in light of the new report.

"But it doesn't tell us anything new," said Mayer. "It doesn't say how safe or unsafe oral sex is, and while 8 percent became infected, a lot haven't become infected."

"We've known since the early days in the epidemic," said Mayer, "that people have become infected without engaging in anal intercourse, and there is a biological plausibility" for infection through oral sex.

"Oral sex is not any more risky now than it was before," added Mayer, noting that any increase in the number of infections through oral sex could be due to an increase in people using unprotected oral sex as a "safer" alternative to unprotected anal intercourse.

"It still comes back to: If you have no way of knowing your partner's [HIV] status, you put yourself at some substantial risk if you engage in some behaviors repeatedly and without protection," said Mayer.

While the report this week may be the "most definitive," it is not the first to warn that unprotected oral sex is not risk-free.

The first real confirmation that HIV can be transmitted through oral sex came in 1989 when researchers with the San Francisco Department of Health said they had confirmed two cases in which men who engaged only in receptive oral sex had contracted HIV. The study involved several thousand men who were followed over a five-year span. At the time, CDC said there had been several other reported cases of oral sex transmission but that none of them had been confirmed.

In 1992, two reports at the International Conference on AIDS said there was risk to a person engaging in receptive oral sex, and one of those studies estimated the risk to be one-sixth the risk of receptive anal intercourse.

Then, in 1996, a study from the University of Washington-Seattle identified four people who appeared to have been infected through oral sex; three of the four were receptive partners but one man indicated he was the insertive partner only. Other studies have indicated that the risk of HIV transmission through oral sex is increased with the presence of dental or gum disease, and oral herpes. And a recent study from Texas indicated that risk of transmission through oral sex increases as the volume of ejaculate increases.

While most believe the risk of transmission decreases dramatically if the active partner does not ejaculate into the receptive partner's mouth, Rick Hecht, a key author of Tuesday's report, indicated that one of the eight men identified in this study was apparently infected by pre-ejaculate fluid.
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