Being Alive - March, 2000
Walt Senterfitt

Enormous press coverage and community anxiety has greeted the findings presented in one poster presentation at the 7th Retrovirus Conference in San Francisco. Physicians and researchers from the University of California at San Francisco, San Francisco General Hospital and the Centers for Disease Control and Prevention (CDC) presented their analysis of the likely routes of infection for 102 gay and bisexual men enrolled in The Options Project between June 1996 and June 1999. The Options Project is similar to Project Open Window sponsored by the HIV Epidemiology Program of Los Angeles County. Both are efforts to identify individuals known to have been infected in the preceding 12 months, offer them early treatment if they so choose, interview them in detail about their behavior around the time of infection, and follow them over time. The risk-behavior interviews offer an unusual opportunity to ask people about the behaviors that probably led to their infection at a time close enough to the event that recall is likely to be much better than in earlier studies asking people about their behavior years before.

For the conference presentation, 102 cases of new or primary HIV infection were included. Risk behaviors (including all kinds of sexual activity, all kinds of substance use, any other potential exposures to blood or dirty needles, etc.) were ascertained by both self-administered questionnaires and interviews. In cases where the route of probable infection was unclear from the questionnaire and first interview, a follow-up interview by an epidemiologist was conducted as well as a review of medical record notes and corroborating interviews with the sexual partner(s) if possible.

Since the risk of oral sex is and has always been controversial, Options Project researchers applied very stringent criteria to classifying someone as a probable "oral sex case." If there was even one reported instance of another potential risk factor during the relevant time period (such as unprotected anal sex or shared needles), the person was not classified as having gotten HIV through oral sex. Participants in the study are seen every three to six months after initial interview. They are asked the risk-behavior questions again at subsequent interviews, recognizing that increasing trust with the project staff and/or coming to terms with their infections may lead them to be more fully honest as time goes on.

Initially, 17 (16.4%) of the participants claimed they had no other risks besides oral sex. Over half (9) of these individuals were re-classified on further investigation or after they acknowledged other risks in subsequent sessions. Four were excluded because they reported a single instance of unprotected anal receptive intercourse (being fucked and cum inside of without a condom) and one reported a condom break during the period when HIV infection occurred. Two were excluded because the information they provided was incomplete and contradictory and could not be corroborated. Two reclassified cases reported never engaging in anal sex but each reported a single episode of substance use associated with blackout during which risk could not be reliably recalled.

By this rigorous classification system, then, 8 (or 7.8%) were classified as being infected through receptive oral sex (blowing someone and getting cum in your mouth). Of these, two reported having only oral sex, 4 reported having anal sex but only and always with protection, and 2 reported having unprotected anal receptive sex, but only with a partner whom the investigators documented as HIV negative.

What the Study Does Not Mean

Some media have reported that this study indicates that oral sex carries an 8% risk of HIV infection. No! Wrong! It means that in this particular, well-studied group of 102 San Francisco men, 8% of them were apparently infected through oral sex. That means also that over 90% of them were infected through anal sex. The proportion infected orally does not equal risk. Risk is calculated by estimating the number of times oral sex has to occur for one HIV infection to occur, on average. That figure has been estimated to be between 1 in 1000 and 1 in 2,500. Nothing in this new study changes those previous estimates.

What It Does Mean

The study offers evidence that oral sex (meaning specifically getting cum in your mouth) does pose a small but measurable risk of HIV infection for a previously uninfected person. This risk is likely somewhat higher than most of us and most HIV prevention messages have assumed. Oral sex may be increasing as the cause of an increasing proportion of new infections, not because the risk is higher but because other more common causes of transmission (receptive anal sex) have been greatly reduced through prevention messages and behavior change.

The risk of sexually transmitting HIV remains 10 to 100 times greater through anal or vaginal sex compared to oral. Thus, on a community or population basis, it remains correct to suggest that a switch or limitation to oral sex is an effective "harm reduction" means to contain the epidemic.

However, for an individual "low risk" does not equal "no risk." Even if the average odds from getting HIV from one episode of cum in your mouth are as small as 1 in 2,500 episodes, if you are the one that gets it, then your risk was 100%. That's a tricky thing about the concept of "odds."

So, how one reacts to this new information (which is consistent with other data, such as those from our local Project Open Window) depends on your vantage point, your values and your priorities. There is no absolutely safe sex except solitary masturbation or sex between two individuals who are both in fact HIV negative. Most of us choose to accept some risk in our sexual lives, as we all do in every other part of our lives. We have the choice of acting on that risk ethically by never exposing another person who may be HIV negative without full disclosure and discussion.

Chasing HIV’s changes
by Lisa Keen, Washington Blade

SAN FRANCISCO -- 2/4/00 -- If there is one thing a person can count on with HIV disease, it is this: almost nothing.

After years of growing consensus around the strategy of "hit early, hit hard," many experts now appear to be backing off the "early." After assuming the development of certain fat deposits were linked to the use of protease inhibitors, researchers now say the phenomenon also occurs in patients who have never taken the drugs. For the past few years, doctors warned patients never to miss a dose; now some are talking about the possibility that deliberate interruption of therapy might be beneficial. And after calculating that the risk of transmitting HIV through oral sex was extremely low, a study emerged this week indicating it is actually "significant." Read more at http://www.aegis.org/news/wb/2000/WB000201.html

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