Back to Oral Sex Information Index IS ORAL SEX SAFE? by Chuck Polisher 15 September 1993 It's not surprising that people are confused about the degree of risk afforded by oral sex. There is lots of believable but conflicting advise being given out. Knowing the right answer is literally a life or death item for many gay men, and may be just as important for lesbians, bisexuals, and even straights. But most people don't know enough about oral sex and transmission of AIDS to feel they're making informed choices in their sexual lives. A wide survey of AIDS information hotlines posed the question "Is oral sex safe?" (See sidebar for a sample of the responses). The range of answers was astounding, with much mis-information given out. One organization even warned against kissing, something that most agree is an extremely low risk activity. Text book answers: A comprehensive search of medical literature for studies of transmission of AIDS turns up hundreds of published articles. Of those, there are about twenty that have some hard data on oral sex. Not surprisingly, the published research doesn't all come to the same conclusions. Two different kinds of reports on oral transmission of HIV emerges from the medical literature. The first kind consists of individual case reports. These are cases where HIV infection is reported where the presumed cause of infection was oral sex. Case reports of oral transmission of HIV are rare. The second kind of research study begins by recruiting a large group of participants, called a cohort, and studying them over a long period of time. Members of a cohort are called in at least once a year to take an HIV antibody test and are interviewed in detail about their sexual activities. Over time, researchers use the data to associate specific sexual behaviors with their relative risk of HIV transmission. It was this method that established, early on in the AIDS epidemic, the extreme danger of anal intercourse for HIV transmission. Large cohorts yield more reliable statistics than case reports. First cohort The Vancouver AIDS-Lymph-adenopathy Study, a federally funded Canadian study, is an attempt to document the natural history of HIV. The study is a longitudinal (cohort) study, and is unusual because it started very early (1982, prior to the first diagnosed case of AIDS in the study area) and because the recruiting was through general practitioners, not STD clinics, bath houses or gay practices. A total of 746 homosexual men were studied every six months. These factors are considered to give a very accurate and unbiased picture of the epidemic compared to any other study of AIDS that has been attempted. The study group was looking for evidence of oral transmission of HIV but didn't find any. Investigators found 21 HIV-negative cohort members who had no receptive anal sex or fisting. After almost two years of following this sub-group, only one man had become HIV-positive. (That man practised insertive anal intercourse in about 80% of his sexual encounters.) Contrast this with the 99 members of the cohort who reported receptive anal intercourse over the same period of time: 36% became HIV-positive. The principle investigator, Dr. Martin Schechter stated: "...no risk associated with oral sexual contact was detected." Dr. Schechter also stated that "HIV is not transmitted orally. Perhaps, after millions of people have been studied, one case of [oral] transmission will be brought to light. But this does not mean that people should engage in unprotected oral sex." His finding generated instant controversy. Common sense said that if one ingests an infected body fluid (semen, saliva) then they will become infected. Dr. Schechter explained how common sense can be reconciled with the results of his study: "Factors which determine whether infection is transmitted include the concentration and viability of the agent within the fluid or tissue, access to a port of entry for the fluid or medium, the presence of receptors at the site of entry, and natural host defences near the site of entry." While some researchers never accepted these findings, the word began to circulate that maybe oral sex wasn't as dangerous as many had imagined it to be. Largest cohort Dr. Larry Kingsley is an investigator with the Pitt Men's Study which is part of the Multi Area Cohort Study (MACS). This is a cooperative study that includes investigators at the University of Pennsylvania (Pittsburg), UCLA, Howard Brown (Chicago), North Western University, and Johns Hopkins. There are over 5,000 men who are being tested at 6 month intervals. Dr. Kingsley feels that if oral sex was a mode of transmission for HIV, then the MACS study would definately have detected it. Still, he feels that oral sex poses an unwarranted risk: "It's like working in a parachute factory--one bad parachute in 10 million... You can't put a stamp of approval on oral sex." But he feels that the real risk of oral sex is for other (than HIV) transmissible agents, such as syphilis and Hepatitis B, both of which are known to be transmitted by oral sex. Dr. Kingsley was quick to point out that gay men must stop engaging in unprotected anal sex, saying that it probably is the reason for "virtually all new HIV infections." He also says, "For men who will not or cannot give up anal intercourse, condoms must be used. But condoms have a failure rate of about 10% in studies of family planning pregnancies, due to slippage, misuse, and breakage." Dr. Kingsley seems concerned that gay men are placing themselves at risk even when they use condoms. "I believe that the failure rate for condoms will maintain a low but unacceptable failure rate." He went on to point out that withdrawing prior to ejaculation is one way to enhance the safety of anal sex when using condoms. Dr. Detels is the investigator for the Los Angeles part of the cohort. His opinion, based on research, is that oral sex among gay men is substantially safer than anal sex (even when condoms and spermicides are used). He believes that if oral transmission occurs that is is rare. (He also feels that Dr. Koop's position was exactly correct: If you cannot abstain from anal sex, use condoms. But this is far from saying: use condoms and enjoy anal sex freely, which is often the "safe sex" message that people hear. FIRST CASE REPORT The first reference to a case of HIV oral transmission in the body of medical literature was reported in a letter to the editors of The Lancet. Dr. Bruce Voeller cited a single case of heterosexual transmission of HIV where oral sex was the presumed mode of transmission. It was a single, oddball case. Dr. Voeller stated privately: "I guess the odds [of oral transmission] are low. Oral sex is one of the lower risks. Don't let anyone come in your mouth." (To put things in perspective, Bruce uses "double bagging" with condoms.) A recent example of a case report is provided by Andrew Gans at the San Jose State University. That report begins, "This case finding study interviewed twelve gay or bisexual men who believed they were infected with HIV through oral sex." Gans goes on to explain that "Participants were categorized as cases of oral sex transmission if they could rule out alternative routes of HIV transmission." Other case reports surface from time to time, but these reports can never have the same standing as carefully administered cohort studies. But they serve as a warning: while the risk of oral sex is low, it isn't zero. Role of saliva Patricia Fultz, a researcher for the US Centers for Disease Control tested the effect of saliva on HIV cultures and found that "Whole [primate] saliva can inactivate large amounts of virus within an hour." Ms. Fultz says that her research "Supports the theory that casual contact does not transmit the virus [HIV]. I cannot definitely say that kissing would be safe. If it [oral transmission] occurs, it would be rare." Don Hicks, a former researcher for the CDC, took this research further by testing the effect of human saliva on HIV. He stated: "When considering the issue of oral transmission we must conclude that while it is obvious that vaginal secretions and semen are excellent sites of transmission, the mouth is a poor receptor site. Our study supports this conclusion. Still, much more research... must occur before any practical conclusion may be drawn... [regarding] safer sex." Parting thoughts Each of us must consider the relative risk of oral sex in light of what we know, what we don't know, and in relation to other risks that we might be taking. We know that studies of large numbers of gay men have not implicated oral sex as a high risk for transmission of HIV. We also know that condoms fail and that unprotected anal sex provides an efficient route for transmission of HIV. It is unlikely that we will ever see government funded research put the stamp of approval on oral sex, but the facts will eventually point the way. Who wrote the safe sex guidelines? Most (but not all) AIDS information providers claim to follow guidelines set by the U S Centers for Disease Control in Atlanta. The CDC is an arm of the US Public Health Service and is responsible for formulating health guidelines for all U S epidemics. CDC public affairs specialist Chuck Fallis explains that they subcontracted this particular set of guidelines to a private company, The Centers for Prevention Services. Dr. Katherine Stone, CPS staff epidemiologist for oral sex, would not respond to inquiries. One might conclude that the basis for the CDC guidelines is not public information. LESBIANS & ORAL SEX The CDC does not maintain a category for lesbians in its monitoring of the AIDS epidemic. This has limited the availability of reliable data on the extent of infection in the lesbian population, and made the issue of lesbian health precautions unclear. Lesbians may find it particularly difficult to find a source of supply for dental dams, which are recommended for oral-vaginal sex. The Colorado AIDS Program (CAP) has a Safer Sex Kit available which may be of interest to women. It contains a glove, a dry condom for toys, a packet of lube, a dental dam, and instructions for use. CAP can be contacted by calling (303) 830-2437.What do the experts say? WHAT DO THE EXPERTS SAY? "Avoid anal sex. If you must engage in anal sex, use a condom. Unprotected oral sex is probably safer than anal sex with a condom. Avoid unprotected oral sex. But if you must... use a condom. There are credible reports of oral transmission. Unprotected oral sex is risky." --Dr. Lawrence Kingsley Multicenter AIDS Cohort Study "I would not be astounded if individuals could acquire HIV orally. It would seem to be realtively rare. The risk is not zero. In the absence of oral lesions it is probably low risk--extremely low on the scale." --Dr. Martin Schechter Lymphadenopathy-AIDS Study Group Vancouver "We've been preaching don't do anal for so many years that our study participants might be afraid to tell us about having anal sex. This could account for some of the oral transmission." --Dr. Lawrence Kingsley Multicenter AIDS Cohort Study "Can you get it from a toilet? You might sit on ten million seats and get it. But that doesn't implicate toilet seats as a mode of transmission. The overwhelming weight of evidence is that HIV is not transmitted by kissing or oral-genital contact. But you have to be prudent when making public health policy. I would not recommend unprotected oral sex." --Dr. Warren Winkelstein, Jr. San Francisco Men's Health Study School of Public Health University of California at Berkeley "Oral transmission is an extremely rare event, probably because of the inactivation of virus by saliva." --Don Hicks Chief of Retrovirology Microbiology Reference Labs "Less than 10% of our study group now engage in unprotected anal sex, down from 90% when we began our study nine years ago." --Dr. Lawrence Kingsley Multicenter AIDS Cohort Study "One of the big problems with studies of sexual behavior is the inherent inaccuracies built in. Sex is not exact and reporting of sex isn't either. Can you remember the exact number of times you went down on someone this year? Of those times, how many of them resulted in climax for your partner? How many of those times did you swallow? We can all see how vague this is in comparison to transmission of virus during dental procedures or needle-stick incidents where careful and complete records are kept." --Dr. BruceVoeller Mariposa Foundation Topanga California WHAT DO THE HOTLINES SAY? "You are not at risk with passive oral sex. The active partner is at some risk. It is more risky to swallow semen. As far as we know, saliva does not transmit AIDS." --U S Centers for Disease Control, AIDS information hotline "As the [insertive] participant, there is no risk at all. As the [receptive] partner, there is a very low risk, but don't let anybody come in your mouth." - Nat'l Gay & Lesbian Task Force New York "The official answer is: use a rubber." --Whitman Walker Clinic Washington, DC "Oral sex is considered to be a low risk activity but not risk-free." --Whitman Walker Clinic Washington, DC "We're not really sure. We've seen literature indicating that it is possibly safe up to the point of climax." --Austin AIDS Project "There is no danger from oral sex unless there is a cut on the penis. Oral sex is probably safe prior to climax." -- Health Crisis Network Miami "We don't recommend french kissing. Oral sex is safer than sexual intercourse." --Colo. Dept. of Health "We really don't know how dangerous it is. Some people enjoy the act of fellatio; we suggest you use a condom if this is the case. Good prostitutes use them [condoms] all the time." --SF AIDS Foundation San Francisco "You have to use a rubber for oral sex. Period." --Gay Men's Health Crisis New York City "If the skin of the penis and the lining of the mouth are both intact there is no risk. We recommend condoms, as unpleasant as that sounds." --Gay Men's Health Crisis New York City "There is an enzyme in saliva that destroys the virus. Don't let someone come in your mouth. A condom or dental dam makes it a low risk activity. --San Diego AIDS Foundation "Oral sex is unsafe. You run a risk any time you exchange bodily [sic] fluids. Bleeding gums pose a risk. A cut on the penis poses a risk." --Metro Health Clinic Denver "Avoid all sexual contact." --U S Centers for Disease Control recorded information hotline Atlanta

Article: 5661 of sci.med.aids
Sender: phil@wubios.wustl.edu (J. Philip Miller)
Date: Wed, 15 Sep 1993 20:32:23 GMT

We have received permission from the publisher and author of the following
article to reprint this article without restrictions. -phil

From: cpolishe@nyx.cs.du.edu (Chuck Polisher)
Subject: Oral sex and HIV
Reply-To: nyx!cpolishe@uunet.UU.NET (Chuck Polisher)
Date: Wed, 15 Sep 93 17:32:13 GMT

The above article with its sidebars appeared in PREFERRED STOCK, a bi-weekly
newspaper published in Denver, CO, in V1 N3, August 12, 1993.

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