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Serodiscordant Couple and Risk
Dear Drs Hook and Handsfield,
I an HIV negative female in a relationship with an HIV positive male. He has been on ARV medication for just over one year, and reports that his viral load have dropped accordingly. In researching safe ways to have a physical relationship, I came across helpful info such as that semen on unbroken skin is not a risk factor for me, and neither is mutual masturbation or kissing. He and I have decided not to have penetrative sex of any kind, and have stuck to that decision-- no penetrative vaginal or anal sex has occurred between us. Unsurprisingly, my question surrounds an oral sex episode where I was the receptive partner. Because he was not going to ejaculate in my mouth at all, I began giving him oral sex without a condom for about 30 seconds to one minute. However, my nerves got the best of me and I stopped, reverting to mutual masturbation instead. The only place he ejaculated was on my chest, which I immediately washed off in the shower. My question is regarding my risk from any precum that may have gotten into my mouth in the brief oral sex episode. I know what my testing options are, but I was wondering if you can weigh in on my risk from this episode? The information regarding oral sex, even on expert-staffed websites, is confusing.
Thank you very much for your time.
I an HIV negative female in a relationship with an HIV positive male. He has been on ARV medication for just over one year, and reports that his viral load have dropped accordingly. In researching safe ways to have a physical relationship, I came across helpful info such as that semen on unbroken skin is not a risk factor for me, and neither is mutual masturbation or kissing. He and I have decided not to have penetrative sex of any kind, and have stuck to that decision-- no penetrative vaginal or anal sex has occurred between us. Unsurprisingly, my question surrounds an oral sex episode where I was the receptive partner. Because he was not going to ejaculate in my mouth at all, I began giving him oral sex without a condom for about 30 seconds to one minute. However, my nerves got the best of me and I stopped, reverting to mutual masturbation instead. The only place he ejaculated was on my chest, which I immediately washed off in the shower. My question is regarding my risk from any precum that may have gotten into my mouth in the brief oral sex episode. I know what my testing options are, but I was wondering if you can weigh in on my risk from this episode? The information regarding oral sex, even on expert-staffed websites, is confusing.
Thank you very much for your time.
MEDICAL PROFESSIONAL
Welcome to the forum. Thanks for your question. Let me start by congratulating you on your decision to move into a sexual relationship with your HIV infected partner, and for the wise and sober approach you are taking to sexual safety. You're off to a great start! However, it is possible you are overdoing the sexual safety part.
I'm happy to confirm the advice and information you received 4 weeks ago from Dr. Cummings on the international forum, so we need not further discuss kissing, mutual masturbation, fingering etc -- all of which carry no risk even for contact with partners with untreated HIV with high viral loads.
The same is true for oral sex. Even without ARV therapy, one estimate is that if a male (penile) partner has HIV, the risk to his oral partner averages once for every 10,000 exposures. That's equivalent to performing fellatio on infected men once daily for 27 years before transmission might be likely. With your partner on ARV therapy -- especially if he has a low or undetectable viral load in the blood -- you can safely consider oral sex to be zero risk, even with ejaculation in the mouth.
In fact, if his viral load is low or undetectable, I would advise you to also go ahead with condom-protected vaginal or anal sex, or any other sexual expression that gives you mutual pleasure. Even without a condom, vaginal and anal sex probably would be safe, but the conservative approach and standard advice is that condoms should be used as well. OTOH, some couples in your situation don't use concoms, especially during times they are hoping to conceive a child -- something for you to know if parenthood is in your plans.
The only slight uncertainty here is that his viral load "dropped accordingly". As noted, the advice above assumes excellent control, ideally with undetectable viral load. This is something to discuss in detail with your partner, and he with his doctor.
Which leads to my final advice: that you accompany your partner to his next doctor/clinic appointment, so you can both have a conversation with his doctor -- or perhaps with a case manager or prevention counselor in the clinic -- about your sexual plans. I'm sure they will confirm my advice above, but you probably will find it reassuring to hear it in person. (If he is in care at a smaller facility without prevention expertise, then you probably could make a joint appointment at your local or state health department instead -- or its equivalent if you're in a country other than the US.)
Best wishes-- HHH, MD
I'm happy to confirm the advice and information you received 4 weeks ago from Dr. Cummings on the international forum, so we need not further discuss kissing, mutual masturbation, fingering etc -- all of which carry no risk even for contact with partners with untreated HIV with high viral loads.
The same is true for oral sex. Even without ARV therapy, one estimate is that if a male (penile) partner has HIV, the risk to his oral partner averages once for every 10,000 exposures. That's equivalent to performing fellatio on infected men once daily for 27 years before transmission might be likely. With your partner on ARV therapy -- especially if he has a low or undetectable viral load in the blood -- you can safely consider oral sex to be zero risk, even with ejaculation in the mouth.
In fact, if his viral load is low or undetectable, I would advise you to also go ahead with condom-protected vaginal or anal sex, or any other sexual expression that gives you mutual pleasure. Even without a condom, vaginal and anal sex probably would be safe, but the conservative approach and standard advice is that condoms should be used as well. OTOH, some couples in your situation don't use concoms, especially during times they are hoping to conceive a child -- something for you to know if parenthood is in your plans.
The only slight uncertainty here is that his viral load "dropped accordingly". As noted, the advice above assumes excellent control, ideally with undetectable viral load. This is something to discuss in detail with your partner, and he with his doctor.
Which leads to my final advice: that you accompany your partner to his next doctor/clinic appointment, so you can both have a conversation with his doctor -- or perhaps with a case manager or prevention counselor in the clinic -- about your sexual plans. I'm sure they will confirm my advice above, but you probably will find it reassuring to hear it in person. (If he is in care at a smaller facility without prevention expertise, then you probably could make a joint appointment at your local or state health department instead -- or its equivalent if you're in a country other than the US.)
Best wishes-- HHH, MD
MEDICAL PROFESSIONAL
An in-home test at 4 weeks will be about 90% reliable. Instead of that test, why not visit a doctor or clinic for a due ("4th generation") blood test? It will be 100% conclusive at 4 weeks, and cheaper than having an oral test now plus additional antibody test at a later time.
That will end this thread. Do your best to accept the reasoned, science-based reassurance I have given and move on with your life.
That will end this thread. Do your best to accept the reasoned, science-based reassurance I have given and move on with your life.
Hello Dr Handsfield-- I am approaching 28 days from my last encounter with my HIV positive partner (on ARVs, low/undetectable viral load) that I described to you on May 25. There haven't been any encounter since then. I am planning to take an at-home test. Can you please give me your professional opinion on how much confidence I should have in the results at this point? If it is negative, do I need to test again at 2 and 3 months?
Dear Dr Handsfield-- Thank you very much for your advice. It has helped me calm my nerves down. I apologize for the vague wording regarding my partner's viral load; I asked him point blank early on if his viral load had been lowered to a "low" or "undetectable" level and he said yes. I'm assuming that he would not lie to me about that, given that he disclosed his status prior to our getting into a physical relationship. I'm also sure that he takes his medicine on a daily basis, responsibly. As such, I am going to assume that your advice here regarding my negligible to zero risk applies.
Thank you very much!
Thank you very much!
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