Trying to confirm my research

[sallysal]

Hi Dr. HHH.,
First off, thank you both for your great service here.
My question is not so much an exposure question, but an avoiding exposure question. I have done as much research as I can both biologically and statistically, and was wondering if I could get some professional confirmation to my results.
I am a female that is starting to venture into being sexually active (with guys), but only orally. The taste of latex is something I don't think I can handle, so I would prefer to not use condoms for oral sex, but I want to confirm that I can do it essentially risk free HIV wise,
I plan to never let a guy ejaculate in my mouth, so I should only be exposed to precum. I have read conflicting information about precum, but it seems the general consensus is that it is of minimal risk HIV wise (I believe you said it was vanishingly low and probably zero regarding oral sex). Most sources say no one has gotten HIV from oral with no ejaculation, the CDC says 1-2 apparently. I know you have stated that such an exposure would put you at a vanishingly low / probably zero risk, but if someone had been infected this way, there would likely have to be some sort of extra risk factor like meth mouth / oral surgery correct? I read that even with ejaculation, any/most reported HIV cases were with horrible oral hygiene/anagesic use that likely masked painful oral sex, ect?
I also read that with blood not a whole lot of exposure is needed biologically to cause transmission, but that for other body fluids a lot more is needed, so is it fair to say that under normal conditions (ie no major cuts etc), that, biologically speaking, transmission would likely not be plausible at all?I keep reading ultra conservative websites stating that I can get it that way.
I know it's tough to say there is NO way, but am I wrong in thinking that biologically speaking, without ejaculation and without atypical conditions, that even a lot of precum likely would not be enough virus for transmission?

[Edward W Hook, MD]

Before I address your "what if"/confirmatory scenarios, I feel it is important to say that while I applaud your plans to take precautions, it would be awful if you were the first person I heard of who got HIV from oral sex.  As safe as oral sex is (and I truly do believe it is safe), there is always that possibility.  Take precautions, choose your partners careful and not indiscriminately, and BTW, there are flavored condoms.  Now on to your questions.

Is pre-ejaculatory fluid less infectious?  Yes, however remember, many women have become pregnant despite having partners who do not ejaculate.  Pre-ejaculatory fluid likely does have less virus in it but less is not none.  At the same, one contributor to infection is the amount of virus one is exposed to and there is less infectious material in pre-ejaculate than ejaculate.

You are correct in our summary of the risk associated with oral sex.  It is the lowest risk exposure of all sexual activity, short of mutual masturbation.

The blood/oral sores argument is silly.  The average figures we cite include persons with gum disease, cavities, pizza burns and various other traumas.  Short of world class meth mouth or a huge, gaping, heavily bleeding cut in the mount, every day oral lesions will not meaningfully change risk.  Whether it is plausible with a perfect, pristine mouth or not is tough to say.  In science we never say never.

Hope this helps.  Stay safe.  EWH

[sallysal]

I suppose there is always that possibility, but from what I've read it's only a VERY small theoretical risk, correct? I guess using condoms for oral just in case is a good idea (if not for other diseases). If I understand correctly though, what your saying is that it's tough to tell because of the lack of research/data out there exactly what the risk is, but that you haven't "heard of" anyone getting infected that way. I guess whenever there is fluid exposure there is a potential risk, but if it isn't happening under normal conditions, could one not conclude that even if it was "possible biologically" that it was not something to worry about.
Surely, with the current knowledge, couldn't one conclude that if infection via fellatio without ejaculation was even possible (I know a doctor will likely never say never), it would be very, very, very, very close to a zero risk)? I know it's not easy to say how transmission could occur this way (or how big of a cut etc would be needed), but if the insanely low odds of infection INCLUDE burns, bleeding gums, ect, wouldn't having good oral hygiene logically lower the risk even more? That's not to say it still wouldn't be possibly, but it's also possible to get hit by 10 meteorites...
I guess the best that can be said is that with fluid exposure, there is always that possibility since research is not at a place yet in which you can say exactly what risk factors it takes, but would I not be correct in saying that even with an HIV+ partner, that without ejaculation and with good oral hygiene, HIV infection would still be very, very, very close to zero, if not "probably zero" as DR. HHH put it hmself.

[Edward W Hook, MD]

I think you have an accurate sense of where things are and we are fencing over the semantics of how low is "very, very low risk".   Within the larger figure of "average risk", based on data from thousands and thousands of observations in well designed studies, there are certainly likely to be higher and lower risk groups, even though the studies cannot make those distinctions on a strictly scientific basis because of methodological and statistical constraints.  Those with good oral hygeine and no lesions would clearly be among the lower risk subgroups.  

While Dr. Handsfield and I agree about the odds, how we phrase it differs.  I want you to appreciate that there is no such thing as "No Risk", should you become the 1 in a million or even 10 million.  At the same time, I don't let my chances of being hit by lightening keep me indoors.  You are correct in saying that "even with an HIV+ partner, that without ejaculation and with good oral hygiene, HIV infection" would be very, very low.  Whether it is "near zero" is a function of what you consider to be near zero - 1 in 10,000, 1 in 100,000, 1 in a million???. Any way you slice it the risk in very, very low, particularly relative to other sexual activites.  EWH

[sallysal]

Ah okay, that's what I was thinking. I guess the thing I do have to get used to is that there is no such thing as absolute zero risk, only that, coupled with questioning your partner's status before any sexual act (I am told that people rarely lie, especially after sex), and taking care of your oral hygiene, that such a risk would be so insanely low risk that it would be "ZERO" under any realistic or risk management terms.
I suppose I was looking for more of a biological answer, because to me, while theoretically a risk is always there (we're talking over a forum so I appreciate that you and DR. HHH realistically can't say "no risk" if you aren't sure of others risk factors), there is a point where under normal circumstances, transmission can logically not happen (or only udner freak occurances). I've read all I can about the risk involved,  know the stats/odds, and I have crunched the biology every which way. But I guess that's putting you in a tough position... I know Dr. HHH has said that precum probably poses a zero risk ( even if it's 1 in a million, I know that risk is still there), but that one person in a millon who say theoretically gets infected is not just a statistic to me... something MADE them have a possible risk that allowed transmission (logically, there must have been some external risk factor that moved them from probably not biologically possible to being that 1 in a million).
But I appreciate that as a doctor, you can't give me such absolutes (even if there is the slightest theoretical chance). I suppose I am analyzing things too much. There are many things which determine whether or not transmission is likely or not to be "possible" (save for anything being possible), so I guess the best I can do is use my own judgement on the biological part of things based on what you guys have said in previous posts. There logically is a fine line regarding what makes transmission biologically logical, and I guess since there are no definitive answers, one must just use their own common sense as I suppose it's unrealistic thinking that in your position you would make such definitive conclusions without proof. The best we can be is porbably and likely.

[sallysal]

Ah okay,
fter thinking about it I think I get what you mean: that you aren't going to go into little semantics as to whether or not certain risk factors etc make it possible or not, just that as it stands, there is as Dr HHH put it: "a tiny theoretical risk at most".

[Edward W Hook, MD]

I think you are thinking about this clearly.  (FYI, Dr. Handsfield and I discussed this thread) and he has no arguement with what I've said and is comfortable with my wording.  Take care. EWH

[sallysal]

Thanks much, I think I was just misunderstanding that you meant I would be putting myself at a real risk. I think I will use condoms just to be safe, because if I'm thinking about it this much, being extra sure is a good idea. I realize there would be no realistic risk (if even possible), but it's best to be safe! Thanks for the advice again!