HIV transmission: guidelines for assessing risk - Canadian AIDS ...

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HIV TRANSMISSION: Guidelines for Assessing Riskenvironment for HIV, because an enzyme in saliva has beenshown to inhibit HIV.The risk of transmission of HIV to the partner giving fellatiois increased if there is a disruption in the oral mucosasuch as bleeding gums, cuts, sores, lesions, ulcers or burnsin the mouth or by a recent tooth extraction. Risk can bereduced by using a protective barrier, such as a condom.Speculation that the risk of transmission is increased ifejaculate is swallowed now appears unfounded, sinceenzymes in the mouth, throat and the stomach are knownto inhibit HIV. The risk of transmission relates to takingejaculate or pre-ejaculatory fluid in an unhealthy orwounded mouth, not into the digestive system, which is ahostile environment for HIV.The risk in fellatio can be reduced by avoiding ejaculation ofsemen in the mouth and can be reduced further by using acondom. It is also recommended that the partner giving fellatiowait 30 minutes to two hours after brushing or flossingteeth before engaging in fellatio, since brushing and flossingteeth may cause temporary bleeding of the gums.In getting fellatio, risk is negligible. A small quantity ofblood from bleeding gums or sores in the mouth couldcome into contact with an abrasion on the head of thepenis, and/or with the mucosal lining of the penile opening.However, the small amount of blood that would be passedunder such conditions makes infection very unlikely.In the absence of some disruption to the oral cavity, the riskinvolved in either giving or getting head can be regarded asquite remote.Evidence of TransmissionTransmission of HIV is reported to have occurred throughgiving fellatio. It is only reported to have occurred veryrarely, usually in circumstances where there is a route ofentry resulting from a disruption to the oral mucosa causedby bleeding gums, cuts, sores, lesions, ulcers or burns in themouth.Much of the evidence of transmission during fellatio isbased on isolated case reports. Several of the earliest epidemiologicalstudies of men who have sex with men failed toshow that giving fellatio carried a significant risk. This mighthave been because one recognized act of a high risk activitywas considered the most likely route of transmission despitemultiple acts of lower-risk activities. Some later studies haveshown a risk but it is much smaller than for other activities,such as penile–anal intercourse without a barrier.Overall, the evidence indicates that transmission throughgiving fellatio is a relatively rare occurrence and thereforeit is classified as low risk. There have been no documentedcases of transmission through getting fellatio.Assessment of Risk of HIV TransmissionFellatio (performing)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom and taking semen and/orpre-ejaculate in the mouth . . . . . . . . . . . . . . . Low RiskFellatio (receiving)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom . . . . . . . . . . . . . . . . . . . Negligible Risk(The risk is increased if there is a disruption in the oralmucosa of the receiving partner, caused by bleeding gums,cuts, sores, lesions, ulcers or burns in the mouth or by arecent tooth extraction or other dental work.)* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Oral Sex: Cunnilingus“Licking out, eating out, going down, licking pussy, boxlunch, eating at the Y”Potential for TransmissionThere is a potential for transmission of HIV by performingcunnilingus (licking the clitoris and/or in or around thevulva) because vaginal fluid and blood can get in the mouth.However, the mouth generally is a hostile environment forHIV, because an enzyme in saliva has been shown to inhibitHIV.The potential for transmission to the performing partner isincreased if there is a disruption in the oral mucosa causedby bleeding gums, cuts, sores, lesions, ulcers or burns in themouth or by a recent tooth extraction, or other dental workthat causes trauma in the mouth. The risk in performingcunnilingus is also higher during menstruation because ofthe presence of blood. The risk can be reduced by avoidingcunnilingus during menses using a latex barrier over thevaginal opening, such as a dental dam or, as an alternative, anew and unlubricated condom carefully cut open and used22 HIV Transmission
HIV TRANSMISSION: Guidelines for Assessing Riskas a barrier between the mouth and vulva or clitoris. It isalso recommended that the performing partner not engagein oral sex directly after brushing or flossing teeth beforeengaging in cunnilingus, since brushing and flossing maycause temporary bleeding of the gums. The amount of timeto wait varies from 30 minutes to two hours since theseactivities can produce cuts and tears along the gum, andthe amount and severity depends on how vigorously onebrushes or flosses their teeth.Receiving cunnilingus involves a small potential for transmissionbecause of the possibility of abrasions in the vagina;these could permit entry of small quantities of blood frombleeding gums or a sore in the mouth. However, the smallamount of blood likely to be involved in such contact makethis a remote possibility.Evidence of TransmissionThere are no well-designed studies offering evidence oftransmission through cunnilingus. However, the extremelysmall number of case reports in which transmission has beenattributed to performing cunnilingus supports the classificationof this activity as low risk.There have been no documented cases of transmissionthrough receiving cunnilingus.Assessment of Risk of HIV TransmissionCunnilingus (performing)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier and not during menses . . . . . . . Low RiskWithout barrier and during menses . . . . . . . . . . Low RiskCunnilingus (receiving)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Oral Sex: Anilingus“Rimming, licking out, eating out, licking or eating ass”Potential for TransmissionAnilingus is not an efficient means of HIV transmission.There is a potential for transmission in performing anilingusif blood is present in or around the anus. There is a potentialfor HIV transmission in receiving anilingus because of thepossibility of contact between blood in the mouth andthe rectal lining. The small amount of blood likely to beinvolved in such circumstances makes transmission highlyunlikely.It should be noted, however, that anilingus is an efficientroute of transmission for other STIs, such as syphilis, gonorrhea,hepatitis A and B, and intestinal parasites (includingCryptosporidium).Any risk from anilingus can be reduced by use of a latexbarrier, such as a dental dam or a new condom carefully cutopen and used as a barrier between the mouth and anus.Evidence of TransmissionThere have been no documented cases of HIV transmissionthrough receiving or performing anilingus.Assessment of Risk of HIV transmissionAnilingus (performing)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible RiskAnilingus (receiving)With barrier . . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without barrier . . . . . . . . . . . . . . . . . . . . Negligible Risk* There is enough evidence of breakage or improper use ofbarrier methods to classify this activity as negligible rather thanno risk.Intercourse: Penile–Vaginal“Fucking, screwing, making love, getting or being laid”Potential for TransmissionThe earliest safer sex advice rightly categorized penile–vaginalintercourse without a barrier as high risk. All of theconditions for efficient viral transmission are in place duringthis activity.Penile-vaginal intercourse without a barrier is a high-riskactivity. The majority of documented cases of HIV transmissionthroughout the world are the result of unprotectedpenile–vaginal intercourse. The risk of transmission can bereduced through the proper use of male or female condomswith lubricant.HIV Transmission23
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