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

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HIV TRANSMISSION: Guidelines for Assessing Riskwould ever be present, the presence of a quantity sufficientfor transmission of HCV to occur cannot be discounted.Evidence of TransmissionSome studies show small amounts of HCV in saliva wherepoor dental health is apparent, indicating that trauma in themouth (bleeding gums) is likely responsible for the presenceof HCV in these cases. It is not known if the enzyme insaliva that inhibits HIV also inhibits HCV. To date, there isno evidence of HCV being transmitted through fellatio.Assessment of Risk of HCV TransmissionFellatio (giving)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom . . . . . . . . . . . . . . . . . . . Negligible RiskFellatio (getting)With condom . . . . . . . . . . . . . . . . . . . . . Negligible Risk*Without condom . . . . . . . . . . . . . . . . . . . Negligible Risk* 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 HCV by performingcunnilingus (licking the clitoris and/or in or around thevulva) because of the possible exchange of bloodThere is a potential for transmission to the partner performingcunnilingus if there is a disruption in the oral mucosacaused by bleeding gums, cuts, sores, lesions, ulcers or burnsin the mouth or by a recent tooth extraction, or other dentalwork that causes trauma in the mouth and the presence ofblood from an abrasion or cut on the clitoris or vulva. Therisk in performing cunnilingus is also higher during menstruationbecause of the presence of blood.It is recommended that the performing partner wait 30minutes to two hours after brushing or flossing teeth beforeengaging in cunnilingus, since brushing and flossing maycause temporary bleeding of the gums.Receiving cunnilingus involves a small potential for transmissionbecause of the possibility of abrasions on the vagina,clitoris or vulva; these could permit entry of small quantitiesof blood from bleeding gums or a sore in the mouth.Although it is likely that only a small amount of bloodwould ever be present, the presence of a quantity sufficientfor transmission of HCV to occur cannot be discounted.The risk can be reduced by using a latex barrier over thevulva, such as a dental dam or, as an alternative, a newand unlubricated condom carefully cut open and used as abarrier between the mouth and vulva or clitoris.Evidence of TransmissionSome studies show a small amount of HCV in saliva wherepoor dental health is apparent, indicating that trauma in themouth (bleeding gums) is likely responsible for the presenceof HCV in these cases. To date, there is no evidence ofHCV transmission as a result of cunnilingus.Some reports suggest that in people living with HIV/AIDSthere is an increased possibility of transmitting HCV.Assessment of Risk of HCV TransmissionCunnilingus (performing)With barrier and during menses . . . . . . . Negligible Risk*With barrier and not during menses . . . . . Negligible RiskWithout barrier and not during menses . . Negligible RiskWithout barrier and during menses . . . . . Negligible 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 HCV transmission.There is a potential for transmission in performing anilingusif blood is present in or around the anus and there is a disruptionto the oral mucosa caused by bleeding gums, cuts,sores, lesions, ulcers or burns or by a recent tooth extraction,or other dental work. Although it is likely that only a smallamount of blood would ever be present, the presence of aquantity sufficient for transmission of HCV to occur cannot42 Hepatitis C Transmission
HIV TRANSMISSION: Guidelines for Assessing Riskbe discounted. Any risk from anilingus can be reduced byuse of a latex barrier, such as a dental dam or a new condomcarefully cut open and used as a barrier between the mouthand anus.Receiving anilingus involves a small potential for transmissionbecause of the possibility of abrasions in or around theanus; these could permit entry of small quantities of bloodfrom bleeding gums or a sore in the mouth. Although itis likely that only a small amount of blood would ever bepresent, the presence of a quantity sufficient for transmissionof HCV to occur cannot be discounted.It is recommended that the performing partner wait 30minutes to two hours after brushing or flossing teeth beforeengaging in anilingus, since brushing and flossing may causetemporary bleeding of the gums.Evidence of TransmissionThere is no evidence of transmission for HCV in thisactivity.Assessment of Risk of HCV 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 TransmissionThere is potential for transmission in the presence of bloodfrom cuts, abrasions or sores on the penis and vaginal area.The presence of menstrual blood also increases the risk fortransmission. Minor or microscopic cuts or tears and soreson the penis (e.g. genital ulcers) can provide a point of entryfor the virus. The foreskin may be particularly susceptible totears, scratches and abrasions, suggesting that its presencemay increase the likelihood of contracting HCV.Evidence of TransmissionSome studies have indicated that transmission of HCV hasoccurred during penile-vaginal sex, when blood is present.As mentioned above, studies show that there is little to novirus present in vaginal fluids and semen, so the evidencepresented to date is under certain circumstances only,resulting in a low risk category for HCV transmission withor without a condom.Some studies indicate that people living with HIV are atgreater risk of sexual transmission of HCV.Assessment of Risk of HCV TransmissionInsertive penile-vaginal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . Low RiskReceptive penile-vaginal intercourseWith condom . . . . . . . . . . . . . . . . . . . . . . . . . . Low Risk*Without condom . . . . . . . . . . . . . . . . . . . . . . . . Low Risk* There is enough evidence of breakage or improper use of barriermethods to classify this activity as low rather than negligiblerisk.Intercourse: Penile–Anal“Butt-, bum- or ass-fucking, screwing, making love, gettingor being laid, anal sex”Potential for transmissionThere is potential for transmission in the presence of bloodfrom cuts, abrasions or sores on both the penis and the anusor rectum. Minor or microscopic cuts, tears or sores on thepenis (e.g. genital ulcers) can provide a point of entry forthe virus. The foreskin may be particularly susceptible totears, scratches and abrasions, suggesting that its presencemay increase the likelihood of contracting HCV.The potential for transmission of HCV through penile-analsex is the same for men or women who have anal sex.Evidence of TransmissionStudies examining the risk of sexual transmission of HCVidentify several activities as risky. These include fisting andanal sex.The specific condition of one or both partners having HIVmay increase the likelihood of transmission of HCV.Hepatitis C Transmission43
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