NetNews Usenet Archive 1993 #3

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Newsgroups: soc.motss Path: sparky!uunet!mnemosyne.cs.du.edu!nyx!cpolishe From: cpolishe@nyx.cs.du.edu (Chuck Polisher) Subject: Re: safe sex question Message-ID: <1993Jan22.054354.12531@mnemosyne.cs.du.edu> Sender: usenet@mnemosyne.cs.du.edu (netnews admin account) Organization: Nyx, Public Access Unix @ U. of Denver Math/CS dept. References: <C11DI2.38I@agora.rain.com> <1jegfnINNl37@meaddata.meaddata.com> <C12DpJ.EDz@agora.rain.com> Date: Fri, 22 Jan 93 05:43:54 GMT Lines: 377 I'm re-posting this article ... I'm the author. Hope this throws some light on the debate. BTW, the research for this was updated and the article was published in Preferred Stock, a GLBO paper out of Denver. Following is a rather long posting that I think hits the major points in the continuing debate on the safety of oral sex. It contains the results of two years of careful, exhaustive research. The starting point in the research process was asking the authorities in the field, "How safe is oral sex?". The following responses were all provided by organizations that provide AIDS information to the public. (Following the quotes we will take a closer look at the facts behind the opinions.) *** *** *** *** "You are not at risk with passive oral sex. The active partner is at some risk. It is more risky to swallow semen. Any intake of semen is harmful. There is no statistical correlation that exists of oral sex and AIDS but if it did exist it would show a correlation." (U S Centers for Disease Control, AIDS information hotline, 3/87) . "Oral sex is sort of a grey area... transmission is theoretically possible if one partner is infected. The receptive partner would be less at risk because saliva contains a low concentration of the virus. As far as we know, saliva does not transmit AIDS. The active partner is more at risk; we presume that some sort of cut or abrasion or sore throat would be required for transmission to occur. There has not been one case traced to oral sex. [The respondent also mentioned that condoms and dental dams would be effective barriers to transmission during oral sex]. (U S Centers for Disease Control, AIDS information hotline, 1/89) . "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." (NGLTF, New York, 3/87) . "Oral sex is considered one of the safer sexual practices. It is an inefficient route for transmission. Virus in semen is fragile, but might have access for infection via sores in the mouth. Once semen gets through to the stomach, it is destroyed by stomach acid. Oral sex without climax is safer. Virus is found in pre-cum. But it is not totally safe." The respondent added that the official answer is, "Use a rubber." (Whitman Walker Clinic, Washington, DC, 3/87) . "A body fluid with a sufficient concentration of the virus (blood, semen, or vaginal secretions) must get into the blood stream for transmission to occur. There would probably be no exposure if you have no cuts in your mouth but it is possible to have breaks in the oral mucosa without being aware of it. Oral sex is considered to be a low risk activity but not risk-free."(Whitman Walker Clinic, Washington, DC, 1/89) . "We're not really sure. We've seen literature indicating that it is possibly safe up to the point of climax. Abrasion or wounds could be infection sites. The area under the tongue is very absorbant, which could pose a danger." (Austin AIDS Project, 3/87) . "Semen carries 30% of the virus in it. It is one means of transmitting the virus. Vagina fluids are the same way. You must however have a blood contact." (Austin AIDS Project, 1/89) . "There is no danger from oral sex unless there is a cut on the penis. The risk is higher for the receptive partner. Some suggest that condoms should be worn. Transmission by saliva is debatable. Three out of four hundred people with AIDS have virus isolated from their saliva. Oral sex is probably safe prior to climax." The respondent personally recommended against using a condom with oral sex. (Health Crisis Network, Miami, 3/87) . "Oral sex is safer than anal sex, but not 100% safe. Virus is present in saliva. Bleeding gums can allow transmission. We don't recommend french kissing. Oral sex is safer than sexual intercourse." (Colorado Department of Health, Denver, 3/87) . "While studies show that oral sex may be relatively safe, we still classify oral sex as 'possibly unsafe'. This is justified by the findings (though only in a few infected men) of HIV in saliva." (SF AIDS Foundation, 3/87) . "If you are engaging in fellatio as the receptive partner, we really don't know how dangerous it is. If you had just brushed your teeth and you have bleeding gums then you are at risk. However, the insertive partner is probably not at risk. Saliva conveys the AIDS virus, but the mouth has anti-bacterial chemicals that would kill the virus... 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, 1/89) . "You have to use a rubber for oral sex. Period." (Gay Men's Health Crisis, New York City, 3/87) . "Oral sex is relatively safe; if the skin of the penis and the lining of the mouth are both intact there is no risk. Virus needs to get into the bloodstream for transmission to occur. Definitely lower risk than anal sex. There are a few known cases of transmission by oral sex [the respondent invented this fact]. We recommend condoms, as unpleasant as that sounds. There is some risk associated with oral sex, although it is very low. (Gay Men's Health Crisis, New York City, 1/89) . "Oral sex is safe if you use a condom. Their is no way to be sure if unprotected oral sex is safe-- there is no absolute proof." (San Diego AIDS Foundation, 3/87) . "They consider it [oral sex] to be a lot lower risk than was previously thought. There is an enzyme in saliva that destroys the virus. It is safe if there are no cuts or abrasions in the mouth. There have not been any reported cases of transmission via oral sex. Don't let someone come in your mouth. A condom or dental dam makes it a low risk activity. When virus comes in contact with the air it is destroyed in a matter of seconds." (San Diego AIDS Foundation, 1/89) . "Oral sex is unsafe. You run a risk any time you exchange bodily [sic] fluids. Its not as bad as anal sex. Bleeding gums pose a risk. A cut on the penis poses a risk." (Metro Health Clinic, Denver, 3/87) . "Avoid all sexual contact." (U S Centers for Disease Control, recorded information hotline, Atlanta, 3/87) . . *** *** *** *** The "experts" were not in agreement so I decided to dig further and to find out the truth about oral sex. Is it safe or isn't it? How safe is it? Who says so and why? I made some more calls and discovered that most (but not all) of the AIDS information providers claimed 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. I called them and asked how they formulated the official guidelines for the prevention of sexual transmission of AIDS. CDC public affairs specialist Chuck Fallis explained that they subcontracted this particular set of guidelines to a private company, The Centers for Prevention Services. I was able to determine that Dr. Katherine Stone was their staff epidemiologist for oral sex, but was told "Dr. Stone doesn't take personal calls." After chasing red tape for a week I concluded that the basis for the CDC guidelines is not public information. I reached a dead end on the guidelines, but I didn't give up the search. My next tactic was to conduct a comprehensive search of medical literature for studies of sexual transmission of AIDS, especially where oral sex was included as a factor. Searching medical literature takes access to a good medical library, the services of a research librarian, and lots of patience. One tool I found to be especially useful was the Science Citation Index. This specialized index locates the key investigators and published research papers in any field. My search turned up hundreds of published articles on transmission of AIDS. Of those there are about twenty articles that had some hard data on the subject. (The most important of these are referenced in the bibliography at the end of this posting) The remainder of this posting consists of information from the research and from personal correspondence and telephone conversations with the principal investigators. While the data from the research have been accepted by the research community, the implications of the research are controversial. That's why I took the trouble of contacting ALL of the principal investigators to discuss the research and my own personal conclusions. I don't want to misrepresent any of the studies! *** *** *** *** The Vancouver AIDS-Lymphadenopathy 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. These factors are considered to give a very accurate and unbiased picture of the epidemic compared to any other study of AIDS that has ever been attempted. The study group was looking for evidence of oral transmission of HIV but didn't find any. The principle investigator, Dr. Martin Schechter stated: "...no risk associated with oral sexual contact was detected." In the study, oral sex includes both oral-anal and oral-genital contact. Privately, Dr. Schechter 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." How can this be? It just stands to reason that if one ingests an infected body fluid (semen, saliva) then they will become infected. Dr. Schechter explains how this 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." *** *** *** *** 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 U of P (Pittsburg), UCLA, Howard Brown (Chicago), North Western University, and Johns Hopkins. There are a total of 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 definitely 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. Dr. Kingsley was anxious 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. He is arguably THE most knowledgeable person about the sexual transmission of AIDS among gay men. His opinion based on the 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 is exactly correct: If you cannot abstain from anal sex, use condoms. But this is far from saying: use condoms and enjoy anal sex freely.) *** *** *** *** There is only one reference to a case of HIV oral transmission in the body of medical literature: 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. This is the only report that claims to show transmission of HIV via an oral behavior, and it is 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.) *** *** *** *** One very interesting fact, that saliva can inactivate HIV, was pointed out by Dr. Voeller, who put me in touch with Don Hicks. Don started out by explaining a failed experiment at the U S Centers for Disease Control in Atlanta (CDC), which is how he became interested: Patricia Fultz tried to infect a chimpanzee by painting highly concentrated HIV on its gums. When this failed, she 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 took this research further by testing the effect of human saliva on HIV. He states "It has been suggested that the lack of epidemiological evidence for saliva transmission may be due to the antibody-bound nature of the relatively few virus particles found in the saliva of HIV infected individuals. Our data indicates that while this may be true, some non- specific inactivation processes must also be occurring with human saliva. ... 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." Patricia Fultz is a research scientist and chief of AIDS animal models for the CDC. Don Hicks is a former microbiologist for the CDC retrovirus laboratory, now chief of retrovirology for Hillcrest Biologicals. (Mr. Hicks was the CDC researcher who established the efficacy of Nonoxynol-9 for inactivating HIV.) Neither Don Hicks or Patricia Fultz have any further plans to research the inactivation of HIV by saliva, and they don't know of anyone who is doing further research in this area. Don's research never got any priority at the CDC, and hadn't been published when I last spoke with him. I would be happy to provide a copy of his paper to any interested party. *** *** *** *** I think it is important to 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 gay men might be taking. We do know that lengthy studies of large numbers of gay men have not implicated oral sex as a risk for transmission of HIV. We don't know of any documented oral transmission of HIV between gay men. We do know that condoms fail and that unprotected anal sex provides an efficient route for transmission of HIV. My personal belief is that we will never see government funded research put the stamp of approval on oral sex, but the facts will eventually point the way. *** *** *** *** (REFERENCES to the medical literature) * Chmiel, Joan S. et al: "Factors Associated With Prevalent HIV Infection in the Multi Area Cohort Study", Am J Epidemiol 1987;126(4):568-577 * Fischl, Margaret A. et al: "Evaluation of Heterosexual Partners, Children, and Household Contacts of Adults With AIDS", JAMA 257(5):640-4 * Godfried, J. P. et al: "Prevalence of LAV/HTLV-III Antibodies in Relation to Lifestyle Characteristics in Homosexual Men in the Netherlands", Intnl Conf on AIDS, June 1986, Paris * Hicks, Dan: "Evidence of In Vitro Partial Inactivation of HIV by Normal Human Saliva" (Private communication) * Ho, David D. et al: "Infrequency of Isolation of HTLV-III Virus from Saliva in AIDS", New England J of Medicine, 19 Dec 85 p.1606. * Kingsley, Laurence et al: "Risk Factors for Seroconversion to HIV Among Male Homosexuals", Lancet 14 Feb 87 pp.345-349. * Lyman, David et al: "Minimal Risk of Transmission of AIDS-Associated Retrovirus Infection by Oral-Genital Route", JAMA, 4 Apr 86 p.1703 * McCusker, J.: "Logistic Regression Modelling of Previous and Current Sexual Behavior and HTLV-III/LAV Antibody Status Among Asymptomatic Homosexual Men", Intnl Conf on AIDS, June 1986, Paris * Schechter, Martin et al: "The Vancouver Lymphadenopathy-AIDS Study", Parts I - IV, Can Med Assoc J, 1 Jun 86 / 15 Jun 86 / 1 July 86, and 15 Aug 86. * Seage, George R. III et al: "Infection and Subsequent Transmission of LAV/HTLV-III in Sexual Partners of Homosexual Men", Intnl Conf on AIDS, June 1986, Paris * Stoddart, Anne M. et al: "Principle Components Analysis to Investigate Associations Between Specific Sexual Practices and HTLV-III Antibody Status", Intnl Conf on AIDS, June 1986, Paris * Winkelstein, Warren Jr., MD et al: "Sexual Practices and Risk of Infection by the Human Immunodeficiency Virus", JAMA, 16 Jan 87 pp.321-325.