From: cpolishe@nyx.cs.du.edu (Chuck Polisher)
Subject: Re: safe sex question
Organization: Nyx, Public Access Unix @ U. of Denver Math/CS dept.
Date: Fri, 22 Jan 93 05:43:54 GMT

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.