Rotti's Safe Sex and HIV Info Page

DISCLAIMER:
READ AT YOUR OWN RISK.
I am not a physician or HIV counsellor, the following represents my personal views and opinions only.
For reliable, up-to-date information see your health care provider.
This page is gay-oriented so don't expect information on issues concerning straight sex.

After I'd gotten over my little HIV scare, Scott suggested I make a page with the stuff I learned while cruising the net for hours and hours, scared shitless and seeking assurance from statistics, probabilities and symptoms. So here it is.

Rule #1: "Nix genaues weiß man nicht" as the Germans say, roughly translated as "who knows?" There are few hard and fast rules and statistics when it comes to HIV. There are assessments of risk, some based on statistics, some based on what makes sense logically, some based on people's opinions. So let's start with what's pretty well established:

The HIV virus leads to AIDS. That's the received wisdom in the medical community from what I gathered. There are dissenters who don't believe that but they appear to be either a small and not very vocal minority or a lunatic fringe, depending on who you ask.

AIDS is a deadly disease. Actually, it's not AIDS itself that kills people but other infections that run rampant after the HIV virus has destroyed the immune system, which can take years and years (10 years from infection to outbreak seems to be pretty average). AIDS is not curable at this point. There are drug cocktails now that can suppress the virus and keep you from developing full-blown AIDS for long periods but they may have severe side effects and not too much is known about them yet since they've only been around for a few years. More precisely, I don't know much about them. So let's focus on how you can avoid getting AIDS in the first place.

The best way not to get AIDS is not to get HIV. Ah, now we're getting somewhere. Now how do you avoid getting HIV?

The safest way not to get HIV is not to have sex with other people. You cannot get HIV from jerking off, no matter how often you do it and what your practices are. But do we want that? Do we want to sit at home and beat the meat in front of the TV because we're scared? Of course not. So how can you have sex AND not get it?

That's where things start to get a little hazy, because now we're starting to deal in relative risk. Quite generally and theoretically, every time bodily fluids of an infected person get into any sort of wound or onto a mucous membrane of another person, there is an opportunity for the virus to pass through and get into the other person's bloodstream. Note that it says "infected person" in the last sentence. Having sex with somebody cannot ever give you HIV if that person is not infected. HIV is a virus, viruses don't just materialize out of thin air, they have to be there already. The problem of course is that you can't see if somebody is infected or not, and although you can ask them they may not know it. And as long as you don't know for sure, there is always the chance that they have it.

So let's talk risk. The problem with risk assessment for HIV transmission is that we have to rely on self-report, i.e. people telling researchers about their sexual practices that may have led to transmission. What we cannot do is conduct real experiments under controlled conditions, e.g. take some HIV infected people with various virus levels in their blood and have them engage in various carefully controlled sexual activities with a large number of subjects to find out how often transmission occurs with what activity and at what virus level. That would be a "clean" experiment, but I think we would all agree that it might raise some ethical concerns among the more sensitive members of the research community. In case you haven't noticed, I'm joking, it's of course totally unthinkable to do such a thing. But that gets us back to the problem of having to rely on people's reports which we can't check for accuracy--so everything MUST be taken with quite a few grains of salt.

A little medical risk assessment first: HIV is relatively difficult to catch. For example, if you have sex with somebody who has both, HIV and Hepatitis B, you're apparently much more likely to catch Hepatitis B from them than HIV. But of course you may catch both. But of course you don't want to catch either. (Btw, there is a vaccination against Hepatitis B, it will cost you about $ 100 for the vaccine, but it's probably worth it. And no, it does not protect against HIV.)

Transmission and How To Avoid It

The discussion of transmission risk below assumes sex without barrier precautions (rubbers, normally). Using barrier precautions reduces transmission risk to almost zero. Why 'almost'? Because rubbers can break, rarely due to manufacturing errors but usually because you made a mistake putting them on. Also, the 'almost' is based on studies where even people who consistently used rubbers got infected. But careful, we don't know if they REALLY used them consistently, it's all self-report, remember? They may very well have been lying to the researcher, which is not uncommon if the behavior inquired about is strongly socially marked, i.e. viewed negatively. Let's just say until we develop an HIV vaccine, rubbers are the best protection you can have.

Which rubber to use? There are quality differences between condoms, as Consumer Reports showed in a study. However, the user factor is still the biggest problem in correct condom use so practice with them before you use them on the battlefield of love (my, wasn't that poetic). Familiarize yourself with how to put them on, jerk off a few times with a rubber on.

For anal sex do not only use rubbers but also plenty of lubricant because there is quite a bit of friction involved, as those of you who had it will know :) . And we all know by now that a lubricant should be water-based (not only water-soluble!), so it should be KY Jelly or Astroglide or another water-based product. How about rubbers for oral sex? If you want to play it really safe and have a rubber for that one too, you can either use a scented brand (there are mint ones, I believe) or a rubber not made of latex but of polyurethane, which is tasteless. The only polyurethane brand I'm aware of is Avanti, but there may be others. Don't even think about lambskin condoms, they may work as a contraceptive device but viruses pass through no problem.

In any case, to lower likelihood of transmission even further it's a good idea to try to cum outside your partner's body. Even a broken condom wouldn't be a catastrophe then. Now don't be thinking you can go back to good ol' coitus interruptus ("I'll be careful") and just not use condoms. Your dick may be faster than your reactions, there is a risk for the insertive partner at all times and there is a very high risk for the receptive partner if you do come inside him.

Now that you know how to avoid infection, what is the risk of not using rubbers? Again, nobody REALLY knows, but a few things are pretty well established. Having another STD increases the risk of getting or transmitting HIV, in other words sores, bleeding wounds, and inflamed areas are bad news. Another general finding is that transmission risk increases with the number of sexual partners you have, which is not a big surprise. Also, risk increases if your partner is a member of a high-risk group in addition to being gay, which is already pretty high risk. Intravenous drug users and prostitutes are higher risk than the average gay man and the likelihood of your partner's being HIV positive is greater in some areas than in others, e.g. San Francisco is particularly risky.

So what is the transmission risk by activity? The following always assumes your partner is HIV positive! You cannot catch HIV from an HIV negative person but again, you and him may not know for sure what his status is.

Anal-penile sex (a.k.a. fucking): the classic transmission mode. The highest risk behavior possible, with the possible exception of exchanging blood. Has been shown repeatedly in a large number of independent studies to be absolutely, definitely and without a doubt dangerous in the case of receptive anal sex, i.e. when somebody cums inside you and thereby deposits his sperm and who-knows-what-else in your rectum. If HIV is present in the deposited fluids it can enter your body through the mucous lining of the lower colon. The HIV Vaccine Preparedness Study estimates that 78% of transmissions are due to receptive anal sex. Not a good thing, we don't want that, no, sir. So: don't have receptive anal sex or have your partner use a reliable condom and plenty of lubricant.

The picture is much less clear for insertive anal sex, i.e. when you come inside somebody else. Some advice columns on the net and hotlines tend to follow the formula "insertive is high risk, receptive is higher risk". But how high? That's hard to tell of course, because again we're dealing with self-report and a lot of people have both, receptive and insertive anal sex, and there is no way of knowing which way they got infected. Reviewing studies from before 1997, the AIDS Knowledge Base, an electronic textbook on HIV and AIDS, located at UCSF comes to the following conclusion:

"Most studies do not demonstrate a statistically significant association between this practice [insertive anal sex] and HIV infection among homosexual men. Because such an association has been reported, however, this behavior may not be completely free of risk." (chapter "Safer Sex" by H. Palacio, 9.5)

That may be putting it mildly, most other sites actually consider it the second highest risk around, third highest if you include vaginal-receptive. So what's your chance of getting HIV from being the insertive partner? The HIV Vaccine Preparedness Study reports 12% of transmissions occurring through insertive anal sex but that doesn't tell you anything about risk relative to total incidences of insertive anal sex. So: Nobody really knows. What does that mean for you? DON'T GET IT! In other words, use rubbers!

Oral sex (blowjob): Okay, one thing is easy with oral sex. If somebody gives you a blowjob, your chances of catching HIV from them just from getting a blowjob are near zero. Possibly if you have a sore or bleeding wound on your penis and they have a sore or bleeding wound in their mouth transmission may occur but honestly, if you have a bleeding wound on your penis, you shouldn't be having sex...

Now what about giving somebody else a blowjob? There is considerable discussion among researchers about transmission risk on that one. Most like to err on the side of caution and say that there is risk associated with it, albeit low. All the available evidence seems to come from case reports, i.e. studies with one subject. Statistically, that's meaningless, but transmission is definitely medically possible, since an infected person's semen can contain HIV, which could then pass into your bloodstream through the mucous membranes in your mouth. However, there is evidence that saliva kills HIV and concentration of virus in sperm does not tend to be very high. A pretty thorough discussion of transmissions by oral sex gives an estimate of about 2.5% of transmissions occurring through oral sex. So again, no clear answer but if you want to play it safe, a good rule of thumb seems to be not to allow the other guy to come in your mouth (also recommended by NIH, 1993). Purely theoretically there is a transmission risk in getting pre-cum in your mouth but I haven't seen any studies on that.

Anal-brachial sex (fisting): Complex statistical procedures have shown a relationship between (receptive?) anal-brachial sex and HIV transmission. So latex gloves and plenty of lubricant are a good idea if you want to play it safe but I honestly don't know what the risk really is here.

Kissing: Dry kissing is considered risk-free, wet kissing can theoretically lead to transmission if both partners have bleeding wounds in their mouths but I don't remember ever seeing any report of transmission by kissing.

Post-Exposure: Prophylaxis and Testing

Okay, so you decided to go ahead and be a FUCKHEAD and have unprotected anal sex (I know, I know, I'm one to talk...). Great, what now? You may consider going for immediate post-exposure prophylaxis. Meaning go and get the drugs they give infected people and take them as though you were infected. It may actually erradicate the virus, but from what I gather it has to be done immediately, preferably within 1-2 hours after possible exposure, but up to 72 hours may be okay. I really don't know much about post-exposure prophylaxis and it is a very new procedure so best AVOID IT!

If you don't do post-exposure prophylaxis, all you can do is hope for the best and get tested. Wait, there is something else you can do. If you don't know whether you may have caught something, at least don't pass it on! Make sure you only have protected sex until you know, and maybe even completely avoid anal sex till then.

Getting tested: the standard test is the ELISA antibody test, i.e. a test that tries to find HIV antibodies in your blood. Your body produces these antibodies when it detects infection with HIV but it doesn't do so immediately, i.e. it takes a while till the level is high enough for ELISA to find them. The standard rule is three months, after three months the vast majority of infected people have detectable antibodies. After six months just about everybody does. So if there is suspicion, you would normally do a test after three months and if that one is negative (i.e. doesn't find antibodies) another one after 6 months, to be on the safe side.

That's all very nice if you're really laid back or on tranquilizers. Otherwise waiting for 3 or 6 months can be pure hell. Particularly if you're a slight hypochondriac and tend to interpret every little ache and pain as a sign of the acute retroviral syndrome, a combination of symptoms that occurs in some people at the very early stage of HIV infection. What symptoms? Well, symptoms that look like the flu or mono, i.e. fever, fatigue, headache, swollen lymphnodes in different parts of your body, sore throat, muscle aches, a rash, and thrush. The problem is that all these symptoms can be caused by all sorts of viruses, bacteria and fungi, they are by no means HIV-specific. When do they occur in the case of HIV infection? Who knows... Estimates go from "10-14 days after infection", to "4-6 weeks after infection" and they supposedly last for 1-2 weeks. Does everybody who's infected get them? Of course not, that would be too easy. Estimates say that 50-90% of infected people experience some sort of acute retroviral syndrome, which may be very mild or so severe that it requires hospitalization. That range is so wide that the syndrome is not a reliable way of telling whether or not somebody has HIV. So what do you do if you don't want to wait for months?

You can go and get a PCR. The PCR (polymerase chain reaction) is totally different from ELISA in that it doesn't look for antibodies but for the virus itself (or more precisely its RNA). So it can find the virus in the blood before ELISA would show anything. When is the earliest point you can use a PCR? No real rules on that one, as far as I know. I was told manufacturers recommend waiting 28 days after possible exposure and claim that it's "conclusive" then. However, I was also told that a day doesn't matter and one guy at a hotline even went so far as to say he would trust a PCR after 16 days.

At the same time, CDC doesn't recommend the PCR because they believe the knowledge base isn't large enough yet. A problem with the test is its slight tendency towards false positives (i.e. finding something when there isn't anything to find) so low readings on the PCR don't necessarily mean infection. The newest PCR versions find as few as 50 copies/ml blood--that's pretty damn precise. My doctor claimed that a result of less than 1000 can be a false positive (I don't know what the chances of a false negative are). The other drawback with the PCR is its cost. It has to be ordered by a doctor, and it's difficult for a lab to perform. I used University Student Health Service so I paid only $7 for the visit, and since I paid cash at the lab they gave me a 50% discount and charged me $135 for the test itself. A doctor in private practice quoted me $500, a commercial testing service with an 800-number would have charged $335. Results only took 2 days in my case but that may vary between labs.

Your doctor should know this but just in case (s)he doesn't: if the test comes back negative it will probably still say something like "HIV-1 RNA by PCR < 50 copies/ml". That doesn't mean that it found a small amount of virus. It just means that nothing was detected above the test's threshold level. Makes sense if you know that PCRs aren't yet officially used as a screening instrument (infected / non-infected) but as a virus load measure, i.e. they assume that there is virus present and that they just can't find it.

Finally...

From Last chance to see by Douglas Adams & Mark Cawardine (New York, Ballantine's Books, 1990):

"So what do we do if we get bitten by something deadly then?" I asked.
He blinked at me as if I were stupid.
"Well, what do you think you do?" he said. "You die of course. That's what deadly means."
[...]
"The only answer, and I mean that quite seriously, is don't get bitten. There's no reason why you should."

There isn't, so don't get scared, get protected. And don't forget to have fun, there is a lot of fun to be had!

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