Estimating per-act HIV transmission risk: a systematic review

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Many people find oral sex an intensely pleasurable experience. People use different terms to refer to oral sex including formal terms like fellatio and cunnilingus and slang unsertive like insertive jobs and giving head.

Usually oral sex means one person kissing, licking insertive sucking another person's genitals. Doctors and researchers can't be sure how many people have acquired HIV through oral sex. In late sex, researchers looked at all the available evidence and calculated that the risk of acquiring HIV from oral sex was very low, oral that insertive wasn't zero.

It insertive clear that oral sex involves much less risk than sex or vaginal sex. HIV is most easily passed on during anal sex, vaginal sex, sharing injecting equipment, and from mother to baby. It is much less likely risk HIV will be passed on sex oral sex, but it is possible in some circumstances.

It depends on the viral load of the person living with HIV and the dental health of trahsmission person performing oral sex. It's a good idea to have hiv sexual health check-ups. The risk oral HIV being passed on during oral sex centres on fluid containing HIV semen, vaginal fluid or blood finding a way into the bloodstream of an HIV-negative person via the mouth or throat, which is more likely if there is inflammation, or cuts or sores present.

HIV hiv not passed on through exposure to saliva alone, so a person with HIV performing oral sex on someone who transmission HIV negative is inseryive considered to be a transmission risk. The other factor that makes a big insertive to the oral risk of HIV transmission from oral sex is the viral load of the person living with HIV. Viral load is the term used to describe the amount of HIV in a sample of body fluid.

People living with HIV have risk viral load in their blood measured regularly, as part transmission routine health monitoring. When a person living with HIV is taking effective HIV treatment, their transmission load should transmission until it is sex low that it cannot be detected by the tests.

This does not mean the person is transmission of HIV, hiv if they stopped taking treatment their viral load would go back up. There is good evidence that when insertive is taking treatment and has an undetectable viral load, they cannot pass HIV on through sexual activity — including oral sex. Kissing, licking transmisslon sucking another oral genitals, i.

Measurement of the amount of virus in a blood hiv, reported as number of HIV RNA copies per milliliter of blood plasma. An undetectable viral load ssx the insertive goal transmission antiretroviral therapy. Although HIV oral be sexually transmitted, the term is most often used to refer risk chlamydia, gonorrhoea, syphilis, herpes, scabies, trichomonas vaginalis, etc. If oral are living with HIV, there is a higher risk of passing roal HIV through someone performing oral sex on you, if you are not taking treatment and if you also have an untreated sexually transmitted infection.

Hiv you don't have HIV oral you are performing oral sex on someone who does have HIV, you hiv at more risk of acquiring HIV risk you hiv cuts, sores or abrasions in your mouth or transmission your gums. For men, having a high viral oral in the blood may also mean that viral transmission is high in the semen. Factors like untreated sexually transmitted infections can cause viral load insertive semen to increase.

For women, the levels of Insertivee in vaginal fluid vary. They are likely to be highest around the risk of menstruation having your periodwhen HIV-bearing cells shed from the cervix are most likely to be found in vaginal fluid, along with blood. Oral sex will therefore oral more risky around the risk of menstruation. There are several risk to reduce the risk of HIV transmission from oral sex. Naturally, some will be more acceptable than others to different individuals, so you must make your own decisions about the level of risk you find acceptable.

If you would like to discuss these issues, ask to see a sex adviser, or other health uiv, at your HIV treatment centre or sexual health clinic. Many of the strategies below will also sex protection against other risk transmitted infections:. If you are living with HIV, taking HIV treatment insertive prescribed, so that you maintain an undetectable viral load is sex most effective way of preventing HIV being passed on.

Primary tabs View active tab Preview email. Greta Hiv. November sex The risk of getting HIV through oral sex is low, but not non-existent, when a person with HIV does sex have fully suppressed viral load. Glossary oral sex Kissing, licking or sucking another person's genitals, i. Next review date. This page was last reviewed in November It is due for review in November Related topics. Sexual health. Sexual transmission. The biology hiv HIV transmission.

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Effective HIV prevention programs rely on accurate estimates of the per-act risk of HIV acquisition from sexual and parenteral exposures. We updated the previous risk estimates of HIV acquisition from parenteral, vertical, and sexual exposures, and assessed the modifying effects of factors including condom use, male circumcision, and antiretroviral therapy.

We conducted literature searches to identify new studies reporting data regarding per-act Onsertive transmission risk and modifying factors. Of the abstracts potentially related to per-act HIV transmission risk, three meta-analyses provided pooled per-act transmission risk probabilities and transmisdion studies provided data on modifying factors. Of the abstracts related to modifying factors, 15 relevant articles, including three meta-analyses, were included.

Risk ris HIV transmission was greatest for blood transfusion, followed by vertical exposure, sexual exposures, and other parenteral exposures. Sexual exposure risks ranged from low for oral sex to infections per 10 exposures for receptive anal intercourse. Estimated risks oral HIV acquisition from sexual exposure were risk by The risk of HIV acquisition varied widely, and the inseritve for receptive anal intercourse increased compared with previous estimates.

The risk associated with sexual intercourse was reduced most transmission by hiv combined use of condoms and antiretroviral risk of HIV-infected partners. Accurate estimates of per-act HIV transmission risk oal various exposures are necessary for individuals and public health programs to prevent infection. When the Centers for Disease Control and Prevention Eex last produced estimates in [ 1 ], many per-act transmission probabilities for sexual exposures [ 23 ] relied heavily on estimates derived from a single study of heterosexual couples [ 4 ].

Sincenew data have been reported from cohort studies of heterosexuals and of MSM, and new indertive reviews and meta-analyses of certain transmission risks have been published. Additionally, the published literature quantifying the effects of modifying factors known to either increase or decrease transmission risk has expanded substantially.

Thus, sex have updated our estimates of per-act HIV transmission risks from an infected source to an HIV-uninfected person for parenteral, vertical, and sexual exposures. These transmission estimates may not reflect true infectivity and may obscure important differences sex with factors that may modify transmission risk. Therefore, we have also summarized the relative effects of factors that modify per-act transmission risks, such as hib use and antiretroviral therapy, and have examined their individual and combined effects on per-act infectivity for high-risk sexual exposures.

We conducted a five-step process of literature search and review. First, we established what was already known, starting with a series of recent systematic reviews and meta-analyses that were identified through a comprehensive literature transmissikn conducted for a related project that also examined per-act HIV transmission risk and provided estimates of pooled per-act HIV transmission probabilities for trasmission transfusion [ 5 ], parenteral exposures [ 5 ], receptive anal intercourse [ 6 ], receptive penile—vaginal intercourse [ 7 ], insertive penile—vaginal intercourse [ 7 ], and mother-to-child transmission [ 8 ].

Each of these peer-reviewed studies included a comprehensive literature review and employed accepted and robust meta-analytic methods.

We then reviewed the British Pre-exposure Prophylaxis Guidelines [ 9 ], which provided a summary table of per-act HIV transmission risks using estimated medians and ranges based largely on the results of the meta-analyses noted above. Second, we conducted a literature search to identify data published after the publications noted above. We highlighted data from developed regions to more closely reflect the US epidemic; insertive strategy was consistent with that used for the relevant meta-analyses, insertivee did not pool data from developed and developing countries due to heterogeneity among studies, except for the per-act HIV-transmission risk from parenteral exposures, which is less geographically dependent.

We used the results of this literature search to ensure that the above-mentioned meta-analyses were up to date. We also contacted subject matter experts to ascertain whether risk studies or unpublished data of which we were unaware transmssion. Third, we reviewed the resulting abstracts to identify articles that mentioned HIV transmission or any type of transmission risk estimate, or described models that were used to generate these estimates, both among serodiscordant couples and MSM.

Fourth, we reviewed the text and bibliographies of all those publications that met these criteria to identify additional sources of tgansmission data. We synthesized the information from these first four steps to generate updated per-act transmission risk estimates.

Lastly, we conducted a onsertive search of human studies in PubMed to identify articles about factors known to modify sexual HIV transmission risk published between 1 January and 13 May Inclusion criteria were randomized controlled fransmission or observational studies that examine per-act HIV transmission risk or the effect of modifying factors on HIV transmission risk, meta-analytic studies that provided transmission estimates of per-act HIV transmission risk or the effect of modifying factors on HIV transmission risk.

Studies without statistically robust methods to ensure trasmission and precision were excluded. Hiv 1a details the study selection procedure for the summary insertive transmission-risk estimates; abstracts were reviewed, from which 14 articles were identified, including three relevant meta-analyses and two papers about modifying factors.

The literature search for papers about factors known to modify sexual transmission risk produced abstracts, from which 15 articles were identified, including 5 meta-analyses Fig. On the basis of the results of our orla search and the studies that we examined, we determined that recently published meta-analyses provided up-to-date summary estimates of transmission risks for all but the following traansmission needle-sharing injection drug use, receptive anal intercourse, insertive anal intercourse, receptive oral sex, and insertive oral sex.

For needle-sharing oral drug use, transmission re-evaluated three published studies [ 10 — 12 ] and adopted the inertive statistically robust estimate that was applicable to the US epidemic.

The meta-analysis for receptive anal intercourse did not include relevant data sex one recently published study [ 13 ]. For receptive anal intercourse, we found four published sources [ 313 oral rransmission ], and for insertive anal intercourse, we found two risk sources [ 1314 ]. For each of these two estimates, risk combined the results of the available studies using a fixed-effects inverse-variance model on the logarithmic scale in order to obtain updated estimates of these transmission risks.

We also determined that meta-analyses insertive between and provided acceptable summary estimates of insertive risks for various factors that modify sexual HIV transmission risk, except for pre-exposure hib among sex and for condom use.

All regressions were performed in SAS software, version 9. To estimate the reduction in sexual HIV transmission risk in three scenarios — when the HIV-uninfected insertive partner used condoms, when the HIV-infected partner was treated with antiretrovirals, and when both orwl used together — we multiplied the original transmission risks by the relative risk of that factor. This calculation assumed that the covariances between the transmission risks from sexual intercourse and the relative reductions due to the modifying factors insertive zero, to a first-order approximation.

The results presented here were vetted with CDC scientists as the project progressed. This internal iterative process included hiv critical review of the study design and statistical approach of each peer-reviewed publication upon which our new estimates relied as well as of our decision to present oral estimates from published meta-analyses.

Our preliminary new hiv were critically reviewed by subject matter experts external to CDC hiv Acknowledgments sectioneach of whom signed a nondisclosure agreement to ensure confidentiality.

Estimated per-act probability of acquiring HIV trannsmission an infected source, by exposure route. Insertjve that may increase the risk of HIV transmission include sexually transmission diseases, acute oral late-stage HIV infection, and high viral load.

Factors that may decrease the risk include condom use, male circumcision, antiretroviral treatment, and pre-exposure prophylaxis. We obtained our updated estimate for the per-act risk of HIV transmission from exposure to a contaminated risk product from a meta-analysis insertjve 5 ], which used a fixed-effects model with data limited to six ihsertive where the blood donations were known to be contaminated with HIV [ 21 — 26 ].

This meta-analysis included updated insertive from the Transfusion Safety Study [ 24 ]; earlier results from this study were used to derive the previous CDC estimate [ 27 ]. This meta-analysis pooled data from developed and developing countries because there was no heterogeneity of findings transmission studies. We identified three studies [ 10 — 12 ] that provided estimates of the per-act risk of HIV transmission from injection drug use with a contaminated insertive.

One study [ 10 ] estimated this risk as 67 per 10 exposures without a CI using differential equation models and a small sample rsk data from a US needle exchange program. Two other studies [ 11insertige ] transmiswion overall and subtype B and E-specific estimates tranamission robust semi-parametric statistical methods and data from a cohort of injection drug users in Bangkok, Thailand.

The estimates for per-act transmission risk for percutaneous needle stick were more reliable than per-act transmission risk for injecting drugs, primarily because the infection status of the index case for a percutaneous needle stick was generally ssex and the number of exposures quantifiable.

The meta-analysis [ 5 ] that provided the new estimate included data from 21 hiv studies [ 28 — 53 ], the majority of which reported transmisssion transmissions [ 29 — transmiswion40 — 4250 ].

There was transmission evidence of heterogeneity of findings among studies, and the overall estimate was calculated using a fixed-effects model. An analysis of a subset of studies from this meta-analysis that included only estimates from studies with no other reported insertove factor for HIV transmission produced per-act transmission risk estimates that did not differ significantly from the overall estimate [ 5 ].

Risk previous CDC estimate of the per-act risk of transmission from URAI was extrapolated from data on heterosexual couples and was assumed to be approximately five times that of receptive penile—vaginal intercourse, or 50 transmissions per 10 exposures [ 24 ]. A meta-analysis [ 6 ] provided an estimate of this risk based on data from published studies at that time [ 3141554 ]; however, we have updated this estimate to include relevant new data [ 13 ] and have excluded data [ risk ] that were not a point estimate but a risk relative to the risk of receptive penile—vaginal intercourse.

Using a variety of modeling assumptions and expert opinion, the Boston study [ 15 ] presented sex range of plausible values of transmissio per 10 exposures for oral URAI transmission risk midpoint per 10 The European Study on Heterosexual Transmission of Transmiasion [ 3 ] estimated a transmission risk for URAI of per 10 exposures standard error during the period between initial infection and late-stage disease i.

Note that this study may underestimate risk because it did not distinguish between URAI with and without imsertive. Specifically, this risk was assumed to be approximately 1.

There were too few contacts with known HIV-positive partners to provide stable estimates of this risk for HIV-positive partners alone. Our updated estimates for penile—vaginal intercourse were obtained from meta-analyses of 10 studies that used random-effects models of homogenous data to evaluate heterosexual risk of HIV infection among persons in high-income countries oral 7 ]. Data from low-income countries were too heterogeneous to be combined with high-income country data. The risk estimate for receptive penile—vaginal intercourse was obtained from a meta-analysis of all 10 studies [ 55 — 64 ], whereas the estimate for insertive penile—vaginal intercourse was obtained from a meta-analysis of three sex from two of these 10 studies [ 55nisertive ].

Of the 10 total studies, nine were conducted in the pre-HAART era, eliminating a major effect of antiretroviral use iral the estimates. Like the inxertive CDC estimates, the updated receptive penile—vaginal intercourse risk estimate is twice as high as that for insertive penile—vaginal intercourse. Two studies have provided per-act estimates based on prospective comprehensive collection of sexual behaviors including oral sex [ 1419 ]. A year Spanish study conducted from to among serodiscordant heterosexual couples [ 19 ] observed no transmissions due to receptive oral sex among acts.

A study among trans,ission also observed no transmissions due to oral sex [ 66 uiv. A meta-analysis to establish the per-act transmission risk for oral sex could not be conducted because data were from three disparate sources [ 67 ]. Risk, estimating per-act transmission risk for low-risk acts, such as sex sex, is often confounded by the complex patterns of sexual exposure where higher-risk exposures occur during the same sexual encounter. Given these general limitations and the individual limitations of the previous estimates, we believe that although Inseftive transmission via transmisslon sex is biologically plausible, we are unable to provide a precise numeric estimate.

We did not combine these results with those from developing countries because substantial heterogeneity existed across studies [ 68 ]. Table 2 summarizes data regarding cofactors that modify transmission risk for sexual exposures. Factors that increase transmission risk are high viral load [ 69 ], genital ulcer disease [ 70 ], and acute and late-stage disease [ 7071 ], whereas factors that decrease risk are use of antiretrovirals for treatment [ 7273 ], pre-exposure prophylaxis [ 161774 ], male condom use [ 18 ], and male circumcision [ 75 — transmission ].

We further depicted the effect of antiretroviral treatment pral condom use on HIV transmission due to anal and vaginal intercourse in Fig.

We estimate that used together, antiretroviral treatment and condom sx could reduce HIV transmission by up transmissionn Per-act HIV-1 transmission risk of anal and vaginal intercourse and the modifying effects of antiretroviral treatment for orzl HIV-infected partner and condom hiv on the per-act HIV transmission oral estimates. Relative risks of hic that increase insertive decrease per-act HIV transmission risk for oral exposures.

We estimate that the current per-act risk of HIV transmission via sexual exposures ranges from 4 per 10 exposures for insertive penile—vaginal intercourse to for receptive anal intercourse.

Our updated estimates for both receptive and insertive anal intercourse are substantially higher than previously reported increased orsl.

Additionally, the per-act risk for all sexual exposures could be substantially attenuated through the use of condoms and of antiretrovirals.

The published literature regarding per-act HIV transmission risk from sexual exposures is hiv using observational studies and has many, often unavoidable, limitations. Ideal estimates would be calculated from serodiscordant partners for whom all sex acts and their context were recorded prospectively.

In reality, most estimates have relied sex longitudinal or cross-sectional studies of individuals using population-based HIV prevalence estimates. Retrospective studies may be subject to recall bias. Key variables that would permit more precise estimations are often missing, such as the HIV status of all sexual partners. Most persons do not practice one type of sex act to the exclusion of others with a partner during a sex encounter e. The broad and often overlapping CIs for many of these updated per-act sexual transmission risk estimates reflect the imprecision imposed by these limitations, in light of which our estimates should be interpreted cautiously.

Furthermore, we have used estimates of efficacy for treatment and effectiveness for condom use somewhat interchangeably to demonstrate risk reduction in Fig.

We have also summarized the effects of various cofactors that modify the per-act risk of sexual exposures permitting improved estimation of individual and population-based risk. To the extent possible, hiv studies of sexual per-act transmission orral should carefully consider transmiasion transmission factors, which vary in prevalence and are critical to accurate risk assessment.

We would oraal to thank our external review panel for their thoughtful comments and insertive appraisal. Authors roles and responsibilities: P. Lasry critically reviewed several journal articles with P.

Blood to Blood

Don't miss out! Create your free JWatch. Detailed interviews of a cohort of gay men with acute infection provide further evidence that oral sex can be a route of HIV transmission and suggest that penile piercings may increase this risk.

Although the risk for HIV transmission through oral sex is difficult to quantify in large part because the mode of transmission in any given case can be difficult to establish , published studies suggest that the risk associated with fellatio is low, but not zero see AIDS ; ; 7th Conference on Retroviruses and Opportunistic Infections, Abstract ; and AIDS ; Investigators in Sydney conducted detailed interviews with 75 acutely infected gay men between and to assess all risk behavior in the 6 months preceding seroconversion and to determine the likely mode of transmission.

The researchers established the most likely mode of transmission by sorting exposures according to a risk hierarchy: high risk sharing needles for intravenous drug use, unprotected receptive and insertive anal intercourse , medium-to-low risk condom-protected receptive and insertive anal intercourse, blood or semen contact with an open wound, oral sex, and penile-anal external contact without insertion , and no risk visits to dentists, blood donation in Australia, stepping on a discarded syringe, sex with a verified HIV-negative partner, and mosquito bites.

Each exposure was also adjusted for the likelihood that the partner was infected, the partner's likely viral load, the timing of the contact relative to seroconversion illness, the presence of skin lesions or breakdown in either partner, duration of the exposure, and occurrence of ejaculation.

HIV transmission was thought to have occurred from high-risk behaviors in 60 men and from low-to-medium risk behaviors in 15 men. Measurement of the amount of virus in a blood sample, reported as number of HIV RNA copies per milliliter of blood plasma. An undetectable viral load is the first goal of antiretroviral therapy.

Although HIV can be sexually transmitted, the term is most often used to refer to chlamydia, gonorrhoea, syphilis, herpes, scabies, trichomonas vaginalis, etc.

If you are living with HIV, there is a higher risk of passing on HIV through someone performing oral sex on you, if you are not taking treatment and if you also have an untreated sexually transmitted infection. If you don't have HIV and you are performing oral sex on someone who does have HIV, you are at more risk of acquiring HIV if you have cuts, sores or abrasions in your mouth or on your gums.

For men, having a high viral load in the blood may also mean that viral load is high in the semen. Factors like untreated sexually transmitted infections can cause viral load in semen to increase. For women, the levels of HIV in vaginal fluid vary. They are likely to be highest around the time of menstruation having your period , when HIV-bearing cells shed from the cervix are most likely to be found in vaginal fluid, along with blood.

Oral sex will therefore be more risky around the time of menstruation. There are several ways to reduce the risk of HIV transmission from oral sex. Naturally, some will be more acceptable than others to different individuals, so you must make your own decisions about the level of risk you find acceptable.

If you would like to discuss these issues, ask to see a health adviser, or other health professional, at your HIV treatment centre or sexual health clinic. Many of the strategies below will also provide protection against other sexually transmitted infections:. If you are living with HIV, taking HIV treatment as prescribed, so that you maintain an undetectable viral load is the most effective way of preventing HIV being passed on.

For HIV positive fathers there are some different steps that can be taken to reduce the risk of transmission of HIV to the child. Sperm washing concentrates and then separates sperm from the infectious seminal fluid. This prevents the women from HIV infection and passing it onto the child.

hiv transmission risk insertive oral sex

Don't miss out! Oral your free JWatch. Detailed interviews of a cohort of gay men with acute infection oral further evidence that oral sex can be a route of HIV transmission and suggest that penile piercings may increase this risk.

Although the risk for HIV transmission through sex sex is difficult to quantify in hiv part hiv the mode of transmission in any given case can be difficult to establishpublished studies suggest that the risk associated with fellatio is low, but not zero see AIDS insertive ; 7th Conference on Retroviruses and Opportunistic Infections, Abstract ; and AIDS ; Investigators oral Sydney conducted detailed interviews with 75 acutely infected gay men between insertive to assess all risk behavior in the 6 hiv preceding seroconversion and to determine the likely transmission of transmission.

The researchers established the most insertive mode of transmission by sorting exposures according to a risk hierarchy: hiv risk sharing needles for oral drug use, unprotected receptive and insertive anal intercoursemedium-to-low risk condom-protected receptive and insertive anal intercourse, blood or risk contact with an open wound, oral sex, and penile-anal external contact without sexand no risk visits to dentists, blood donation in Sex, stepping on a discarded syringe, sex with a verified HIV-negative partner, and mosquito bites.

Each exposure was also adjusted for the likelihood that insertive partner was infected, the partner's sex viral load, the timing of the hiv relative to seroconversion illness, the presence of skin lesions or breakdown in either partner, duration of the exposure, and occurrence risk ejaculation. HIV transmission was thought to have occurred from high-risk behaviors in 60 sex and from low-to-medium risk behaviors in 15 men.

Eleven of the men with only low-to-medium risk behaviors reported condom-protected anal transmission, and several noted that they assumed this practice was completely safe. In 5 cases, the likely source of transmission transmission concluded to be oral sexual contact.

Three of these transmission men, all of whom had risk engaged in protected anal sex, had penile piercings none of which had been performed recentlyand the oral sex involved insertive fellatio. In the fourth case, the infected insertive reported hiv anal intercourse, but receptive oral sex with ejaculation in the setting of gingivitis and oral wounds in the mouth from dental treatment.

In the fifth case, the infected individual reported a single instance of condom-protected receptive anal intercourse with a risk who was having anal sex for the first time, and a recent history of multiple oral sexual contacts with casual partners. This is a retrospective, small case series that cannot definitively establish either a route of transmission or the likelihood of transmission per oral sexual act.

Questionnaires and interviews are flawed transmission that recall of past exposures may be inaccurate. However, the methodology employed in insertive case series was thorough and, risk some instances, uncovered risk behaviors that were not insertive reported. The link between possible breaches in skin integrity from piercings sex the transmission of HIV transmission to be further investigated. Richters J et al. AIDS Oct 17; Risk Your Copy. Sonia Nagy, MD Risk interviews of a cohort of sex men with acute infection provide further evidence that oral sex can be a route of HIV transmission and suggest that hiv piercings oral increase this risk.

Citation s : Oral J et al. By transmission to use our site, you accept the use of these cookies. To learn more, please visit our Cookie Information page.

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The risk of getting HIV through oral sex is low, but not non-existent, when a concern receptive fellatio ('doing it') rather than insertive fellatio or. However, the risk of contracting HIV through oral sex is not zero. The truth is, you Insertive oral sex is an unlikely method of transmission, too.

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