Dear Alice,

What's the latest word on oral sex without condoms? What is the risk of HIV infection for each partner, with and without contact with orgasmic ejaculation? Sure I know that this is supposedly low-risk behavior, but if that is so, why are so many gay men still becoming HIV positive? Are they all having unprotected anal sex? Many of my friends practice oral sex without condoms and I tell them they are crazy but I've no hard data to back up the risk since not a single case of HIV has been proven to be transmitted by oral sex.

Signed,
Uneasy

Dear Uneasy,

First, it's good to note that gay men aren't the only population infected with HIV — many men, women, and non-binary people, regardless of their sexual orientation or the gender of their sexual partners, are living with HIV every day. Generally, the risk of HIV transmission during oral sex, even without using a condom or dental dam, is quite low, although there are some factors that may increase the likelihood of transmission (more on this in a bit). While transmission can occur due to having anal sex without a condom, it's not the only reason that men who have sex with men (MSM) have higher rates of HIV. There are complex factors that contribute to this such as not knowing their HIV status, substance use, social discrimination and cultural issues (such as not having access to quality health care), and there being an already existing high prevalence of HIV among the MSM community. As for why your friends have oral sex without condoms, it could be for any number of reasons.

Your friends also could mistakenly have confused a lower risk of contracting HIV from unprotected oral sex with no risk. It's true that unprotected oral sex carries a lower risk for HIV transmission than either unprotected vaginal or anal sex. Although the virus can enter the body through the mucous membranes that line the vagina, rectum, urethra, or the mouth, transmission through the vagina and the rectum are most common.

However, even though the risk for oral sex is known to be relatively low, the Centers for Disease Control and Prevention (CDC) states that a number of other factors, such as open sores in a person's mouth, may increase the risk of oral HIV transmission. A person living with HIV may have semen with relatively high concentrations of the virus. Sexual partners of individuals who produce semen, can reduce their risk of contracting HIV by not letting semen contact any mucous membranes, including the lining of the mouth. Pre-ejaculatory fluid (pre-cum) also contains HIV, but because the concentration is lower, and there is generally so little fluid, it isn't considered a significant risk factor. In terms of cunnilingus (oral sex performed on a person with a vagina), menstruation is the time of greatest risk of HIV transmission for the person giving since there's a high concentration of HIV in the blood of a person who's HIV-positive. There's also a smaller risk during times other than menstruation because vaginal secretions can contain the virus as well. An HIV-positive person giving oral sex could also theoretically transmit the virus to the person receiving, but this risk is very small. Using condoms or dental dams during oral sex significantly reduces the risk of transmission of HIV. Additionally, the use of pre-exposure prophylaxis (PrEP) can help lower the risk of people getting infected, particularly for those who may be at a higher risk.

Finally, your friends may want to consider that other sexually transmitted infections (STIs) that can be transmitted through oral sex. Herpes and gonorrhea, for example, are transmitted orally much more easily than HIV. And these other STIs are often asymptomatic (meaning that a person doesn't experience any symptoms despite having an infection), so it can be hard to tell if either partner has an infection. If a person is sexually active, it's wise to get tested for STIs regularly, even if they aren't actively experiencing symptoms.

You're a caring person for trying to look out for the health of your friends. If you're concerned about their behaviors, you may try having a conversation with them about their perception of risk. You may want to share this information with them to encourage them make a more informed decision, but ultimately, you can't make decisions for them. 

Here's to safer sex, 

Alice!

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