To the Editor: Transmission of HIV by male receptive oral-genital contact has been described by several investigators since 1987(1-10). An increased frequency of oral sores and crack cocaine smoking has also been associated with HIV seropositivity(11). Animal model experiments have demonstrated the feasibility of acquiring HIV infection by direct contact with the virus on intact oral mucosa(12). We have encountered a man who may have had increased risk of transmission of HIV through the oral mucosa because of surgical trauma to the oropharynx.
The patient is a 36-year-old man who undergoes twice-yearly anonymous HIV testing at a local clinic. In June 1996, he was seronegative for HIV-1. Later that month, he underwent uvulopalatoplasty and tonsillectomy for a chronic sleep apnea disorder. The surgery was complicated by two episodes of pharyngeal bleeding within 3 weeks after the surgery, both of which required outpatient cauterization of the bleeding vessels. Shortly after surgery, he resumed sexual activity and reported approximately 20 anonymous partners with whom he had receptive oral-genital contact without condom use. He reported tasting preejaculate during many of the encounters but denied contact with ejaculate during any of the 20 episodes. He was aware that two of these men had tested HIV positive, one of whom he engaged in receptive oral sex during the first week of August. He also had one anonymous partner with whom he had receptive anal intercourse with the use of a condom.
In early September, the patient presented to his primary care provider with symptoms of pharyngitis, adenopathy, temperature to 103°F, myalgias, and fatigue. Two days later, he visited an emergency room with complaints of worsening symptoms, where he was given a prescription for penicillin. Because of concern about HIV-1 infection, he was tested 5 days later and was found to be HIV-1 positive by ELISA. His reverse transcription-polymerase chain reaction RNA level was 168,000 copies per mL. HIV-1 was isolated from peripheral blood mononuclear cells, and his seroconversion was demonstrated by Western blot 3 weeks later. At the time of first interview, this patient reported believing oral intercourse was a safe practice.
Although the patient had receptive anal intercourse, it was infrequent (1 of 21 partners) and associated with condom use. He did, however, have at least 20 oral-genital experiences with anonymous partners, including partners known to be HIV seropositive. His greater risk of exposure appears to be unprotected receptive oral-genital contact without ejaculation. Exposure so soon after his surgical procedure raises the possibility of nonintact mucous membranes on his palate and posterior pharynx, further increasing his risk of infection with HIV. Several accounts published since 1987 have reported high-risk oral-genital contact in at least 20 individuals who subsequently seroconverted to HIV positive(1-10). The patient's exposure to only preejaculatory fluid again raises the issue of infectivity of this fluid(13). As the frequency of higher-risk activities such as unprotected anal intercourse decline, the transmission of HIV by lower-risk sexual behaviors may become more evident(3,5,10). Recommendations for safer sex practices should include discussion of receptive oral-genital contact with and without ejaculation as a risk behavior for HIV transmission.
M. Michelle Berrey
Program in Infectious Diseases University of Washington Seattle, Washington
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