Penile piercings could be the reason why three gay men became infected with HIV via insertive oral sex, according to investigators from Sydney writing in the October 17th edition of the journal AIDS.
The Australian researchers suggest that the stud or ring in a penile piercing could cause ongoing subclinical inflammation and provide a potential entry site for HIV.
Between 1993 and 1999, 75 gay men in Sydney with documented HIV seroconversion were interviewed in depth about their HIV risk behaviours in the previous six months. Using previous epidemiological data investigators constructed a “risk hierarchy.” Sharing injecting equipment and unprotected receptive or insertive anal sex were categorised as high risk. Protected anal sex, oral sex, blood or semen contact with an open wound, and penile-anal contact without penetration (“nudging”) were classed as medium-to-low risk.
One man reported sharing injecting drug equipment with an HIV-positive partner, and 59 men unprotected anal sex with an HIV-positive partner or man of unknown HIV-status as their most likely HIV risk behaviour.
Of the remaining 15 men, eleven reported protected anal sex, and the investigators reasoned that this was their probably mode of infection.
On the basis of the sexual behaviour reported by the men, the investigators judged that oral sex was the most probable cause of HIV transmission for five men. Initially they expected that receptive oral sex with ejaculation would be the oral sex behaviour involved in HIV transmission. However, in three of the cases the insertive oral sex by a man with a penile piercing was judged to be the highest risk behaviour.
Although the HIV and hepatitis C risks of unhygienic piercing practices are well understood, the investigators suggest that most men are unaware of the risk of infection through piercing sites once the initial wound has apparently healed. However, they add that men with penile piercings may have more sexual contact with HIV-positive men, as they are likely to be involved in more esoteric sexual subcultures that include a high proportion of HIV-positive men.
Of the other two possible cases of oral transmission, the presence of bleeding gums and an open wound in the mouth following recent dental work is thought by the investigators to have led to one case. The other case involved a man who reported one instance of protected anal sex but multiple casual partners for oral sex.
Their use of in-depth interviews was more likely, the investigators suggest, to have elicited reliable data than written questionnaires. However, they acknowledge that it is possible that not all high-risk behaviour was reported, as "even the most skilled interviewer cannot elicit a clear account of an event that is remembered through an emotional or drug-induced haze".
The investigators emphasise that their study cannot quantify the risk associated with oral sex, and note, “it is clear from the cohort and case-control studies that have analyzed the risk that it is very low. Cohort studies of serodiscordant couples in whom sexual behaviour data are collected prospectively have not identified any cases of orogential transmission.” (See liks to aidsmap.com reporting of these studies below). Nevertheless, the investigators assert that HIV can be transmitted in unusual ways, and call for further research “to investigate HIV transmission by breaches in skin integrity…body piercings, particularly of the genitals may constitute a breach even when the skin has apparently healed on the surface, as the presence of a metal stud or ring may well cause ongoing subclinical inflammation.” Furthermore, inflammatory skin conditions such as psoriasis could provide an entry for HIV and such skin conditions are poorly recognised as such by gay men.
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Richters J et al. HIV transmission among gay men through oral sex and other uncommon routes: case series of HIV seroconverters, Sydney. AIDS 17: 2269 – 2271, 2003.