2.3. How do you minimize your odds of getting infected? (AIDS)
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This article is from the AIDS FAQ, by Dan Greening with numerous contributions by others.
2.3. How do you minimize your odds of getting infected? (AIDS)
"Playing the AIDS Odds" (21 Oct 93)
Robert S. Walker, Ph.D. Phone: (210)224-9172
Emeritus professor Internet: rwalker@trinity.edu
Trinity University, Pol.Sci.
715 Stadium Drive office: 128 Main Plaza, No.310
San Antonio, TX 78212 San Antonio, TX, 78205
Everyone worries about the degree of transmission-risk involved in
various activities. Can you get infected from mutual masturbation?
From fisting? From using poppers? From this and from that? The real
question is, "Is it possible to provide answers with sufficient
precision to allow an individual confidently to assess risk and modify
behavior in specific situations?" The answer is "No." No one knows
enough about either sexual or drug behaviors, and their relation to
HIV sero- conversion, to speak with assurance. But this doesn't mean
that meaningful recommendations are out of the question.
Those interested in risk assessment might read two articles
representing different approaches. First: Michael Shernoff,
"Integrating Safer Sex Counseling into Social Work Practice, Social
Casework: The Journal of Contemporary Social Work, vol. 69 (1988),
pp. 334-339. The author offers a scaled list of 30 sexual behaviors
from abstinence through fisting to condomless, receptive anal
intercourse. The list is graded from "least likely" to transmit virus
to "most likely." Some of the relative rankings are arguable, but the
biggest problem is that the intervals of the "risk" scale are not
equal. For example, #29 is "vaginal intercourse to orgasm without
condoms," #30 is "anal inter- course to orgasm without condoms;" these
two are separated by the same scaler distance as abstinence (no.1) and
solitary masturbation (no.2). But everyone agrees that, anal
intercourse is many times more dangerous than vaginal for the
receptive partner, not just "one interval" more dangerous. Such lists
are not too useful; I doubt that any subscriber to this list needs to
be told that solitary masturbation is safer than receptive anal
intercourse. Further, until a lot more is known about the
relationships between specific behaviors and sero-conversion, the
intervals cannot be meaningfully quantified.
The second article is Norman Hearst and Stephen B. Hulley,
"Heterosexual AIDS," Journal of the American Medical Association,
April 22, 1988. The authors calculate probabilities for HIV
transmission for different parameters (such as: the area's
seroprevalence rate, the infectiousness of a partner, the
condom/spermicide failure rate, and the number of sexual
encounters). The "odds" of transmission with different parameters
(such as: 500 encounters, .01 condoms failure rate, area
seroprevalence of .0001, and so forth) are then projected. The
resulting odds range from a "low" of 1 chance in 5 billion to a "high"
of 1 transmission in 500 encounters. In the lowest risk example, there
is 1 in 5 billion chance that HIV will be transmitted when: (1) your
partner tests negative; (2) he/she has no history of high-risk
behavior; (3) condoms are used in intercourse, and the condom failure
rate is .01; (4) the area seroprevalence rate is 0.000001, (5) the
infectivity value is 0.002; and (6) there is only one sexual
encounter.
As behavioral guides, neither approach is very helpful. When the
possible sex or drug scenarios become as disparate as they are in
real-life situations, and when the odds resemble your chances of
winning a major lottery, then stating intervals or odds does not
provide much more than a illusion of knowledge and resulting security.
I suggest a different approach to thinking about risk. First, do not
worry about practices for which there is no documentation of
transmission (as distinct from speculation about it). If there is any
risk in kissing, masturbation, skinny-dipping or whatever, it is
probably much less than the chance of being hit by lightning - and few
people worry about that. Focus on those activities, like intercourse
and/or injecting drugs, which common sense tells you are risky, if for
no other reason than that they have a long history of transmitting
other diseases (like syphilis or hepatitis). Such behaviors would
clearly include injecting drug use within a group, condomless anal
and/or vaginal intercourse, and less clearly oral sex, fisting, or any
S&M practice that involved a possible blood exchange.
Second, take into account the overall setting within sexual or drug
activity is taking place. While it seems that we are all biologically
at equal risk, we do not face equal environmental risks. While HIV
theoretically can spread uniformly from the North to the South pole,
it has not in fact done so. It is one thing to pick up someone at a
bar in Brahma, Oklahoma and another in San Francisco, California. The
risk involved in employing a prostitute in Des Moines is much less
than in Newark, NJ or Washington D.C. where the seroprevalence rate
among prostitutes is very high. Similarly, patronizing a Newark
shooting gallery or crack house is like asking for AIDS, but the risk
of transmission within the West Coast drug scene is much less. For
area comparisons see the Centers for Disease Control's quarterly
HIV/AIDS Surveillance Report, and/or Jonathan Mann et al, AIDS in the
World, Harvard U. Press, 1993.
What I am suggesting is that some information plus common sense is a
better guide than current statistical or quasi-statistical statements
about relative risk. This will remain the case until a great deal more
empiric data is amassed about some of our most private behaviors. If
you are a person who does not feel comfortable without precise,
reliable, quantified guidelines, then your only course is to abstain
from activities wherein there is a possibility of transmission. There
are many mood-altering substances that do not require injection, and a
lot of sexual behavior that does not involve penetration and fluid
exchange.
With respect to non-sex or drug modes of transmission, all one can say
is that there have been no documented cases of transmission through
insect bites, shared utensils, shared occupational space or equipment,
food handling, and so on. Theoretical risks for an infinite number of
imagined scenarios can be computed, but in the actual world there are
no data supporting transmission in these scenarios. An excellent
survey of 14 principal articles searching for data on other routes of
transmission can be found in: Robyn R.N Gershon et al, "The Risk of
Transmission of HIV-1 Through Non-Percutaneous, Non-Sexual Modes: A
Review," Department of Environmental Health Sciences and Department of
Epidemiology, The Johns Hopkins University School of Hygiene and
Public Health, distribut- ed by New York City's Gay Men's Health
Crisis, AIDS Clinical Update, October 1, 1990. There have been cases
of transmission through transfusions /transplants of contaminated
whole blood, blood products, donor organs, and dental work. The only
thing one can do is to be aware of the possibility, and make sure that
those who treat you take all precautions.
Currently, the only way to load the dice in your favor is to use
common sense in any situation wherein someone else's body fluids might
be introduced into yours through sexual or drug behaviors. If one can
foresee that there would be opportunity for fluid exchange - blood,
semen, vaginal secretions - then a large measure of safety can be had
from the use of condoms (see: Condom Faq) and/or your own works for
injecting drugs. The only safer course - and it is an honorable and
intelligent one - would be to abstain from such activities altogether.
What must be kept in mind is that the risk of HIV transmission is
totally unlike the risk of losing at the races. Because you cannot
recoup the loss represented by infection, you ought not think of the
"odds" in the same way. In fact, it is better not to focus on the so-
called "odds" at all. Given that (1) infection almost always leads to
AIDS (estimates=95%), and (2) that AIDS almost always leads to death
(estimates=99%), people must now think of sex or injecting drug use as
an all-or-nothing game, . Each time you play, there are only two
possible outcomes. If you win you have, perhaps, enjoyed a pleasant
encounter; if you lose, you die. And each time you play without regard
to common sense evaluation and personal protection, you enhance the
possibility that you will lose. Its as simple as that.
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