spit or swallow? Does it affect STI risk?

We know that oral sex does carry risk for STI transmission. The risks vary depending on which infection we are discussing.

Some STIs are transmitted through skin-to-skin contact, including oral-genital and oral-anal contact. For example, herpes and syphilis are spread by contact with infectious sores or lesions, so oral sex could definitely spread these infections regardless of ejaculation. HPV can also be spread from genitals to mouth, or from mouth to mouth (http://cebp.aacrjournals.org/content/23/12/2959). Ejaculation during oral sex makes no difference with any of these infections.

Many people believe that gonorrhea and chlamydia can only be transmitted if ejaculation happens, but this is not true. The infections live in the epithelium (skin cells) of mucous membranes, like the cells lining the urethra (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC523569/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886739/). The bacteria are present on these cells, and can be transferred to the throat without ejaculate (cum) or even pre-ejaculate (pre-cum) being present. Interestingly, one study (https://sti.bmj.com/content/93/2/88) showed that gargling with Listerine reduced the amount of gonorrhea bacteria in the throat, but this study didn’t follow up to find out if this means fewer cases of gonorrhea were transmitted from throat to genitals.

Oral sex with or without swallowing semen both carry a very low risk of HIV infection – so low that we cannot calculate an accurate number (https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html).  We do not have any studies that look specifically at the difference in risk without ejaculation.If you are concerned about the low risk of HIV transmission via oral sex, you could communicate this to partners and then not swallow any semen that is present. From a harm reduction perspective, this may be less risky, but we just don’t have any scientific proof to say for sure if swallowing makes a difference.

A sex partner just told me that they were diagnosed with an STI. I feel fine, so I am pretty sure they didn't get it from me. They want me to get tested anyway. Do I need to?
That's great that your partner was able to share this with you - they must care about your health as well as their own.  Many STIs are asymptomatic which means you can have one and not know it.  Even if you feel ok, the STI could be causing inflammation and problems for your body, and you could potentially give it to someone else without knowing it. Therefore its super important that you get tested. There are a bunch of different STIs, so if you can find out from your partner what they have, that will help your medical provider take the best care of you.
I recently met a woman who said she had tested positive for HPV after an abnormal pap smear. She said she has never had warts, and that it had been diagnosed as the more high-risk kind. Since that pap smear she has had several subsequent ones that came back normal. Could she transmit HPV to me? Is there anything I can do to protect myself?

Over 70% of sexually active adults will show evidence of a past HPV infection. Most HPV infections are asymptomatic - that is, people are infected and do not know it. It's possible you've already been exposed to the strain that this woman was diagnosed with. Many HPV infections go away on their own. When HPV infection goes away the immune system will remember that HPV type and keep a new infection of the same HPV type from occurring again. However, because there are many different types of HPV, becoming immune to one HPV type may not protect you from getting HPV again if exposed to another HPV type.

Some HPV infections persist and stay in the body. Some strains cause warts. The strains referred to as ""high-risk"" can cause changes to cells that eventually can lead to cervical cancer, anal cancer and rarely, oropharyngeal cancer. It is not possible to know if she has cleared the virus completely and at this time there are no tests to detect HPV in men.

As for ways to protect yourself, condoms can decrease the risk of HPV transmission. There is also an excellent vaccine that protects against 9 of the most common strains of HPV -including 4 high-risk strains and 5 strains that can cause warts. Its recommended that all men and women <26 receive this vaccine.

I received a HPV vaccine shot a few years ago but never went back for the 2nd and 3rd shots. Should I start all over?
One of the most common questions we get asked is, “If I missed a dose of HPV vaccine, do I need to start all over again from the beginning of the series?”  No, with the HPV vaccine, you can just pick up right where you left off. You get credit for the first or second dose that you’ve already gotten.  If you're < 15, you only need 2 doses of the HPV vaccine.
I received a hepatitis B vaccine shot a few years ago but never went back for the 2nd and 3rd shots. Should I start all over?
No. Regardless of when you received your first hepatitis B shot, you do not need to start over. You should go ahead and get your second shot as soon as possible and then get the third shot two months later. You can also ask your provider to order a blood test to see if your body has responded to the vaccine by making antibodies.
I'm on PrEP and I just bottomed with a guy who came inside me. Do I need to start PEP?
The medication regimens for PEP and PrEP are similar, but usually a PEP regimen contains 3 medications active against HIV while PrEP is 2 medications (combined into one pill). If you've been taking your PrEP regularly, there is no need to add a 3rd medication. PrEP alone is extremely effective at preventing HIV. If you've been missing PrEP doses, you should talk to a provider about whether it makes sense for you to add a 3rd drug for PEP.
I'm on PrEP and my boyfriend is HIV positive. We've been together for about a year and neither of us play around outside of the relationship. He's been undetectable for years. Would it be safe for me to stop my PrEP?
There is no universally correct answer for everyone in this situation; it depends on factors in your relationship, your comfort level, and the possibility of changes in your sex life. However, if your partner is taking HIV medications and maintains an undetectable viral load, and he is your only sexual partner, there is no risk of him sexually transmitting the virus to you. This concept is called U=U (Undetectable = Untransmittable). If you do sometimes have other sexual partners, or may in the future, continuing PrEP will continue protecting you. It is also perfectly reasonable for you to continue PrEP as long as you would like if it helps you feel protected, or if you are unsure how comfortable you are stopping.
Is it possible to get HIV from oral sex?

Receiving oral sex (i.e. having your partner suck your penis or lick/kiss your vagina/clitoris), carries NO risk of HIV transmission.  Performing oral sex (i.e.  licking/kissing a vagina/clitoris or giving a blow job/sucking a penis) is extremely low risk in terms of HIV transmission.  There are a few case reports and individual experiences that support getting HIV from performing oral sex on a penis, but it’s extremely rare. As far as whether oral sex is riskier if you swallow semen, truthfully no one really knows. Having bleeding gums, recent dental work or large sores in your mouth may slightly increase the risk.

Other STIs like syphilis, gonorrhea, chlamydia, herpes, and HPV are transmitted through oral sex. Many of these infections are easily diagnosed with simple tests and can be treated with available medications. If you are worried about your risk for HIV or STIs, talk to your health care provider about getting tested and ask them if PrEP (pre-exposure prophylaxis) makes sense for you.

Is it possible for a person to clear their body of Chlamydia without treatment?

Yes, over time the immune system in some people can clear chlamydia infection, but most people need to take antibiotic medication to get rid of it. Untreated chlaymdia infection can cause serious health issues —such as sterility, pain, and pregnancy outside the womb. In addition, if you have chlaymdia, you can pass it on to your sex partners even if you don't have any symptoms. Getting re-infected with chlamydia after treatment is common, so be sure that your partners know about the infection and get treated too. Here's a great resource on how to talk to your partner about STIs: https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/get-tested/how-do-i-talk-my-partner-about-std-testing.

We recommend that everyone diagnosed with chlamydia get a test 3 months after treatment to make sure you were not re-infected.

My partner gets cold sores and his doctor said they are from herpes. Is it possible for him to transmit herpes to me when he goes down on me? If so, does it matter whether or not he has cold sores when we have sex?

It is definitely possible to spread herpes from one partner’s mouth to another partner’s genitals during oral sex, which would result in the uninfected partner contracting genital HSV-1. Transmission is more likely when sores are present, but sometimes herpes can be transmitted without any symptoms – we call this “asymptomatic viral shedding.” This shedding can happen in both oral and genital herpes infections. Shedding is most common in the first few months after getting a new infection, and the frequency of shedding depends on which type of HSV you have and where the infection is. For example, oral HSV-1 (what we call “cold sores”) sheds about 12% of days, and genital HSV-2 sheds about 20% of days (https://academic.oup.com/jid/article/198/8/1098/879583). Another study showed shedding of genital HSV-2 on 10% of days (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144252/). Since this shedding is invisible, its not possible to know for sure when your partner is potentially contagious.

Even though your partner has herpes, it is not a guarantee that you will contract the infection. One study showed that transmission between couples is about 10% per year, and about 70% of these transmissions happened when the infected partner had no symptoms (https://annals.org/aim/article-abstract/705283/risk-factors-sexual-transmission-genital-herpes?volume=116&issue=3&page=197).

Avoiding contact with visible sores will reduce your risk of getting oral HSV-1 when your partner goes down on you.

At City Clinic, we perform herpes tests by swabbing sores. This is the most accurate way to test, and this kind of test can distinguish between HSV-1 and HSV-2. There are blood tests available, but we do not routinely use these for our visits. City Clinic does not have blood tests for HSV-1 – if you would like this test, please talk with your primary care provider.

One of my sex partners just found out that he has syphilis. The last time we had sex was about 3 weeks ago. I was tested for syphilis at my PrEP follow-up visit last week and was negative. My doctor says I still should get the shot. Is that true? Why do I need it if I'm negative?
The syphilis test can take up to 12 weeks to turn positive after someone is infected. Syphilis is really easy to transmit. It’s very possible that you got syphilis from him when you had sex 3 weeks ago. By getting the shot, you will get rid of any incubating syphilis. This will prevent you from developing symptoms and also prevent you from transmitting syphilis to any of your other sex partners. It’s great that your partner told you and that you're both getting checked out and taking care of your health.
My new partner just told me that he has a history of genital herpes. I really like him, but I'm terrified of getting herpes, what should I do?

Genital herpes is common. It is usually caused by HSV-2, but it can also be caused by HSV-1. About 12% of people in the US have been infected with HSV-2. Its possible you've been infected with HSV-2 in the past and don't know it, because not everyone who gets infected with HSV-2 develops symptoms (for example, ulcers or an ""outbreak""). You could ask your primary care provider to test you for antibodies to HSV-2, this would tell you whether or not you've already been infected.

If you've already been infected with HSV-2 in the past, then your partner can’t transmit to it you. If you have not been infected with HSV-2, then there are a few things you can do to protect yourself. Condoms reduce the chances of HSV transmission by about 50%. Another way to prevent HSV-2 transmission is for your partner to take a daily anti-HSV medication (like acyclovir or valacyclovir). This will reduce the chance that your partner will pass HSV-2 on to you. For more info about herpes, look here and to http://www.ashasexualhealth.org/stdsstis/herpes/

One study of people with genital HSV-2 who took a daily antiviral medication showed that people taking medication were both less likely to shed virus, and less likely to transmit the virus to their partners. In addition, people who both took daily medication and used condoms for intercourse had further reduced risk of herpes transmission in this study.

Do I need to douche before or after sex?
It’s never necessary to douche. Vaginas are designed to be self-cleaning and douching can throw off the healthy environment, which can lead to increased risk for STIs or other vaginal infections. For this reason, vaginal douching is discouraged. Some people who have receptive anal sex (i.e "bottom" or have someone else's penis in their butt) douche before anal sex so that sex is not messy. Douching is a personal choice. It is most important to avoid injury to the anal/rectal tissue to reduce the risk of STIs.
I missed two days of my BC pill and had unprotected sex with my boyfriend. What are the chances of getting pregnant? Are there hormones left in my system that will cover me for the days I missed? What should I do?
Yes, it's true, you may be at risk for pregnancy if you had condomless sex after missing some birth control pills. Your exact risk depends on a few things, like which week of your pill pack that you missed your pills. For example, missing two pills at the very beginning of a new pill pack puts you at high risk for pregnancy. Missing two pills in the last week (where the pills don’t have hormones, they are just reminder pills) does not increase your risk for pregnancy. Depending on what week you were in when you missed your pills, you may need to use a back-up method of birth control (such as condoms) for 7 days until your pills are effective against pregnancy again. There is a very handy chart that you can check to see how to restart your pills and whether you need a back-up birth control for the next week. If you had sex within the last 5 days, you can come in to get emergency contraception (the morning after pill). Please come in as soon as possible so we can help you get this medicine. If you are not able to come to the clinic, one kind of emergency contraception (Plan B) is available without a prescription at most pharmacies.
I lost my job and my insurance. Is it possible to get PrEP if you're uninsured?

Yes! There are many ways to access PrEP if you're uninsured. Visit PleasePrEPMe.org to find a provider near you. There are also patient assistance programs to help you cover the cost of the medication. If you're in San Francisco, walk-in to SF City Clinic or call us at 415-437-5537 for more info on our PrEP program clinic.

Lately I've been having problems getting an erection while wearing a condom. I'm on PrEP, so I'm not too worried about HIV, but I've had chlamydia and syphilis a few times and want to protect myself against STIs. What should I do?
There a lot of different reasons why you might be having a hard time getting an erection. Sometimes when we're mentally stressed or depressed, our dicks work (or don’t work) differently.  One idea is to practice jacking off with a condom to make it easier to get hard when you're wearing a condom with a partner. You may also want to see a doctor to talk about other things that could be making it difficult to get hard, such as medications or medical problems like diabetes.  Its great that you're on PrEP, but as you shared in your question - PrEP prevents HIV but not other STIs. Therefore we recommend you get tested for both HIV and STIs every 3 months.
I just tested positive for an STI and had 3 partners in the past month. Do I need to tell them? How do I tell them?

To protect the health of your partners and prevent you from getting an STI again, we encourage you to tell all your partners.

Self-disclosure is the act of sharing with sex partners about a recent diagnosis with an STI or HIV, and how they might have been exposed. Self-disclosing may feel personal or vulnerable. But self-disclosing can be empowering, honest, and helps your sex partners get the care that they might need as well.

There are two ways self-disclose:

  1. Talking with your sex partners directly
  2. Sending your sex partners an anonymous text message with TellYourPartner.org

The best method is the method that is most comfortable for you. Each one shows that you care about protecting your partners’ health and want to stop the spread of STIs or HIV in your community.

Talking with your partners

Talking to your partners about a recent diagnosis, or self-disclosing, will help them access STI testing and treatment as soon as possible.

Here are some tips on talking with your partners/self-disclosing:

  • Share when you’re ready, comfortable, and in a safe space.
  • Practice what you will say in front of a mirror or with a trusted friend.
  • Learn more about your diagnosis to feel confident sharing information about it to your partner: STI Basics
  • Direct partners to testing sites such as the SF City Clinic or another location that is more convenient.
    • The SF City Clinic offers free testing and treatment with drop-ins and appointments.
    • Follow this link to a list of other locations that can be more convenient: GetTested
  • Share other resources available to them such as PEP, PrEP, and doxy-PEP.

Here is a video with an example of what it can be like to talk with your partner

Using TellYourPartner.org

TellYourPartner.org is a FREE, ANONYMOUS online service that can send a text message to your partners notifying them of a recent contact to an STI or HIV.

Learn more on how this service works.

How to use TellYourPartner.org (available in English and Spanish)

  1. Click the link to open the website
  2. Click the rectangle box “Send a Text”
  3. Move through the 5 steps to get started. This is where you will provide your partner’s cell phone number, select the STI you were diagnosed with, and then send the anonymous message.

I just bottomed with a guy who came inside me. He says he is HIV negative and has no STIs. I can't be sure of how honest he is being, and now I am panicking. What should I do?
It would be a good idea to see a medical provider and get a complete HIV and STI checkup. If its been < 72 hours since the sexual encounter, you should seek care right away as PEP can prevent HIV if started soon after a possible exposure to HIV. If its been more than 72 hours, its still a good idea to talk to a medical provider. You can get tested for HIV and STIs, and talk to your provider about whether PrEP is right for you.
I just began a new relationship. We got tested for HIV together and are both negative. We want to be able to have sex without a condom. What else should be we be getting tested for?

Kudos for being so responsible and prepared. What tests you need really depends on your gender (that is, are you a man, woman, trans man, trans woman or something else?), the gender of your sex partner and what type of sex you're having. A medical provider can help you figure out what tests you need. Also if you are in a heterosexual relationship, you should talk with your partner and medical provider about pregnancy prevention (contraception). Many people are nervous about talking to their provider about sex. Here are some strategies:

How safe is barebacking if the partner withdraws before ejaculating?
Dipping - being penetrated or penetrating without ejaculation (cumming) - is a common practice.  Herpes, gonorrhea, chlamydia and syphilis infections can all be transmitted without any cum present. HIV is found in pre-cum and could be transmitted even without full ejaculation. The risk of transmitting HIV without ejaculation is definitely lower than with ejaculation because there is less virus, but there is still some risk involved.  It can also be hard to tell if your partner starts to cum before he pulls out. PrEP is a great way to protect yourself from HIV if you're having anal sex without a condom; and if a condom breaks, PEP can be effective if started within 72 hours of the possible exposure.