HIV Risk Without Ejaculation During Sex

Estimating your risk of HIV is a tricky business. While most people know that HIV is mainly transmitted through sex, does this mean that the risk is the same for all types of sex?

The answer is no. Each type of sexual contact carries its own risk of HIV transmission. Receptive anal sex, for instance, carries a higher risk of infection than receptive vaginal sex. Oral sex has the lowest risk of transmission.

But what if the insertive partner pulls out before ejaculation? Is the risk of HIV less?

A stack of multi-colored condoms
Getty Images / Rafe Swan / Cultura

The answer to that question is not straightforward or simple. This article aims to explore the factors that contribute to HIV transmission and whether "pulling out" is an effective strategy to prevent HIV. In addition, the article will examine ways to reduce the risk of HIV if external (or "male" condoms) and internal (or "female" condoms) are not used consistently.

HIV in Pre-seminal Fluid

You can only get HIV by coming into direct contact with certain body fluids from a person with HIV. These fluids are:

  • Anal secretions
  • Blood
  • Breast milk
  • Semen
  • Vaginal fluids

Although pulling out before ejaculation decreases the overall risk of transmission, it doesn't prevent it altogether. Why? Because pre-seminal fluid can contain the virus too.

In people with HIV, pre-seminal fluid is just as potentially infectious as semen, containing roughly the same concentration of HIV. This means that even if the insertive partner pulls out before ejaculation, the receptive partner can still be exposed to HIV through pre-seminal fluids.

Recap

Pre-seminal fluid ("pre-cum") contains roughly the same high concentration of HIV as semen. During unprotected (also referred to as "condomless") sex, pre-seminal fluid can potentially cause an infection.

Risk Factors

People often consider pre-seminal fluid to be less of a risk with respect to HIV because the volume of fluid released is generally lower than semen. However, there are numerous factors that can increase that risk.

Pre-seminal Fluid Volume

Some men can produce high amounts of pre-cum. This is especially true after a prolonged period of abstinence, in which males can produce up to 6 milliliters, or roughly 1-1/4 teaspoons, of pre-cum.

HIV Viral Load

An untreated HIV infection can lead to a high viral load. The HIV viral load is a measure of the number of viruses in a sample of blood, ranging from undetectable to well over a million. A higher viral load in the blood corresponds to a higher concentration of viruses in pre-cum.

Anal Sex

The risk of HIV from anal sex is high because rectal tissues are delicate and easily broken. This allows the virus to pass directly into the bloodstream.

At the same time, the rectum has only a single layer of cells overlying tissues that are rich in immune cells called CD4 T cells. These are the very cells that HIV targets and infects. Because of this, even a small volume of fluid may establish an infection.

Sexually Transmitted Infections (STIs)

Some STDs like syphilis cause ulcers that provide HIV easy access into the body. Others like gonorrhea cause inflammation that draws immune cells, including CD4 T-cells, to the site of infection, giving HIV more targets to infect. These factors can raise the risk of infection.

Studies have shown that having gonorrhea or chlamydia increases your risk of getting HIV by 800 percent.

HIV Shedding

An STI or similar infection can also increase the number of viruses in semen through a process known as viral shedding. The inflammation caused by the infection can speed up the production of the HIV virus in the tissues of the genitals. The viruses are then "shed" into semen and pre-seminal fluid, increasing their infectiousness.

Even people with an undetectable viral load in the blood can have detectable HIV in semen and pre-seminal fluid as a result of shedding.

Recap

Even though the concentration of HIV in the pre-seminal fluid is lower than in semen, certain factors can increase the risk of HIV, including having a high viral load, having an STI, or engaging in anal sex.

Weighing the Risks

In the end, there is no hard and fast rule as to "how much" or "how little" pre-seminal fluid is needed to cause an HIV infection. There are many variables that play a role in determining a person's risk.

While pulling out before ejaculation may reduce the chances of transmission, it does not eliminate it. For example, one study showed that condomless receptive anal sex with ejaculation was found to be approximately twice as risky as condomless receptive unprotected anal intercourse with withdrawal. While the risk of contracting HIV is lower with withdrawal, there is definitely a risk.

If you don't use external or internal condoms consistently, there are ways to reduce the risk of getting HIV or passing it to others:

Recap

The current evidence suggests that pre-seminal fluid can transmit HIV. To reduce the risk of infection, you can take the HIV prevention pill (PrEP) if you don't have HIV, or start antiretroviral therapy and maintain an undetectable viral load if you do.

Summary

Pulling out before ejaculation does not prevent the transmission of HIV. Pre-seminal fluid contains roughly as much HIV as semen. And, even though fluid volumes tend to be smaller, there may be enough to cause an infection. Factors like a high viral load, having an STI, or engaging in anal sex can increase the risk.

If you don't use external or internal condoms consistently, consider starting pre-exposure (PrEP) to reduce your risk of acquiring the virus. If you have HIV, you can substantially reduce the risk of transmission by consistently using antiretroviral therapy and maintaining an undetectable viral load.

A Word From Verywell

If you are concerned that you've been exposed to HIV, don't wait to get tested. Instead, head to your nearest clinic to request post-exposure prophylaxis (PEP). This is a strategy in which antiretroviral drugs are taken for 28 days after exposure to avoid an HIV infection.

PEP needs to be started no later than 72 hours after possible exposure, ideally within 48 hours. A rapid HIV test is given beforehand to ensure you don't have HIV. Another HIV test is given afterward to confirm whether the infection has been prevented.

Frequently Asked Questions

  • How do you help prevent HIV transmission?

    There are several key ways to avoid HIV, including limiting your number of sex partners, using external or internal condoms every time you have sex, and avoiding sharing needles. If you are HIV-positive, it is important to take your medications correctly to keep your viral load undetectable. Your partner can also take PrEP to reduce their risk of getting HIV.

  • How is HIV treated?

    HIV is treated with antiretroviral drugs. Lifestyle changes can also keep you strong and help you avoid infection. This includes quitting cigarettes, eating a healthy diet, exercising regularly, and keeping up with routine HIV checkups.

  • What are the symptoms of HIV?

    The symptoms of HIV vary by stage.

    • In Stage 1 (acute HIV), symptoms may include fever, chills, headache, night sweats, sore throat, fatigue, and swollen lymph nodes.
    • In Stage 2 (chronic HIV), there may be few, if any, notable symptoms.
    • In stage 3 (AIDS), symptoms can be severe and include wasting, dementia, and potentially life-threatening opportunistic infections.
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