Recently had a high-risk exposure to HIV and am curious about your thoughts. A week ago, I (male) had sexual intercourse with a stripper who, when asked after if she was HIV positive, would not give me a straight answer and her response was concerning.

We did deep kissing, both gave oral sex to the other and then had brief vaginal intercourse. The oral sex was unprotected and the vaginal sex was protected, however the condom only covered maybe the top half of the penis (slid off somewhat due to loss of erection). I am circumcised.

After the incident, I noticed a small scratch (no blood or open wound) on the side of the tip of my penis (this was covered during the vaginal sex) and several small red bumps (not bleeding or open) near the base of my penis. I believe both of these abrasions came from rough oral sex with her. It is likely that her vagina touched the small red bumps at the base of my penis.

There were no evident wounds or bleeding on/around her vagina or in our mouths. I started taking pep ~68 hours after the exposure.

How concerned should I be? I suspect she may have been HIV+ given her failure to respond directly to my question but am not certain. Thank you in advance for your help.

IF she was infected, there remains a greater than 99.9% chance that you would acquire HIV.  The risk for acquisition of HIV is less than 1 infection per 1000 exposures from unprotected vaginal sex with an infected partner; the risk for unprotected oral sex on an infected woman is less than 1 in 10,000 and there are no proven cases in which HIV has been acquired from receipt of unprotected fellatio.  The scratch on your penis in no way changes these probabilities.  

Your starting PEP further reduces any risk there might have been.

At this time, the likelihood that you acquired HIV is very, very low- you do not know for sure that she had untreated HIV (FYI, if she had HIV and was on effective therapy, she would not be infectious to sexual partners) and if she did, the risk is very, very low.  At this time, you need to plan to test for HIV at 4-6 weeks after you complete your PEP.  Results at that time will be definitive.  In addition, I suggest you check for the far more common bacterial STIs, gonorrhea and chlamydial at your genital and oral sites at this time (PrEP{ does not prevent bacterial STIs.  Results of STIs at this time will be reliable.

I hope this information is helpful.  Your risk is very low.  EWH

Thank you very much for your response, this is very helpful. A few follow-ups:

1. I assume you meant "IF she was infected, there remains a greater than 99.9% chance that you would NOT acquire HIV."?

2. Does the fact that a condom covered most of my penis during the vaginal penetration lower the risk of potential infection?

3. Is there a risk of infection if vaginal secretions touched the red bumps on the base of my penis during intercourse?

with respect to pep/testing:

4. does the fact that i started pep ~68 hours after potential exposure reduce the risk of efficacy from your experience?

5. is there any benefit to having an RNA test sooner than 4-6 weeks after completing pep? I have seen mixed information regarding whether an RNA test would be impacted by pep.

6. can a 4th gen duo test at completion of PEP be helpful?

Thank you very much!

2. A condom does not need to cover the entire penis to prevent infection.  As long as the tip of the penis is entirely covered, the condom will do its job

3.   No- surface contact with infected secretions would not put you at risk

4.  The sooner PEP is started the more effective it is.  PEP is not considered effective when started more than 72 hours after an exposure.  68 hours is pretty close to 72 hours

5.  When persons become infected, RNA PCR tests become positive, sometimes before 4-6 weeks after completion of PEP however there are few precise data on this

6.  It would be reassuring but certainly not conclusive

Good questions.  I hope my responses are helpful.  Again, my apologies for the typo.  EWH

Dr. Hook,

Hope all is well. I have a follow-up questions regarding testing and symptoms.

My timeline for exposure/pep/testing is as follows:

Day 0 - Potential exposure

Day 3 - Initiation of PEP (~65 hrs post-exposure)

Day 11 - Onset of mild symptoms (myalgia)

Day 13 - RNA qualitative test (negative)

Day 23 - Worsening of symptoms (malaise, fatigue)

Day 24 - RNA qualitative test (negative)

Day 31 - 4th gen test (negative) & RNA qualitative test (negative)

Day 33 - Same symptoms (malaise, fatigue) persist

I am planning to get a 4th gen test at 4 weeks post-PEP as you recommended. In the meantime, I have the following questions:

1. If my symptoms were caused by HIV, would the 4th gen/RNA tests post-onset of symptoms have been positive? I have been concerned about these persistent symptoms.

2. Is a test at 4 weeks post-PEP conclusive or would I have to return at 6 weeks/3 months for additional testing (assuming test is negative)?

Thank you very much!

1.  The symptoms of the ARS are caused when high levels of HIV virus resulting from recent infection interact with antibodies made in response to that infection.  As a result, in persons with symptoms, IF those symptoms are due to HIV, HIV RNA PCR tests are always positive and after symptoms have been present for a day or so, antibody tests are also always positive.  This would be the case even if a person were taking PEP as you were.  Your multiple negative tests prove that your symptoms are not due to HIV.

2.  Because PEP failures are uncommon recommendations for PEP follow-up tend to be conservative.  While a negative test at 4 weeks is strong evidence that you were not infected, we would still recommend a follow-up test 4-6 weeks after completion of PEP.

Given the persistence of your symptoms, I would recommend looking for other causes.  Persistent symptoms of the sort you describe are non-specific but could be caused by mononucleosis or other viral infections.  I suggest you see your doctor to look for the cause of your persisting symptoms.

As you know we provide up to three responses to each client's questions.  This is my 3rd response.  Therefore this thread will be closed shortly without further responses.  Take care.  EWH