[Question #10061] STI/HIV risk from CSW—PEP needed?

26 months ago

I visited a high volume massage parlor and had the CSW mainly provide a handjob and put my penis between her breasts. However, during the course of the session, she licked my testicles while providing the HJ and briefly provided unprotected oral sex with some tooth scraping.

After returning to vigorous (almost painful) hand stimulation, she took off her panties and sat on my legs. She then attempted to insert my unprotected penis, to which I pushed back. There is a chance the head of my penis rubbed against her vagina but I’m not sure. She then continued the HJ but thrusting her pelvis toward me, which her vagina was rubbing against my testicles and shaft until I finished.

Risk of HIV? HSV 1/2? HPV? Should I take PEP? Clock is ticking

H. Hunter Handsfield, MD

26 months ago

Welcome back to the forum. Thanks for your continued confidence in our services. FYI, I scanned your discussion with Terri four months ago and agree with her replies and advice. Did you follow up with an HSV Western blot?

The event you describe was little or no risk -- probably zero risk -- for any and all STDs. No STDs or HIV are ever transmitted by hand-genital contact (no matter how vigorous), or by penile contact with skin (including breasts). Brief oral sex carries some risk, but low for all STDs and none for HIV. (Oral sex is much safer then vaginal or anal sex.) And the brevity of the contact further lowers any risk. A bit of "tooth scraping" is risk free, assuming no overt bite or tooth injury with bleeding. Finally, the very brief penile contact with your partner's vaginal area, without significant penetration, also carries little ir any risk. To your specific questions:

HIV? No risk, definitely not high enough to warrant PEP. Statistically it is unlikely a partner like yours has HIV; and when a female partner has HIV, even with entirely unprotected vaginal sex to completion, the average risk to her male parter is once for ever 2,500 exposures. Nobody has ever been known to be infected from the kinds of exposure you experienced. Honestly, I don't even advise HIV testing, unless you feel a negative test result will help relieve your fears, beyond what I can say.

HSV? Partly discussed with Terri. If you have HSV2, which I agree is possible if not confirmed by the test result you reported to her, you are immune to catching it again. If you had the WB and the results was negative for HSV2, you're still at very little risk from the events described. With vaginal sex to completion, IF your partner has HSV2, your risk would have been around one chance in a thousand of being infected. Considering the superficial nature of the exposures and the low chance she had active HSV2, your risk was exceedingly low. Your risk of HSV1 also was very low and only from the brief oral sex exposure.

HPV? My main response is that it doesn't matter. As a sexually active human, you have had HPV, probably more than once, and could still be carrying it. A new exposure of this sort does not significantly elevate your chance any higher than it was before. Anyway, there is no test for HPV in males.

As I said above, I would not recommend PEP. Not only is the risk nil for practical purposes, but there's a downside to PEP you might not have considered. PEP doesn't always work, so HIV testing is required afterward. With PEP, the window period clock starts with the last dose of anti-HIV drug, so you'd be in the situation of wondering and perhaps worrying for at least 10 weeks -- i.e. 4 weeks on drug, plus another 6 weeks to conclusive testing. How prepared are you for that much delay? If somehow I were in your situation, I might not even be tested for HIV and would continue unprotected sex with my wife without worry.

You don't mention the three main bacterial STDs. There's slight risk of gonorrhea from the brief oral exposure; and syphilis is transmitted skin-to-skin, so penetration isn't always required. I would suggest you have a syphilis blood test in 6 weeks, and you could consider a urine test for gonorrhea and chlamydia. Here too, the risks are very low, but not quite zero.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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26 months ago

My initial IgG test (from a different exposure) returned an HSV-2 positive value over 6, was followed up with an "Inhibition assay confirmatory test," resulting in score of 8.7 "normal, in range" but an inhibition interoperation of 95.0 H "positive". Is that a WB test, or is the WB test offered by Washington the only WB? To date (almost 6 months after the initial test)--still no lesions or any symptoms that I notice. The only penile change I observed was the appearance of a few darker colored round spots in certain parts of the shaft---but they are not painful and have been there for months. I had one of these prior to the whole HSV diagnosis as well.

HIV/STI Follow Up: (1) Assuming I am HSV-2 positive, I believe I read it increases a risk of HIV. W (2) The CSW also massaged my prostate and put her fingers in my anus slightly before I asked her to stop. Would either of those points change your assessment of risk? (3) What is the threshold for PEP, inservitve sex to completion?

H. Hunter Handsfield, MD

26 months ago

Those HSV2 test results make it likely have HSV2, but still not solid proof. It was not a Western blot. Herpes doesn't cause "darker colored round spots" and herpes lesions never last more than 1-2 weeks. If you have HSV2, it is asymptomatic but still transmissible to sex partners. I'll invite Terri to take a look at this information and provide her own guidance about next steps, including how to arrange for WB if you wish to do so.

1) Having HSV2 roughly doubles the chance of HIV infection if sexually exposed. "Double" sounds like a lot, but it usually makes little difference. For example, if the risk of HIV is say one chance in a million -- like for many straight men in Europe or North America -- double risk makes it one in 500,000, still zero for practical purposes.

2) Hand-genital contact, including anal fingering, rarely if ever transmits HIV or other STDs. This doesn't change my evaluation or advice.

3) There is no rigid threshold for PEP; it depends on several details of risk analysis and every case is different. Unprotected anal or vaginal intercourse is one consideration, but it also depends on the likelihood one's partner has HIV.

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Terri Warren, RN, Nurse Practitioner

26 months ago

Hi, thanks for the invitation to pop in on this conversation.

We've seen positive inhibition assays both confirmed and not confirmed by western blot. The combination of a positive IgG at an index value of > 6 and positive inhibition assay do suggest that you have HSV 2, but for greater certainty, you could do the western blot. I would be happy to work with you on the blot if you are interested at westoverheights.com. Your call.

In the meanwhile, be looking for symptoms in the entire boxer shorts area. Mostly, you would be looking for blistering sores or ulceration or scabs. Little red bumps are very common in this area and are likely NOT herpes.

Terri

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25 months ago

Thanks to both of you for thorough and helpful responses. I am satisfied with the PEP guidance and have nothing more to ask on that subject—thank you again.

But, with the last two responses from Dr HHH and Terri—I do have some lingering uncertainty. From what I gather, the infrequent visits to massage/CSWs are low risk for STDs/HIV given the mostly hand or oral actions. Is it fair to say that protected vaginal and oral sex encounters with female CSW would also be low risk? I think I saw 1 in 1000 as the risk of exposure?

Leading into my second question. If I do indeed have HSV-2 (WB test to confirm) I can’t understand how. Since my last negative IgG test, I’ve only had 1 mostly protected vaginal sex encounter with a. CSW—rest were oral or hand services and unprotected vaginal, oral with same SO for 4 years. Far as I know, she is negative. I don’t know how I can have that talk with her either.

H. Hunter Handsfield, MD

25 months ago

Condom protected sex is always low risk -- but not zero risk, especially for HPV and syphilis (and HSV2 from vaginal sex, if you're not already infected). The chance of HIV from any one exposure in these circumstances would be under one in many thousands.

Your mystery about possibly having HIV isn't necessarily mysterious at all. Depending on factors that we don't know about you (where you live, race/ethnicity, etc), 15-25% of US adults have HSV2. You could well have acquired it assuming you've had several sex partners, apart from CSW events. Among HSV2 infected people who didn't have an obvious symptomatic infection at the outset, most do not know when and from who they were infected. Once again I (and Terri) would advise you to arrange for Western blot testing.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful.

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