[Question #10465] Qu. For Mr.Handsfield- HIV scare
22 months ago
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Good afternoon Mr.Handfield. I am male 42 years of age. About 28 hours ago I visited a massage parlour in Korea (Busan area) and had unprotected vaginal sex for 1-2 minutes (with lady aged about 50). Terrible decision. HIV rates are pretty low in Korea (less than 20,000 estimated cases overall) but I’m scared. She didn’t offer a condom- (a few months ago she did the same- at that time I refrained). My friends have mentioned similar ‘no condom use’ amongst some (mostly older) massage workers here. Many other International sex workers here in Korea do insist on condoms, and other Korean CSW do the same. I visited the massage parlour
Today to speak with the lady, but she wasn’t there - her colleague said ‘don’t worry’ but was evasive about blood tests.
Should I should visit Seoul tomorrow morning (52 hours post exposure) and get PEP? It’s about 5 hours drive away and I would need to skip work (cost is high- close to 1000 dollars). Having a PCR test in 12 days might be better for my mental health! If you were in my position, what would you do? Thank you kindly for your time.
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Edward W. Hook M.D.
22 months ago
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Welcome to our Forum. Clients are no permitted to request whether Dr. Handsfield or I answer their questions. Dr. Handsfield and I have worked together for over 40 years and have never differed in the facts of our replies although out verbal styles differ. On this occasion your question happened to be assigned to me.
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Whether or not to seek PEP is a personal choice but I'll be glad to provide you with some relevant information.
Your risk: Most commercial sex workers do not have STIs including HIV and most single exposures do not result in acquisition of infection. Further, s you point out, HIV is relatively uncommon in Korea. The likelihood of acquiring HIV from a single vaginal exposure with an untreated HIV infected woman is estimated to be less than 1 infection per 2500 encounter- in other words, statistically there is a more than 99.9% chance that you would NOT be infected, IF she had untreated HIV. The likelihood that you would be infected is very, very low.
PEP does reduce risk for HIV, being more effective the sooner it is started and having little effect more than 72 hours after an encounter. As a rule the drugs are relatively well tolerated however, PEP would delay that time it would take to provide you information on whether or not you got infected, adding 30 days ( the amount of time you would be taking PEP) to the time until results would be reliable.
As you point out, at any time more than days after an encounter HIV PCR tests are felt to provide reliable information about infection status (many experts still recommend testing using a 4th generation, combination HIV antigen/antibody test 6 weeks after PCR testing but we have never seen or heard of anyone with a negative test at 11 or more days who went on to become positive)
Those are the facts. In my opinion, your risk is close to zero and I would opt for testing rather than taking PEP but that is a personal decision that you'll have to make. I hope that the information I have provided is helpful to you. EWH
22 months ago
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Thank you Dr. Hook. Your time is much appreciated. I stated that the CSW I met seems to never use condoms (elevating my concerns). And I have a theory. Dr. Handsfield and yourself often said that most CSWs do not have HIV (maybe only around 1%) so the likelihood of contracting HIV from one exposure is 1/100 *1/2500- almost 1 in 250,000-encouraging odds.
BUT- what If there was a sub-category of CSWs who regularly have sex without protection (let’s say 5 to 10%). Then, this minority of CSWs would be responsible for infecting all of the male clients.
Thus, the notion that only 1 in 100 CSW has HIV could be misleading since the suspect group in question should be calculated as a different percentage (in the same way that African American women are often considered a different HIV risk to Caucasian women). If a man was to have sex with a CSW from the ‘condom abstainers’ group he would be at massively greater risk. May I ask your thoughts on this idea?
Finally, do you feel that 1/2500 or 1/1000 (both V. low but still markedly different) is a better estimate for risk of infection for men (insertive penile with HIV positive woman)? I have seen both figures here. Thank you again! You do wonderful work.
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Edward W. Hook M.D.
22 months ago
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I appreciate that you were thinking analytically about this. You were right that amongst commercial sex workers, some sub groups are more likely to have HIV than others. Among the groups who are more likely to have HIV are those who typically do not use condoms, those who also use inject drugs, and those whose clients tend to be higher risk such CSWs who are working on the street as opposed to those who are working in establishments such as brothels or as masseuses. Even in those situations, as a generalization. the odds that your partner would have HIV infection is substantially less than one in 100.
The one in 2500 figure is an estimate for which there are factors which can increase or decrease the likelihood. Some of those factors have been studied, mother said that. For instance, we know that uncircumcised men are somewhat more likely to become infected than men who are circumcised thus, for those who one and 1000 figure might be better. On the other hand, there are unstudied variables such as the use of lubricants, the duration of intercourse, etc. which are in studied and contribute to the variability in the estimate. No matter what, however, the risk is certainly less than one and 1000 making it a 99.9% probability that you were not infected in the unlikely circumstances your partner had HIV. EWH
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