Hi,

Had unprotected sex with a csw.  Within 8 hours, I noticed pain/tenderness in my right lower abdominal area when I was drying off after showering (few inches to the right and below the belly button).  It was a bit red but I did not pay much attention to it.

About 24-36 hours later I took another shower and the pain was there when I rubbed the towel there.  It now looked like red inflamed skin with white pustule like eruptions that were separate (kind of like folliculitis because there was a hair in the center of most of the white pustules).

48 hours later, I did a close examination and found numerous white pustules in my pubic area (beneath the pubic hair) and slightly on the top portion of my penis.  Again, it seemed like this was around hair follicles and looked similar to what was on my abdomen.  I put neosporin on the affected parts and went to sleep.  When I woke up, the white pustules around the pubic area had gone away and only thing remaining was the redness.  The area on the abdomen still has the white pustules and redness, but doesnt really feel that tender as before.

Could this be herpes or some other STI?

Would herpes sores appear where there is no hair (or does that not matter).  I do have a lot of body hair.

Where exactly would a genital HSV infection appear if it was first time (or recurrent)?

What HSV test can I take and when to rule in/out infection?

Almost certainly this isn't herpes. First, neither herpes nor any other infection can start to cause symptoms after 8 hours. Onset as soon as 36 hours may be possible, but symptoms of newly acquired herpes generally start 3-5 days after exposure, on rare occasions as long as three weeks. Second, the location is wrong:  in general, for infection to take hold HSV must be massaged into the exposed tissues, so initial genital lesions usually are at sites of maximum friction during sex -- the penis in men and the vaginal opening and labia in women. Third, hairs emanating from many or most lesions is evidence against hereps but typical of folliculitis (as it seems you already know). Finally, herpes lesions cannot clear up in less than 7-10 days, and also would not improve overnight with antibiotic ointment like neosporin; this aspect also favors folliculitis.

That pretty well covers your specific questions, but to assure no misundrstanding:

1) Almost certainly not herpes, and your description also doesn't fit any other STI. Conceivably your CSW partner is colonized with staph or strep and you caught it, but most likely it's just a coincidence in timing.

2,3) See my comments above. Initial herpes could appear in a hair-bearing area, but only if directly exposed. Don't confuse lesion location for initial versus recurrent genital herpes. Later outbreaks generally are within the "boxer shorts" distribution, i.e. including hairy areas like the pubic area, buttocks, upper thighs, etc.

4) I recommend against HSV testing. A blood test would be the only option, but the standard tests are so often wrong or misleading that expert consensus -- including this forum and advice by CDC -- is for testing only when infection is quite likely because of typical symptoms (which you do not have) or repeated sex with a known infected partner. However, having had unprotected sex with a CSW, you might consider a urine test for gonorrhea and chlamydia (valid any time 4-5 days or more after exposure) and, after a few weeks, blood tests for syphilis and HIV.

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

HHH, MD

Terri

Hi Dr. Handsfield,

I am very concerned now as I went for several HIV tests at the 2 week mark including HIV Duo and HIV RNA detection.  Normally the Duo test result is available within 24 hours, but the lab told me that while the report is ready, it needs to be approved by the doctor.  I am very worried that the result is reactive or borderline reactive, otherwise why would they need to have the doctor review it?

I am now thinking the rash (which is still faintly there 2 weeks later) may have been due to HIV even though it happened so quickly?  I did not really have any other symptoms except I was very tired/sleepy for the first week and felt discomfort in the lymph node areas on the back of my neck right side but did not notice any lumps.

It seems the protocol at the lab is that if its non-reactive, they automatically issue the results, and if there is some issue, then the doctor needs to look and decide whether to re-test or issue the report.  Just the fact that it now requires doctor approval has got me very worried.  Looks like I was barking up the wrong tree being worried about HSV when HIV should have been the main concern.

Thanks

You still can expect a negative HIV test result. Try not to worry while you wait.

Hi Dr. Handsfield,

You were right - I was worrying for no reason regarding the delay.  I received a non-reactive HIV Duo test result (result was 0.25 with cutoff being 1.0) shortly after my earlier message to you, and then later in the day received not detectable results for the following tests: (1) HIV 2 RT Qualitiative (Real Time PCR) with sensitivity of 100IU/ml, (2) HIV 1 RNA Detection Qualitative by Taqman with sensitivity of 20 copies/ml, and (3) HIV P-24 Antigen Detection (this was part of the panel, but seems useless since DUO tests for antigen anyway).

But I'm wondering if I should be relieved?  Are the above tests at 14 days good enough to rule out HIV or do I still need to test?

Also, I did take 2.5 grams Azithromycin and 800 mg Cefixime a few days after the incident, so assuming I am in the clear for bacterial STI's.  I was going to do the following tests at the 6 week mark and would appreciate your views on any changes/additions to the tests or timing:  HBsAG, Anti HCV Total Antibody, RPR/VDRL.

Thanks!

Of course you "should be relieved". There is no realistic chance e you have HIV. Ninety-eight percent reliability does non mean a 2% chance you have HIV. You had an exposure that carried no more than one chance in 250,000 of HIV infection (assuming 1% risk your partner had HIV plus average risk for unprotected vaginal sex 1 in 2,500); with a 98% reliable test, the possibility you have HIV would be around 1 chance in 12.5 million, which is zero for all practical purposes. So you can feel free to skip the 4 week test if you wish.

The antibiotic combination is 100% protective against syphilis, gonorrhea and chlamydia. There is no point at testing at 6 weeks or any other time. And for sure nobody needs hepatitis B or C testing after a single heterosexual exposure. The risk was zero for both viruses. (If you've been vaccinated against HBV, you can be even more certain. And contrary to popular believe, HCV is not heterosexually transmitted at all. The only proved sexual transmission risk is between males with potentially traumatic rectal exposures.)

That concludes this thread. I hope the discussion has been useful. in the event of future sexual events, I would advise you try to gain better understanding of STI/HIV risks and not go so far overboard with testing or self treatment!