[Question #10577] Unprotected vaginal sex when I had Mycoplasma genitalium

21 months ago

So I'm in Germany and I met a sex worker from Colombia, South America. She said she was just visiting Germany for 1 month so she is not from here. So long story short, the condom broke while I had sex and I think I was exposed for around 2 or 3 minutes.

After this, I freaked out and asked her if she was tested. She said she hasn't had a test for a few years now but she said she always uses condoms. But I have to assume the worst in this case.

I went to the hospital immediately, but they recommended against PEP because it was just vaginal sex and the risk is quite low. So I agreed and did not ask for PEP. But I did a full STD test anyway and found out that I have an existing Mycoplasma genitalium infection, maybe from some other sexual encounter.

So my question is,

1) Assuming I had asymptomatic Mycoplasma genitalium for a few weeks or months already, and I was exposed to this potentially HIV positive person, was it a mistake not to take PEP? Is the risk still considered low when I had an existing Mycoplasma genitalium infection?

2) When can I take an HIV test and know for sure if I'm infected or not from this encounter?

21 months ago

Thanks a lot for all the help

H. Hunter Handsfield, MD

21 months ago

Welcome to the forum. Thank you for your confidence in our services.

Going first to your two numbered questions, which indicate that your main concern is HIV:

1) I agree with your hospital doctor(s) -- that the risk of HIV was too low to warrant PEP. Your Mycoplasma genitalium infection doesn't change that; there are no data to suggest that M. genitalium elevates the risk of HIV if exposed to it. And the frequency of HIV is extremely low in Western Europe, including female sex workers -- and to my knowledge also is not common in sex workers from South America. In other words, I don't think you should "assume the worst".

2) Nearly conclusive HIV testing (98% reliability) is available with the standard antigen-antibody (AgAb, "4th generation") HIV blood tests 4 weeks after exposure, and 100% certainty at 6 weeks. Standard practices and recommendations may differ in Germany, however; it would be reasonable to follow whatever advice you were given by your hospital doctors. In any case, even if your partner were known to have HIV, your risk from a single unprotected vaginal sex exposure is estimated to be around one chance in 2,500 -- so you definitely can expect to test negative.

The other question here is whether your M. genitalium infection needs treatment. Opinions on this vary, but most experts -- and especially relevant, the official European Union guidelines on M genitalium -- would advise treatment to prevent future nongonococcal urethritis (NGU) and reduce the risk of transmission to your future sex partner(s). Treatment isn't necessarily straightforward: the ideal treatment depends on whether your particular strain is susceptible or resistant to azithromycin. If resistant, or if resistance testing wasn't done, probably you should receive doxycycline for a week, followed by another week of treatment with moxifloxacin. However, these guidelines also are evolving rapidly. It would be wise to see a doctor or clinic with strong expertise in infectious diseases and/or STIs.

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

HHH, MD

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21 months ago

Hello Dr. HHH,

Thank you so much for the clarification. You're providing such a valuable service for anxious people like me and I'm so grateful for your help.

1) I'm glad to hear the Mgen diagnosis doesn't change anything with regards to HIV transmission. So the doctor at the hospital told me that I can get tested for HIV at 6 weeks, but it might be better to wait for 3 months to be 100% certain. I suppose that's the same timeline the CDC recommends as well? Or does it depend on the type of test?

2) Regarding the Mgen treatment, you're indeed correct that the opinions vary. The doctor here told me that we don't necessarily need to treat it, and we could potentially monitor my symptoms to see if I develop any discomfort, and if so treat it at that point. But they also told me it might be better to treat it anyway for future partner's sake. So I agreed to take the medicine, and I received one single dose of Azithromycin of 1500mg. Is it usually resistant to Azithromycin? I suppose I should get retested after 1 month to check if it's gone? And if not, ask for doxycycline?

Thanks again for your help!

H. Hunter Handsfield, MD

21 months ago

1) Three months for HIV testing is indeed a common recommendation in some settings. Nevertheless, the data are conclusive that the AgAb tests are conclusive by 45 days (which on this forum we round off to 6 weeks); and this is the CDC recommendation as well.

2) Azithromycin alone may work, but in most geographic areas >50% of M. genitalium strains are resistant -- and although I'm not familiar with the situation in Germany, in much of western Europe 70% or more are resistant. And even when sensitive, advice in the US (e.g. CDC) is to first treat with a week of doxycycline, and only then administer azithromycin (or moxifloxacin). This approach is consistent with EU guidelines: https://pubmed.ncbi.nlm.nih.gov/35182080/

And yes, I would advise test of cure, especially if you do not receive treatment other than azithromycin. (However, it could be that your strain already has been tested and known to be susceptible to azithro. Ask your doctor.)

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21 months ago

Thanks again for the clarification. I'm feeling quite anxious again and I had a few more questions,

1) I read on the CDC page (https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm) that Mgen apparently increases the risk of acquiring HIV. Do you know by how much? And I read on another website that it increases the risk 7-fold. Also I am uncircumcised so I guess that doubles my risk as well. So I was quite worried if all this adds up to me having a considerable risk.

2) It's been about a week now since the exposure. I heard HIV probably will cause some symptoms by the 2-4 week mark. Will everyone get these symptoms? How common is this initial symptomatic response? What kind of symptoms should I keep an eye out for?

Thanks again for all the help!

H. Hunter Handsfield, MD

21 months ago

1) Almost all STIs raise the risk of HIV if sexually exposed to it. There actually are few data on this for M. genitalium, but because gonorrhea and chlamydia do so, it is assumed that M gen does as well. However, you still have to be exposed to HIV; and even if the risk is doubled by M gen, that doesn't really mean much. If you start with an HIV risk of say one chance in a million, then double risk is still only one in 500,000. Same deal with circumcision status. These factors definitely do NOT "add up to [you] having a considerable risk" for HIV.

2) Symptoms of acute retroviral syndrome (ARS, i.e. new HIV infection) typically start 1-2 weeks after exposure, not 2-4 weeks. And despite your assumption, symptoms are a very poor indicator of new infection. Even typical ARS symptoms (sore throat, swollen lymph nodes, fever, skin rash) usually have other causes; and half of all new HIV infection cause no symptoms at all. I suggest you ignore symptoms entirely and just plan on having an HIV blood test a few weeks after your most recent sexual contact.

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