[Question #1062] Hiv PEP after blood exposition fresh cut , mucuos membrane and GNU

49 months ago
I had one week ago an encounter with a female prostitute. I performed on her oral and did fingering with open bleeding cut that I noticed after.  We had vaginal intercourse that was protected at this time I saw also some blood on her buttock but wasnt shure if it was really blood. But the blood was for shure on the condom. So I asked her abouth this and  she acknowledged that she has menstruation.  The condom on my penis after intercourse was on my penis and entire Im foremost 100 percent shure. I check this after all intercourses and the condom looked like in all other cases only with some blood on it.  I removed the condom and washed my hands with a hand disinfectant. It doesnt hurt. Quick after I noticed a fresh wound on my finger it wasnt deep but it was bleeding.  I think the wound happened when she scratch with her nail before fingering her. Im foremost shure that I fingered her with this finger with wound.I asked her if she does only safe sex and if she does thest for hiv because i was a bit concerned.I suggested her to share hiv test results I did last test in june 2016. She refused but then when dismiss she asked if Im healthy I proposed her again to share hiv status. She refused. It was like she asked me to give me impression If I get it i had it already or from someone else. Because the facts on medhelp that fingering and oralsex isnt realrisk I went over. Till two days later I get burning when passing urine, clear fluid from penis also white now 7 days after threatment I went to ER. They proposed me medication for Gonorrhea because its likely symptoms prescribed I had it (urine tests ok, swap test results in days) I took it. I also asked for PEP. The doctor asked virologist he thought that risk is minimal but if the blood is not menstrual the risk can be higher and they dont exlude hiv transmission. So I took PEP 49 hours after "exposition" truvada, prezista, novir. Than I researched again and the consensus of the experts is no risk fingering oral with o
49 months ago
I had one week ago an encounter with a female prostitute. I performed on her oral and did fingering with open bleeding cut that I noticed after.  We had vaginal intercourse that was protected at this time I saw also some blood on her buttock but wasnt shure if it was really blood. But the blood was for shure on the condom. So I asked her abouth this and  she acknowledged that she has menstruation.  The condom on my penis after intercourse was on my penis and entire Im foremost 100 percent shure. I check this after all intercourses and the condom looked like in all other cases only with some blood on it.  I removed the condom and washed my hands with a hand disinfectant. It doesnt hurt. Quick after I noticed a fresh wound on my finger it wasnt deep but it was bleeding.  I think the wound happened when she scratch with her nail before fingering her. Im foremost shure that I fingered her with this finger with wound.I asked her if she does only safe sex and if she does thest for hiv because i was a bit concerned.I suggested her to share hiv test results I did last test in june 2016. She refused but then when dismiss she asked if Im healthy I proposed her again to share hiv status. She refused. It was like she asked me to give me impression If I get it i had it already or from someone else. Because the facts on medhelp that fingering and oralsex isnt realrisk I went over. Till two days later I get burning when passing urine, clear fluid from penis also white now 7 days after threatment I went to ER. They proposed me medication for Gonorrhea because its likely symptoms prescribed I had it (urine tests ok, swap test results in days) I took it. I also asked for PEP. The doctor asked virologist he thought that risk is minimal but if the blood is not menstrual the risk can be higher and they dont exlude hiv transmission. So I took PEP 49 hours after "exposition" truvada, prezista, novir. Than I researched again and the consensus of the experts is no risk fingering oral with or withouth blood. So I have doubt that they prescribed me PEP because of only that but because of the GNU(that isnt approved). when I got GNU from this event the doctor think maybe that I did penetrative sex withouth condom and thats why they prescribed me PEP. What you think should I quit PEP? Thank you.
Edward W. Hook M.D.
Edward W. Hook M.D.
49 months ago

Thanks for your question.  Several additional pieces of information might help me to address your questions.  You mention that you performed oral sex on this partner, masturbated her with a finger that had a cut on it, and had condom protected sex.  None of these events are acts which would put you at risk for HIV and thus are not reasons to take PEP.  My questions which might change my response however include:

1.  How did you get NGU or gonorrhea?  Did she perform oral sex on you?

2.  Can you tell me a bit more about your partner- what country are you in?  Was she a licensed commercial sex worker or not?

I may have further comments when I receive the answers to your questions.  EWH

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49 months ago
thanks mister Hook for your response. I agree that the action is low risk hiv but with the gonorrhea it makes maybe a bit riskier.  I must said to this that i will have today testresult abouth Gonorrhea and I speak with specialist about PEP it can be that its a NGU as the other doctor made threatment because of the symptoms not testresults.. So briefly to you question: 1. She didnt perform oral sex on me I only did on her the condom looked after intercourse not bursted. It can be that I aquired GU 3 days before of this event when another woman (prostitute )performed oralsex withouth condom on me on this encounter vaginal sex was protected and Im shure of this that nothing happened with condom.
 2. Im in switzerland she isnt registered (in switzerland prostitutes didnt need testing for hiv and other stds its voluntary) she works independent and is from origins spaniard or hispanic. I had bad feeling after this encounter because I guess she dont telled me the truth she acted strange and dont wanted sharing hiv results even when she asked me abouth my health and I advised her to test together  or share results she dont wanted. also the fact that she does anal and wrote on the advertising that she is open for foremost everything but she telled me that she performs only penetrative sex with condom. I honestly dont believe her. The window period for this event is two days for the Gonorrhea so maybe the other event five days ago was responsible for this infection also because I had no penile oral sex with her? My concerns are is it worth to take PEP furthermore or are the risk so minimal that the side effects of PEP wouldnt justify this? So far I can live with the side effects.
Edward W. Hook M.D.
Edward W. Hook M.D.
49 months ago
Since to did not have any unprotected sex with your most recent commercial sex worker partner, my suspicion is that you acquired gonorrhea or NGU through receipt of oral sex from from the partner before you had sex with the partner who was menstruating.  If this is the case, whether you had NGU or gonorrhea, the risk that you acquired HIV is very low. the choice of taking PEP is a personal choice but I do not see a medical indication for you to continue based on the exposures that you report.  EWH
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49 months ago
So I had today doctor talk with virologist in universit├Ątsspital z├╝rich. I must mention that the PEP threatment  9 days ago I get in other hospital ER that other doctor advised to get after consulting with virologist that is in vacation now . The junior doctor that I talked today after consulting also chief resident think that I should been on PEP because of the bleeding  from woman that was presumably menstruation blood. He argumented that I can also been infected when I did oral on her or if my fresh wound came in contact with blood of her in the vagina although the wound seemed minuscule.  The gonorrhea and chlamidia swab were negative. Because the medication 8 days ago stopped almost all my symptoms regarding urethritis I mentioned if its possible that the not even two days after I get symptoms (presume that the last woman had infected me with GU) could have no reiable testresult after two days still it is a GU? He thinks that this can be the case but also like you said that the first woman five days before last encounter  would be more likely that I get GU from this and it can be also a NGU that was aquired trough blowjob or mutual masturbation that I did when fingering her.   What you think can it be that GU after you have symptoms can be not tested proper when its early in the beginning like my  case two days?  I clearly said what I read abouth oralsex on women with menstrual blood and also fingering with open wound that no case in the hiv literature is documented that this transmission route get infect an individual. I said also that I would understand the need of PEP when he thought that I have hiv risk on this event because I didnt see that the condom was bursted or they dont thrusted me that I had vaginal protected sex and the GU were an indicator that Im also at risk for Hiv. But he staid on the stance that the fresh wound on the finger and the blood from woman (menstrual or not) and my active oralsex on her ist the key because i get PEP  and not the aquired GU or NGU also considering:  that I saw only blood on the wound that was almost my blood no blood on fingernails and other hand. Also no noticeable blood on my hands after I touched condom a few times to control it after intercourse. when I did wash my hands with strong disinfectant quick after sex it doesnt burned on my fingers. The wound I saw only when i was in bathroom after sex if the wound was before fingering her is not clear. 
What the doctor said at last that its also at some point true that anxious persons are more recommendet to get PEP than others and thats also why I get it at some point. I said that the PEP threatment should be evaluated on medical facts not subjective things because its strong medication and no favour is given on patient when on theoretical exposition is given PEP because the patient will have another situation where he thinks that PEP is needet when its not. He said again the risks on this encounter are low but there is some risk mentioned above and thats why he recommend me to take still PEP. What you think Mr. Dr. Cook abouth the evaluation from the doctor abouth PEP  and abouth the urethrithis? thanks
49 months ago
I wanted to add that no NGU, GU was found on the swap token 9 days ago, all negative includet C. trachomadis N. Gonorrhae, Treponema Pallidum.  Is this test reiable for both encounters (five days before test and two days before test which I took PEP) ?  What I wanted to add is that the symptoms of urethrithis are again back today even If had relief of symptoms quick after threatment still yesterday. Threated in ER nine days before with Ceftriaxon 500 mg together with Azithromycin 1g. What you think should I go the route of the doctor or are they just informed regarding exposure risk hiv infection?
Edward W. Hook M.D.
Edward W. Hook M.D.
49 months ago
Your test results for gonorrhea, chlamydia and syphilis are reliable and there is no need for more testing or treatment.   I suspect that you got NGU from receipt of oral sex with your earlier partner.

As far as the PrEP,discussion, I am going to disagree with the junior doctor you spoke with.   I disagree that there was risk for the exposure you describe, to a partner whose HIV status you do. to know.  There is NO scientific evidence that anyone has ever gotten HIV from performing oral sex on an infected person or from swallowing menstrual or other types of blood.  Similarly there is no evidence that anyone ever got HIV from masturbation of a partner.   Personally, I see no benefit to you from continuing to take PrEP.  On the other hand, it sounds like you may be tolerating it well.  Whether you continue it is up to you and a personal choice.

This is my third reply to you and therefore this thread will be closed later this evening.  If you have additional questions you will need to start a new question. Take care.  EWH
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49 months ago
Thanks Dr. Hook . only this questions I promise.   I think its misunderstanding abouth last woman (prostitute) or I dont understand proper.  I dont know her hiv status and she rejected vigorously to share hiv status or do new tests. I think she is hiding something. You asked me abouth the prostitute if she was licensed and so on. (no she isnt) I presume that hiv risk statement of PEP is also to include the sex partner. It was a randomly encounter I saw this woman the first time and my feeling said to me after a strange conversation after the sex. that she hide something even if she stated she doesnt have any STD or Hiv. Ok its only speculative but maybe an indiz.

"I suspect that you got NGU from receipt of oral sex with your earlier partner."  That meant also the junior doctor but honestly imho It cant be happened this way because the earlier partner was five days before testing for all GU and NGUs so the urine test and swap test must show some infection but its all negative also trichomasis etc. I suppose that I get GU infection on last encounter and it didnt show on the test because it was only two days period (incubation period). Also the fact that after the medications the symptoms disappear almost completely within  a few hours. it makes sense to you? 
In all the hurry I forget to mention that junior doctor (that also spoke with chief doctor) asset the risk for hiv beside the wound and bleeding in my case higher because of my preexisting urethrithis that I had likely from earlier partner. But it doesnt make sense for me because tests doesnt showed positive five days after earlier encounter? And I had safe vaginal sex with condom last encounter that didnt burst so how the risk would be greater? It would make more sense when they think I get infected in last one with GU but testresult not valid because of time and because of that the vaginal fluid and menstrual blood have a higher viral load for hiv than without GU and that my wound would be so be more likely infected.  What you think abouth this? Yes I can handle with PEP at the moment but its for shure not pleasant and I admit I have fear that in a week or so the side effects would increase but I have more fear to quit because correlation of GU and hiv. Thank you very much Mr. Hook. When I have other questions I will start other thread.