[Question #11092] HIV/STI risk after Bangkok encounter. Anxious and nervous.

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17 months ago
While travelling I visited a parlour in Bangkok for a body to body massage. Really regret this but here's what happened:
-After massage we had penetrative sex (condom on)
-Changed positions to "titfucking",condom on. Started slipping and she took it off. She didnt wash up and just added lube to her breasts and continued "t*tf*ck"
-Gave me a handjob 
-I washed lube off my penis and put on new condom
-She gave me oral and proceded with vaginal intercourse till the end (both condom on)

Concerns
-Her breast and hands had vaginal fluids while doing unprotected t*tf*ck and handjob. So the entire encounter was not fully protected. How risky is it to contract HIV/STI's this way?
-I read that HIV transmission is from vaginal fluids entering the urethra, which would happen during "t*tf*ck" and handjob?
-this was 24h ago. should I get PEP right away?

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H. Hunter Handsfield, MD
17 months ago
Welcome to the forum. Thank you for your confidence in our services.

Neither HIV nor any other STIs are transmitted by "body to body massage". From that aspect, you don't need testing for anything. Even condom protected, the main risk here was for the vaginal sex. Your risk still was low, but nevertheless higher than the other contacts you describe. To your specific "Concerns":

- "Her breast and hands had vaginal fluids...."  Still no risk. Not enough STI bacteria and viruses can be carried in this fashion to cause new infection. With rare exceptions, penetrating sex is required for STI transmission.

-  "I read that HIV transmission is from vaginal fluids entering the urethra...." That's true (as well as contact with the penile surface in uncircumcised men). But the amount of virus matters tremendously:  large amounts of virus are required, and must have contact with specialized cells susceptible to the virus. With entirely unprotected vaginal sex to completion (several minutes) with an infected female, the average risk for her male partner is one chance in 2,500. It's zero, or close to it, for the kinds of contact you describe. As I said above, your HIV risk was higher on account of the condom protected vaginal sex than with any other aspect of this exposure.

- "should I get PEP...?" PEP decisions always must be made by local providers familiar with the epidemiology and risks in the immediate environment. If a Bangkok clinic or HIV specialist has information that partners like yours are especially likely to have untreated HIV, perhaps they would advise PEP even given the very low risk of the event. Most likely they would not advise it if they understand the details of the exposure. But we do not provide medical are and not in a position on this forum to make specific recommendations from this distance.

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

HHH, MD
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17 months ago
Thank you for your insight. Unfortunately I am not in Bangkok and therefore do no have access to local clinics. You mentioned 1/2500 for unprotected sex, what are the chances for protected? Also I read that PEP has irriversible side effects like bone density loss and some loss in kidney function. Is that true? Based on my situation do you recommend me taking PEP?
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17 months ago
I forgot to mention as well I am uncircumcised. Not sure if relevant.
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H. Hunter Handsfield, MD
17 months ago
Being uncircumcised makes no difference in my assessment of your risk. I have no additional advice about PEP; as I said above, "we do not provide medical are and not in a position on this forum to make specific recommendations from this distance." I also said that if I were in your situation, I would not do it. In any case, PEP has no benefit when started more than 72 hours after exposure, so at this point it might be too late.
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17 months ago
Noted on PEP. I have actually consulted a doctor and he too said my risk was low. He did give me the option to get PEP and I have taken a dose yesterday (52 hours from exposure). The doctor did a baseline blood/liver/kidney test as well yesterday and today it showed that everything was normal and I have mild leucopenia. My WBC count showed 3.4 x 10^9/L [normal (4-10)]. Does this indicate that HIV is already in my system or is blood drawn 2 days after exposure be too early to indicate anything? I am considering stopping PEP due to the side effects if the WBC count does not mean anything. Also, while travelling a friend of mine who I was with most of the time had a cough and flu. (not sure if this means anything regarding WBC count)
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H. Hunter Handsfield, MD
17 months ago
No, it's much too soon for HIV to affect your blood count. I doubt the results have anything to do with your friend's "cough and flu", but perhaps this is something to discuss with your doctor. 

Final comment about PEP:  Are you prepared to remain uncertain about having HIV for 3 months instead of a month or sooner? With PEP, the timeline for testing to confirm no HIV infection starts with the last dose of drug, which is 4 weeks away; and most experts would then advise an AgAb test (4th generation) 6 weeks later as conclusive. If not on PEP, you can have a conclusive negative RNA ("viral load") test 2 weeks after the exposure, or an AgAb test at 6 weeks. Many persons at risk and many physicians don't think about this issue in deciding about PEP.

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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