[Question #1125] Risk Assessment/Broken Condom

96 months ago

Hello Doctor(s),

Had an episode with a CSW (online profile) of color (early 20s, light skinned/African American or Latina) in the suburbs of a major east coast city. While protection was used, unfortunately there was a complete condom rupture and full exposure , anywhere from 30 seconds to a minute and a half before I realized what happened. I believe this may have been caused by lubrication drying up, but it was shocking nonetheless since that hadn't occurred to me in many years. After I withdrew, I rubbed anti bacterial sanitizer gel all over my penis out of panic. We then proceeded with a new condom to finish. She tried to assure me that she is disease free and gets tested, and indicated that she herself would be thinking about what happened. I did assure her of my status. I note that she provided and insisted on condom use, so I know it is her general practice to practice safe sex, There was no visible signs of any lesions on her and no signs of drug use that I could tell.

I understand from my online research that HIV, while theoretically possible, would probably be low risk given heterosexual transmission rates in one time, somewhat brief exposures. I do understand that geography and demographics can play a part in the overall assessment, but let me know if you agree that this was low risk for HIV, or if you think PEP, rapid testing etc is in order. It would seem that other STIs would be a bigger concern, but would you think the risk is still generally somewhat low for chlamydia, herpes, gonorrhea etc given the type of exposure described? This was less than 24 hours ago so I know it's too early to test, but I am curious to see what you think of the STI risk and next steps, if any. I'm trying not to worry too much, but obviously can't help it.

Thanks or your help.

H. Hunter Handsfield, MD

96 months ago

Welcome to the forum. Thanks for your question. My first reaction is to congratulate you for using a condom in this situation. Condoms can fail, but in general consistent condom users are at low risk and it's a mark of sexual wisdom. Second, thanks for researching the issues before asking your question; it sounds like you found mostly reliable information. In particular, I agree exactly with your statements at the start of paragraph 2.

It is very unlikely you acqured HIV (and would recommend against PEP), and the risk was low for STDs in general. First, among people at high risk for STDs, including most sex workers, at any point in time most are not infected. Second, STDs in general are transmitted inefficiently -- i.e. most exposure don't result in transmission. For HIV, the risk from a single episode of vaginal sex, if the woman is infected, has been calculated to be around once for every 2,000 events. Third, most people don't lie about HIV/STD status when asked directly. Finally, it sounds like your partner is on at relatively low risk compared with some sex workers -- consistent condom use, perhaps gets tested regularly, etc.

So the risk was not zero, but low enough that I consider HIV/STD testing as optional. In general, for persons at risk (multiple partners, commercial sex, etc) without symptoms of STD to be tested periodically -- e.g. every 3 months to yearly, depending on actual frequency of exposure -- rather than being tested after any single exposure. On that basis, if you haven't been tested in the past several months, this might be a good time, while it's on your mind; but not so much because of this particular event. However, if you link testing to this exposure, a urine or urethral swab specimen for gonorrhea and chlamydia will be valid any time about 4 or more days after the exposure; HIV testing can be done at 4+ weeks with a 4th generation (combo) test or 6+ weeks with an antibody-only blood test; and 6+ weeks for syphilis testing.

You don't say whether you have a regular partner you are concerned about. But to put this in personal terms, if somehow I were in your situation, I would wait about 10 days to assure I did not develop symptoms like urethral discharge or penile blisters/sores. If not, and if chlamydia/gonorrhea testing were negative, I would resume sex with my wife without worry -- even though I probably would also seek HIV and syphilis testing at 6 weeks.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD

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96 months ago

Thank you so much Dr. Handsfield. To answer your last question, I do have a regular partner I am concerned with so this situation is obviously disappointing to me for several reasons. I will certainly take action should symptoms occur. If for peace of mind I do decide to test for this one encounter, do you think 2 or 3 days post exposure for gonorrhea and chlamydia would be reliable enough (just to hasten the process)? Lastly, I assume that for Herpes, it would be prudent for now to check for those symptoms in that 10 day window and, assuming no symptoms develop, just test for that as part of my regular periodic testing and not necessarily for this particular encounter. Please let me know if that assumption isn't correct. I think that covers it. Take care.

H. Hunter Handsfield, MD

96 months ago

2-3 days is fine for gonorrhea but maybe a bit early for chlamydia. There's been no research on time to positive tests, but chlamydia is slow growing and it might take 4-5 days for a reliably negative test result.

Exactly right about HSV testing: Maybe OK as a routine screen (but probably only once, wouldn't even do it once a year); but not on account of this particular event. Your chance of having genital herpes is no higher from this event than it would have been without it.

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96 months ago

Hello Dr. Handsfield,

Just as an update, I did get tested for chlamydia and gonorrhea 4 days after the incident (actually about 3 1/2 days -- morning of the 4th day) and the results came back negative ("Not Detected"). At this point there are no signs of a discharge, blisters or sores, but I will continue to monitor. I'll let you know if there are any other developments. Thanks again for your advice and reassurance.