[Question #11433] Unprotected oral

14 months ago

HI. went to a massage parlor and ended up having unprotected oral, which lasted a few minutes, and protected vaginal intercourse with a Vietnamese CSW. the whole thing lasted maybe 10 minutes, with me being mortified with how things were progressing but unable to stop. there was no visible breakage of the condom. The CSW insisted I kiss her on the lips as I was leaving and i managed a quick peck with mouth closed.

Was really worried about any STD's, as I live with my partner, and visited a STD clinic the next morning, around 18 hours after exposure and proceeded to get PEP (Biktarvy - 50/200/25mg). i was also concerned about Syphilis/Gonorrhea/Chlamydia, and was prescribed Zithromax 4x 250mg (which I took immediately as a single dose of 1000mg, i.e. all 4 pills) and Doxycycline 100mg (to be taken twice daily) - the Doxy prescribed is for a week's regimen so 7 pills.

This is Day 2 of the regimen, and I'm worried about the potential of HIV and STD transmission, especially as I live with my partner and have discontinued sex with her since the day of exposure (2 days ago) but I can't continue to do so anymore. I have even limited kissing her to just her cheeks due to concern of transmitting anything I may have caught through kissing. It will be day 3 tomorrow and I intend to test for Gonorrhea and Chlamydia

1- What is the likelihood of having been exposed to STDs

2- what is the likelihood of me passing on any STD to her, including HIV, through Kissing, unprotected oral and protected sex? to be clear, we always use a condom.

3. Is Biktarvy a good PEP and is there any concern of me passing any HIV to her, while on PEP, or even after the PEP regimen?

4. Is it possible to continue having sexual relations with my partner?

H. Hunter Handsfield, MD

14 months ago

Welcome to the forum. Thank you for your confidence in us.

You overreacted to a very low risk situation. I would have strongly advised against PEP to prevent HIV, for which you were at essentially zero risk. The odds are strong that your massage/sex worker partner does not have HIV; condoms are nearly 100% effective in preventing HIV transmission; and the virus has never been proved to have been transmitted by oral sex, i.e. mouth to penis. The main effect of PEP will be to delay the time until you have a reliable negative HIV test until 3-4 months from now, instead of 4 weeks after the exposure. Are you really prepared to be uncertain that long? Did the prescribing doctor or clinic discuss this aspect? As a matter of policy, we never advise actually stopping treatment -- but you might want to discuss this with your doctor or clinic.

The brief kiss was zero risk for any and all STDs.

I also would have advised against the azithromycin and doxycycline treatments. The risks of gonorrhea, chlamydia and syphilis were not as low as for HIV, but low enough that these treatments really were excessive. That said, at least they won't be harmful. However, there is now no point in testing for any STD, assuming you complete the full 7 days of doxycycline.

Those comments pretty well cover your questions, but to be explicit:

1. Very low risk; see above.

2. Zero for the diseases mentioned. Of course there is never zero risk for things like herpes and HPV, but on the other hand no reliable tests -- and they are unlikely in absence of symptoms.

3. Biktarvy works very well as PEP, but there was no HIV risk to start with and I've discussed the main downside of taking PEP when HIV is very unlikely.

4. There are no 100% guarantees, but the risk to your wife is near zero. If somehow I were in your situation, I would continue unprotected sex with my wife without worry -- even if I had not been taking the antibiotics and Biktarvy. And even without those treatments, I would not have sought testing for any STD.

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

HHH, MD

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14 months ago

Thank you for your response Doctor. The HIV PEP was a means to reduce risk of HIV to zero, should something have slipped through the condom or should the oral have been risky. While I'm on doxy over the 7 days, and having protected sex with my partner, is there a risk I could pass any lingering, albeit embattled, S/G/C cells on to her? Ditto for unprotected vaginal intercourse and unprotected oral intercourse (giving and receiving)?

H. Hunter Handsfield, MD

14 months ago

In the very unlikely chance you actually were infected with S/G/C, the antibiotics have totally aborted them and there is no possibility of infecting your partner. For the same reason it makes no sense for you ever to be tested for them.

I still disagree strongly with your decision to start (or continue) PEP. But that's your business, not mine.

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14 months ago

Apologies, Full message here.

Thank you for your response Doctor Handsfield. It is a privilege to be communicating directly with esteemed individuals such as yourself, Dr Hook and Terri.

The HIV PEP was overboard, but was a means to reduce risk of HIV to zero, should something have slipped through the condom or should the oral have been risky.

14 months ago

My thinking is this - if there was any risk of HIV due to contact at the onset, taking PEP and preventing replication should ensure that this risk is completely dealt with by the end of the PEP; i.e. there is more certainty provided to me, that I will not have any HIV (if by chance I had picked it up) at the end of the PEP regimen, by going on PEP rather than not.

14 months ago

Truth is, this would give me more peace of mind, as opposed to not being on the PEP and waiting 4 weeks to get a test done.

Nevertheless, your comments have made me breathe a lot easier.

Thank you for the clarity and advice.

H. Hunter Handsfield, MD

14 months ago

I indeed wish you "more peace of mind", but to me it doesn't seem worth the inconvenience -- not to mention the small risk of serious side effects from the PEP drugs. But thanks for the thanks. I'm glad to have helped! Best wishes and stay safe.

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