[Question #12192] Encounters with CSW's, risk assessment

9 months ago

I have some questions regarding recent sexual encounters I had with CSW’s regarding my risk profile. I am a male.

Over about the course of a 10 days, ending about a week ago, I saw 5 total female CSW’s in another country. These were expensive escorts, by appointment, and the agency lists their latest STD testing date. Two of the escorts had been tested about 6 weeks prior to my meeting them (more time than I would like), the others all within the previous two or three weeks. However, I know for a fact that some of these escorts offer condomless sex with their clients, I was offered twice for more money.

With these 5 escorts, we kissed, I performed cunnilingus on all, received oral sex with no condom, and I had penetrative vaginal sex using a condom with 3 of them.

My main concern is not putting my current partner at risk. She has had no sex previous partners, other than oral, before me. To that end, I have taken the following medications: 800 MG single-dose Cefixime, 1 G Azithromycin single-dose, and 2 G single-dose Metronidazole. Would this treatment be effective?

I am trying to understand if my assessment of my current risk for the major STI’s: Chlamydia, Gonorrhea, Trichomoniasis, Syphilis, Genital HSV-1 (I get cold sores about once a year), Genital HSV-2 and Oral HSV-2 (I have a cold sore that just developed, about a week after this activity. Could this be HSV-2?).

HPV – Are genital warts a large concern?

I am wondering if I should take any further action to protect myself and my partner.

H. Hunter Handsfield, MD

9 months ago

Welcome to the forum. Thanks for your confidence in our services.

You clearly pursue this sexual lifestyle with great safety. It would be helpful to know what country -- if an industrialized one (e.g. in Western Europe) and not in a highly HIV endemic area (like sub-Saharan Africa) -- the chance partners like you describe have untreated HIV or other active bacterial STDs is very low. I would not be concerned by reported negative test results 6 weeks versus 2-3 previously. While it's a small red flag that the escorts apparently have condomless sex with some partners some of the time, remember that most partners of expensive female sex workers are themselves at fairly low STD/HIV risk (men like you).

As for your specific sexual practices, cunniligus is very low risk for any and all STDs. I wouldn't worry about that aspect at all. The important thing is your consistent condom use for vaginal sex. That said, of course the risk rises in proportion to the number of exposures.

As for your antibiotics, they eliminated whatever risk there was of gonorrhea, chlamydia, and syphilis (and probably trichomonas, but that risk from any one exposure was too low to warrant metronidazole). They had no effect on the chance of herpes or HPV, but those risks are trivial in absence of symptoms. The chance your new cold sores is HSV2 (from cunnilingus) is minuscule compared the the probability of a recurrence of your oral HSV1 infection.

As for HPV, we all are infected and you can assume you have had it, probably several times given your sexual history, and could have an active infection now; these events did not materially raise that chance or the possibility of infecting your wife. But she probably has been infected as well. You should look at HPV as a normal, expected, unavoidable consequence of human sex. This is why even women at apparently zero STD risk should follow routine Pap smear guidelines. In any case, visible evidence of HPV (like genital warts) doesn't show up until many weeks or months after exposure, or even several years.

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

HHH, MD

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9 months ago

Thank you for your response. The country was Japan.

You state that any risk of gonorrhea, chlamydia, and syphilis (and most likely trichomonas) has been eliminated. Given my encounters and treatments that I've had, is there any value in any sort of testing before having with sex with my partner? What would I even test for? Any Mgen concern?

My partner has had the HPV vaccine, and I assume this provides good protection for her. Would you recommend the vaccine for me?

About Trichomanas - is it near zero risk from oral sex? What about protected vaginal sex? I read the CDC's recommended treatment for males is 2 G of metronidazole - is that correct?

One last question: genital HSV-2. I understand this is a risk of vaginal sex, even protected. How large of a risk would you estimate?

Thanks!

H. Hunter Handsfield, MD

9 months ago

I see no need for testing and would not do it if somehow I were in your situation. M. genitalium also would likely have been prevented by azithromycin; and in any case, all experts agree against testing for it in absence of symptoms.

Trichomonas does not infect the oral area and therefore is rarely if ever transmitted by oral sex. (Same for M. genitalium, by the way.)

From any single unprotected vaginal sex exposure I would put the chance of HSV2 at under one chance in a few thousand thousand or lower. With condom maybe around double that. Once you pass 5 days without symptoms, one chance in a million.

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