[Question #12619] STD/STIs Risk and Testing Recommandations

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6 months ago
I am 28M and recently visited a massage parlor in Korea that led to full intercourse with a sex worker. This included oral sex (me to her), kissing, protected penetration (70% of the time), and unprotected penetration (30% of the time). 
1) From this single exposure, what would be the chances (in %) of acquiring HIV and HSV 2?
2) The following are my current testing plans. Would you advise me to proceed any differently? [Week 6]: get urine PCR test and blood test (IgG for herpes), [Week 12]: get the same test as week 6, [Week 16]: get a western blot test from UW
3) I understand that I need to perform IgG for herpes. Is it the same for other STDs, such as HIV and syphilis? 
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6 months ago
One thing I forgot to add but could be important is that the duration of the penetrative sex was about 20min. Unprotected penetration was probably about 5 min. Thank you. I appreciate the website and the help you guys provide
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H. Hunter Handsfield, MD
6 months ago
Welcome to the forum. Thank you for your confidence in our services.

Any unprotected intercourse is risky. Using a condom only 70% of the time is the same risk for HIV and STIs as not using a condom at all. For safe sex, there should be no penetration at all without the condom in place. (What were you thinking??) Cunnilingus (oral-vaginal contact) is very low risk for all STIs; there has never been a known case of HIV as a result of such exposure. So the main risk here was from the vaginal sex. To your numbered questions:

1) Most STIs and HIV are inefficiently transmitted; that is, most single exposures with infected partners do not result in infection. If we assume your partner had untreated HIV, the average risk has been calculated (by the US Centers for Disease Control and Prevention [CDC]) to be under one chance in 2,000. For HSV2, one research study suggests a transmission risk of roughly one chance in 1,000 from vaginal sex with an infected partner who is not having a visible outbreak of herpes at the time. If we consider there's say a one percent chance your partner has untreated HIV and a 20% chance she has HSV2, your risk would be under 1 in 200,000 for HIV and 1 in 5,000 for herpes. Your risks are higher than these for chlamydia (probably the highest risk of all0 and gonorrhea.

2) You might consider having a urine and throat swab tests for gonorrhea/chlamydia now; these are valid within 4-5 days of exposure. It makes no sense to wait 6 weeks for these; by then, you could have acquired gonorrhea or chlamydia that were cleared by the immune system. Six weeks would be the right time for an HIV antigen-antibody (AgAb, "4th generation") test and a syphilis blood test. I would advise against testing for HSV, assuming no symptoms in the next few days. The HSV tests are not highly reliable in absence of symptoms, with significant risk of false positive results. If you decide to test anyway, have a standard IgG blood test for HSV1 and 2 at 12 weeks; and for sure do not have a western blot if that result is negative. That makes no sense at all.

3) I'm glad you already understand that IgM testing for HSV is highly unreliable and never should be done, even when offered by seemingly reliable laboratories. But this doesn't apply to HIV and syphilis tests, which often include both IgG and IgM. The problem with IgM is only for HSV.

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

HHH, MD
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6 months ago
Thank you for your response. This is really helpful! I want to ask follow-up questions. But for some reason, I'm not able to submit a reply that is longer than this, what should I do?
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6 months ago

Perhaps this would work

1) For HSV2, if we assume she had an active outbreak present, how much would that increase the chance of infection?

2) Can you further elaborate on gonorrhea/chlamydia being cleared by the immune system by 6 weeks? Does that mean they won't be detected by PCR after a certain date after the exposure?

3) When should one expect HSV2 symptoms to appear after the exposure? What are the chances of them not appearing despite the infection?

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6 months ago
*I'm asking the 2nd question as I'm still in Korea and testing is quite expensive here. I was planning to get tested when I go back to the States. But, if 6 weeks is too long to get an accurate test, I'm willing to get it here in Korea. Thank you.
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H. Hunter Handsfield, MD
6 months ago
1) I don't accept the premise; the likelihood of an overt outbreak was very low. Would you have sex in the presence of painful genital sores? If it happened, of course it would raise your risk, maybe even to a 50% or higher chance you would be infected.

2) Most infections are cleared by the immune system over time. Before antibiotics were developed, most people with pneumonia survived; same for skin, urinary tract, and most other infections. STDs too:  in the pre-antibiotic era, gonorrhea usually was done after several weeks in men and a few months in women. Chlamydia lasts longer, but still not often more than a few months. Of course this doesn't mean antibiotics aren't important:  even if cured without them, before that happens serious complications are possible. Once cleared by the immune system, all tests for gonorrhea and chlamydia are negative.

3) Herpes symptoms generally begin 3-5 days after exposure, rarely as long as 3 weeks. Some infections cause no symptoms, but that's usually in people who are blasé about it and don't care; are genitally unaware; or may be spaced out (e.g. drugs, alcohol). Someone as concerned as you are usually would know it if they were infected:  I'm sure you are attuned to every twitch and tingle you might feel in the genital area. (Not to imply twitching, itching, or tingling are significant herpes symptoms:  they are not.)

Be clear:  the overall chance you have any STD from the exposure you are concerned about is very low. And in general testing isn't advised at all after single high risk exposures, assuming no symptoms; after 5-10 such events, it would make sense, but rarely after only one. So waiting 6 weeks for testing is no problem, unless you're likely to have sex and expose new partners before then. But please do not test for HSV:  the chance of a falsely positive result for HSV2 is a lot higher than the possibility you were infected and have no symptoms. But if you test for HSV anyway, don't do it until 3 months after the exposure. And for sure avoid IgM testing, only IgG.
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6 months ago
Thank you. I just want to be clear on what you advise. So, do you recommend I get tested for gonorrhea and Chlamydia at this time? (It's been 10 days since the event. Am I already too late for the test?). Based on the answer, I'm thinking perhaps I should test it in order to avoid possible complications, just in case I'm infected. Lastly, when these infections are cleared over time and cannot be detected by the test, does that mean I'm free of these infections, or they are just dormant to potentially cause problems in the future and infect other people? Based on a Google search, most sources seem to argue that these infections don't clear without antibiotic treatment. Is this incorrect? If not, what is the reason for such misinformation being so prevalent?
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H. Hunter Handsfield, MD
6 months ago
"...do you recommend I get tested for gonorrhea and Chlamydia at this time?" From a medical/risk perspective, no, I do not. But only you can decide whether, from the standpoint of reaassurance -- independent of actual risks -- you need additional proof you are not infected. It is not too late to test.

"when these infections are cleared over time and cannot be detected by the test, does that mean I'm free of these infections?" Yes. There is no such thing as "dormant" gonorrhea or chlamydia that cannot be detected by testing.

"Based on a Google search, most sources seem to argue that these infections don't clear without antibiotic treatment. Is this incorrect?" Yes, it is incorrect. Be careful with google:  anybody can write whatever they want. You will be unlikely to be misled if you limit searching to professional or professionally moderated sites; and be especially wary of sites run by and for people with or worried about the problem you are concerned about -- like Reddit, for example. Re-read my reply to question no. 2 immediately above -- and concentrate this time. The science on this is clear and unequivocal.

That completes two follow-up quesitons and replies and so ends this thread. I hope the discussion has helped you gain a more realistic perspectiv on these issues and to move along. If you remain concerned, I would advise you to carefully re-read your quesitons and my replies; and to limit future online searching as i have just suggested. Good luck with it.

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