[Question #12802] Big Mistake

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5 months ago
Hello, I made a big mistake. I visited an escort and put on a condom. We did some kissing and the. I inserted my penis into her vagina and I felt something but didn’t think much of it. When I pulled out I realized the condom broke. I was inside for about 2 mins. I am very stressed now that I caught HIv and other STIs. What do I do? When can I take the rapid Insti Test? What are the chances I caught HIV? What are the chances I caught other STis? When is the earliest I can’t test with the rapid HIV test?
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H. Hunter Handsfield, MD
5 months ago
Welcome. Thanks for your confidence in our services.

Like many persons after a new sexual exposure, you may not understand STI risk in general. Even with entirely unprotected sex with new partners at high risk, the large majority of exposure do not result in any infection, In this case, you describe several aspects that suggest your risk was very low. First, escorts -- expensive female sex workers who work by appointment (as opposed to bar pick-ups, street walkers, brothel workers) -- are generally at low risk for STIs:  they care about their health, use condoms, get tested frequently, and have low risk clients (men like you). They very rarely have HIV. The chance you caught any infection at all is probably under one in a hundred, maybe less than one in a thousand. For HIV, it's more like one chance in a million or lower.

Whether HIV tests are "rapid" or not isn't so important; what makes the difference in time to conclusive results is test generation. If you have an antigen-antibody (AgAb, "4th generation") test, negative results are highly reliable at 4 weeks and conclusive at 6 weeks. An HIV RNA PCR test is conclusive at 11 days, but there are no rapid or self tests; this must be done by a laboratory. Do whatever you like, but really testing is optional.

As for other STIs, the risks are higher but still low. The most common infections of any importance are gonorrhea and chlamydia; you can have a conclusive urine test 4-5 days after the event. You also could consider a syphilis blood test after 6 weeks, but the chance of syphilis is almost as low as for HIV.

All in all, you really shouldn't be so worried. I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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5 months ago
Thank you Dr. Hansfield. You have put my mind and some ease but still so many questions running in my head.

1. I am circumcised does that increase odds in my favor as I’ve read circumcision helps in prevention.?

2. When symptoms appear what is the avg time of onset?

3. I’ve been reading through the forums and you mentioned 1 in 2500 but for me you mentioned 1 in million is that due to assumption the escort is not positive? What if she was positive do odds go 1 in 2500 and does short duration and circumcision better the odds?

4 the test here in Toronto is the Insti Rapid test 3rd generation which checks for antibodies. They state at 21 days most are detectable. Do you agree?

5. Most places here do not perform RNA PCR test unless it’s for high chance of HIV. I’d be willing to drive to Buffalo NY but the labs state it takes 10 days for results. Any recommendation?
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5 months ago
Dr Hansfield. I know you mentioned my risk being low but I am wanting not to take any chances. I have few hours within the Pep window. If I take pep is it proven to be 100% effective? Are the side effects very common or mild and manageable?
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H. Hunter Handsfield, MD
5 months ago
*Sigh*

1.  Being uncircumcised roughly doubles the risk of HIV if exposed -- but only if exposed, which almost certain you were not. And even if she had HIV, double risk really doesn't mean much if you think it through. If your risk otherwise was one in a million, double means one chance in 500,000, which still is zero for all practical purposes.

2. Contrary to lots of nonsense on the web, it is almost never useful to judge symptoms either for or against HIV. Innumerable medical conditions cause exactly the same symptoms, so even with the most typical symptoms, almost all people do not have HIV. And most newly infected people don't have symptoms, so absence of symptoms is not necessarily reassuring. I advise you to ignore and not look for symptoms. But to answer your question, ARS symptoms usually start 1-2 weeks after exposure, sometimes up to 3 weeks.

3. One in 2,500 is the risk from completely unprotected vaginal sex (to completion, 10-15 minutes) with a known infected female partner. None of this applies to you. My guesstimate of one in a million is a combination of the new zero chance a partner like yours has HIV and only brief exposure without the condom.

4. Yes, most would be positive at 3 weeks with the INSTI test -- probably 80-90%.

5. I'm glad most Canadian public health authorities and providers have a more rational approach to HIV testing than in the US. I agree that PCR tests should only be done in high risk settings. That we have a wacko health care system in the US doesn't make it right.

It is exceedingly difficult to design studies to document the exact effectiveness of PrEP. It's probably close to 100% within 24, hr then declines; it has no effect after 72 hr,. It would be very dumb of you to take PrEP. If you came to my clinic we would refuse to prescribe it; you might not be able to find a provider in Canada willing to prescribe it, assuming you were truthful . PrEP usually is harmless, except for one aspect you might not have considered:  If you take PrEP, you cannot have conclusive HIV testing to prove you were not infected for another couples of months --- a couple weeks after the last dose of drug. Without it, you'll know much sooner. Are you prepared for an extra 4-6 weeks of uncertainty?

As for PCR testing in Buffalo, if somehow I were in your situation, I would not do it and would be continuing unprotected sex with my wife. But if you insist, the test is conclusive at 11 days after exposure. It is nonsense that it requires 10 days for results. Typically the same or next day.

Please believe me:  there is no realistic chance you have HIV. You have an ethical obligation to yourself to ignore irrational thoughts like "not wanting to take any chances" when those chances are zero for all practical purposes. 

Perhaps you would also like to know that in the 21 years of this and our previous forum at medhelp.org, with thousands of questions from people worried about HIV after a possible exposure, not one has turned out to be infected. If and when it happens, it surely will be from a genuinely high risk exposure (think unprotected anal between two men) and not a trivial event like yours.
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5 months ago
A decision was made to start Pep at 26 hours post incident. I understand you would have not recommended and delayed testing but I wanted to not take any chances. Just a few questions on Pep.

1. I read on this site that within 24 hours Pep is 100% effective. What would effectiveness be at 26 hours post exposure roughly? Would I be near the 100%?

2. Are there quite a few studies on the effectiveness of Pep or is it more theoretical?

3. They also did some baseline tests for Everything including Gonohrea and Chlymydia at the 24 hours post exposure mark. Would those have not picked up anything that early?

4. No discharge or painful urination at 3 days does that mean anything?
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H. Hunter Handsfield, MD
5 months ago
I don't agree with PEP, but it's your decision. But be aware of a downside you might not have considered. Without PEP,  you could have conclusive HIV testing -- to prove you were not infected -- 11 days after exposure. With PEP, conclusive testing must be delayed until 2 weeks for the last dose of drug. Are you prepared for 6 weeks' uncertainty about it?

1,2. There is almost no scientific research on the effectiveness of PEP in humans -- only expert opinion based on studies in primates, plus the informal experience in providing PEP to persons at risk. That said, there are few if any reports of PEP failing to prevent HIV, and most experts indeed agree it is nearly 100% effective within 24 hours. I would assume the same for 26 hours.

3. 24 hours is too early for meaningful gonorrhea/chlamydia testing. It takes 2-3 days for gonorrhea to be detected and probably 4-5 days for chlamydia. You should be tested again for both after 4-5 days.

4. Absence of these symptoms at 3 days is slightly reassuring for gonorrhea, for which symptoms typically begin 2-5 days after exposure. For chlamydia it's 7-14 days; absence of symptoms at 3 days is meaningless.

In addition to repeat ngon/chlam testing after 4-5 days, I would advise a syphilis blood test in 3-4 weeks for ~90% certainty and again at 6 weeks for 100%.

That completes the two follow-up comments and replies included with each question and so ends this thread. Don't be very worried -- as we have discussed, there is almost no chance you have HIV and very low chance of any other STI. I hope the discussion has been helpful to you.
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