I was planning to have safe sex with a new partner (and not resort to asking this), but something unexpected happened:

Whilst having oral sex, my partner noticed frank blood on the bed sheet. He was fingering me, so at first I thought it may be coming from me(female) vaginally. However, it was actually his (male) anal hemorrhoids that started bleeding. It definitely dripped on to the sheets, but I’m not sure if it landed anywhere on my vaginal mucosa, not that I was able to see upon inspection. 

We’re planning to get tested asap, I was recently tested and everything was okay. I don’t know my partner’s status, only that he’s a heterosexual male. And he’s been in a relationship, so no recent testing on this part. 

What is your risk assessment given that his blood from hemorrhoids may have come in contact with my vaginal mucosa? I didn’t see it, but cannot rule it out. Do you think I need PEP? It happened five hours ago. I am concerned. This was wholly unexpected. He said his hemorrhoids haven’t bled before. We were planning to have protected sex, not this type of an occurrence. 

Please advise. Thank you.  

Presumably you believe your partner to be at low risk for HIV -- if you thought he was high risk, it seems obvious you would not have agreed to sex with him, even condom protected or otherwise safe. And from your previous questions, I believe you are in the UK, where the likelihood of HIV in even the most sexually active straight men is very low. And even if he has, HIV the chance of infection from contact with HIV infected blood on sheets, clothing etc is nil -- and that's true even if his blood came into contact with your vaginal mucosa.

I certainly would not consider PEP in this situation; even HIV testing itself is optional. But since you're planning to be mutually tested, I would advise just waiting for his result (knowing your own will again be negative). In the meantime, I see no cause for worry.

I hope these comments are helpful. Let me know if anything remains unclear.

HHH, MD

Thank you, as always, for a prompt reply. 

I’m actually from a North American version of the UK, i.e. Canada. I’m guessing that makes HIV prevalence stats similar to those of the US.

My partner went ahead and got himself tested with a rapid HIV test. That’s what he told me. I didn’t see the results. He advised the result was negative using an INSTI rapid test (one C dot, not two dots). That provides additional reassurance. 

I do wonder, you said that the chance of infection of HIV-infected blood with vaginal mucosa is NIL. Can you please explain why is that? I thought that’s how infections occur, with a bodily fluid coming in contact with vaginal mucosa. I honestly don’t know if the blood from his hemorrhoids dripped solely onto the bed sheets (no risk) or dripped directly on me (some risk).

I’m about 36 hours into the event, can still get PEP, although I was advised that the ER may not give it to me since this isn’t considered high risk (unlike a needle stick injury). But from the sound of your reply you decisively think I do NOT need PEP.  

I just never had frank blood potentially dripping on me during sex, hence being alarmed. 

The earliest, I imagine, I can get tested with a rapid test is around the 3 week mark. The tests are 3rd gen. Would it be possible to leave the thread open until then for me to report the result? 

Thank you 

Nobody can say there is zero risk from a small amount of blood, but there has never been a known HIV case transmitted by such superficial contact with blood. Even unprotected vaginal sex, with billions of HIV in semen deposited deep in the vagina, has under 1 chance in 2,000 of infecting the female partner. I agree with the ER:  My clinic (or my local ER) also would refuse to prescribe PEP in this situation, no matter how strongly you insisted.

I do not recommend HIV testing, especially given your partner's negative test. What would be the point?

I did start PEP, albeit late, at a

68H mark. First dose was Tivicay and Truvada, thereafter it’s been Biktarvy. 

I’m assuming you’ll say that PEP wasn’t needed, but I don’t know if blood from hemorrhoids came in contact with my inner labia minora/vaginal mucosa and given his dishonesty about other things, I’m apprehensive.

I’m D8 into PEP, plan to take the 28 day course with Biktarvy. Would you say that starting PEP this late but with a strong medication like Biktarvy still has 60-80% efficacy in preventing systemic infections? 

I parsed  the literature and wasn’t able to find cases of seroconversions in similar circumstances, unless there have been instances of re-exposures while on PEP, non-adherence to meds, etc. True failures of PEP appear to be quite rare (med resistance). 

Also, when I asked for written results he agreed to provide, but got angry and spoke disrespectfully. I understand that IT has no bearing on his medical status, but as it stands I don’t trust him. 

I wonder how you would assess risk (PEP at 68H) given the new influx of information. 

Thank you in advance, Dr. HHH

"wasn’t able to find cases of seroconversions in similar circumstances..." Of course not, since your "circumstances" are that you were not at risk for HIV. I do not agree your partner's behavior or communications increase the likelihood he has HIV; almost certainly he does not. Probably most persons would be prone to become angry and perhaps "disrespectful" if asked to provide written documentation of what that they say about HIV status or anything else.

Biktarvy is equal in efficacy to all PEP regimens, not more "strong than other options. Don't confuse theoretical advances as actually translating into improved effectiveness.

I don't know what "new influx of information" you refer to.