[Question #13210] Long term Risk

1 months ago

I am a 41 yo male and currently STD-free (except HSV1) and wish to remain so long-term despite ~20 annual encounters with up to 10 different female CSWs. I

1) consistently use condoms properly for all sex (including oral), 2) target "higher-end" CSWs (online escorts), avoiding those who’ve lived in Africa, have signs of IV drug use or offer condomless sex, 3) inquire about partner testing, 4) visually inspect genitals for signs of outbreaks, 5) minimize incidental skin-to-skin contact at the penis base/genital area, 6) take suppressive Valtrex for recurrent HSV1 (hoping for some HSV2 protection?), and 7) get tested bi-annually for main STDs (always negative to date).

Considering this protocol and my high-frequency, multi-partner sexual activity, what is your expert opinion on the cumulative long-term (20 years) STD risk? What additional measures would you recommend to further minimize this risk and maintain disease-free status over decades? Ok to continue having unprotected sex with my wife throughout?

H. Hunter Handsfield, MD

1 months ago

Welcome to the forum.

You need to understand that despite continuing condom use, you remain at some risk for STDs. Condoms are good protection but not perfect. With 20 exposure and 10 partners annually, you should be tested for common and potentially serious STDs from time to time, like maybe once or twice a year, as you already plan to do. -- specifically for gonorrhea, chlamydia, syphilis and HIV (but usually no others). There are no data on which to base an estimate of your risk in numerical terms. But assuming no symptoms, the chance anything will ever turn up positive is low, but not zero. Better safe than sorry!

As for the specific prevention strategies you mention, most are potentially helpful in reducing risk but there are no guarantees. The most important is no. 1 -- consistent condom use for vaginal or anal sex and optionally for oral exposures. (Oral sex is inherently much lower risk than vaginal or anal intercourse.) No. 2 also is a good approach; "higher end" sex workers tend to have low rates of HIV and other STDs. Inquire about STD testing (no. 3) is OK, but you'll find that most such women are frequently tested; and most of their clients are unlikely to have STDs themselves. No. 4, visual inspection of partners' genitals, probably adds no significant benefit at all. There is no need for no. 5, i.e avoid skin-skin contact above the condoms. No. 7 is discussed above.

As for no. 6, can you clarify your HSV1 status. Do you have confirmed genital herpes due to HSV1? Or just a positive blood test? Even for genital herpes, valacyclovir has little if any benefit for HSV1 protection of partners, since genital HSV1 almost never is transmitted sexually to partners. Taking valacyclovir might prevent HSV2 if exposed but has never been studied and its effectiveness isn't known.

As these comments suggest, there is no way to pursue this sexual lifestyle without putting your wife at risk. However, as long as you have no symptoms and test negative for common STDs at 6-12 month intervals, her risk will remain quite low. With one exception: you can assume you will be repeatedly exposed to HPV and likely are infected now -- condoms reduce the risk for any single exposure, but over time even the most consistent condom users have no lower chance of being HPV carriers than non-users. If you and your wife have been vaccinated against HPV, your risk is greatly reduced. But even if not, the large majority of infections remain asymptomatic and cause no health problems. On the other hand, this is why all women should follow standard Pap smear guidelines regardless of their apparent STD risk.

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

HHH, MD

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1 months ago

I take 500 mg of valtrex daily for effective management of recurrent nasal HSV-1 outbreaks and plan to continue this indefinitely. I don't have genital HSV 1 or 2. I'm curious if Valtrex might also reduce the risk of acquiring new HSV-2 infections, though I haven't found studies on this.

My wife has a history (since before we met) of high-risk HPV (pap), I've certainly been exposed. Would you recommend the HPV vaccine for me?

Humor me: for HIV, I've estimated the risk for each exposure as a 1 in 20 million chance, factoring in partner infection (1 in 100), condom failure (1 in 100), and transmission (1 in 2,000 for vaginal). Over 600 exposures (30 years), the cumulative risk is roughly 1 in 33,333. This is comparable to the lifetime risk of being struck by lightning and significantly higher than being seriously injured in a car accident over 30 years. Reasonable?

H. Hunter Handsfield, MD

1 months ago

I'm glad to hear your recurrent nasal area herpes is well controlled. Whether I would prescribe it if I were your doctor would depend on outbreak frequency. That said, valacyclovir is harmless for all practical purposes so I have no problem with you continuing it. As I said above and you already understand, it likely would prevent HSV2 if exposed, but can't really be sure in the absence of research (or to my knowledge even published informal opinions on the topic).

The HPV vaccine protects against 9 HPV types, which together account for around 90% of all infections. At age 41 and with your sexual lifestyle, I would bet you've already been infected with several of those types, perhaps most of them including your wife's infection, and you're immune (or at least highly resistant) to second infections with the same HPV type. Therefore, I doubt the vaccine would significantly lower your risk (or your wife's) of a new infection. OTOH, aside from cost the vaccine is harmless and might give you a bit more confidence about the issue. You could discuss it with your personal health care provider.

Your analysis of HIV risk looks good, except I would put the likelihood of HIV in the upscale escorts you describe at more line one in a thousand rather than 1% -- making your long term risk of HIV tenfold lower.

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1 months ago

Thank you!

Noted on the 1:1000 prevalence in high end escort population. So cumulative risk of HIV in my situation is more like being struck by lightning…on a Tuesday.

Final question - I presume that for encounters where only covered oral sex occurs, the risk is essentially zero for all STDs? If so, it’s a modifiable behavior I can use to reduce risk in any higher risk situations that arise.

I really appreciate you, Doctor, and your service. You’re the GOAT! Thank you!

H. Hunter Handsfield, MD

1 months ago

Yes, condom protected oral sex is zero risk for all STDs.

Thanks for the compliment. I'm glad to have helped.

That completes the two follow-up comments and replies included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes and stay safe.

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