Hi,

I'm a male hetereosexual that is uncircumcised.  I want to know if there is any risk of HIV to me if I tested partners immediately post unprotected vaginal sex with HIV Duo and their result was negative.  I understand there is a window period, but I also have read that undetecable means untransmissable.  So, if they had early HIV (no anitbody) then the antigen part of the Duo test would have picked it up?  And if it was later the antibody part would have picked it up.  So basically, they could still have HIV and be in the window period, but I am at zero risk of becoming infected?  Is my logic correct?

Also, I had found a small bleeding cut on my foreskin which was very swollen during/after the act as there was some anal sex involved also.  Am I at risk for Hepatitis A,B,C from this and if so when should I test and which test?  Also, whats the incubation period for herpes?

I did prophylaxis of 2.5G Azithromycin and 800g cefixime, so would this cure all bacterial STDs or do i need to test for this at some point?  

Yes, I know this was very stupid of me and have learned my lesson on safe sex.  But am hoping I am lucky one more time.

Thanks!

HIV first:  I agree you were at little risk, since in most geographic areas HIV is rare in sexually active women, including sex workers; and their negative AgAb (duo, 4th generation) HIV tests are nearly conclusive evidence they did not have HIV at the time of your exposures. You may have a slight misunderstanding about U=U, undetectable = untransmittable. That concept refers only to the PCR tests for HIV RNA, not to antibody or AgAb texts. In theory, the AgAb tests could be briefly negative in someone with recently acquired HIV that might be transmittable. But still your partners' negative tests make it exceedingly unlikely they had HIV. Further, when a female has untreated HIV, the risk to her male partner from a single episode of unprotected vaginal sex is estimated to be under one chance in 2,000. Anal sex is higher risk for HIV transmission than vaginal, but that aspect doesn't materially raise your overall low chance of HIV from the events described.

Being uncircumcised roughly doubles the risk of HIV infection if sexually exposed, but with your overall risk well below one chance in a million, double risk means under one chance in 500,000 -- still zero for all practical purposes. The same is true about sex in presence of a "small bleeding cut" of the foreskin. While theoretically that might raise the risk, there is no scientific evidence that this actually happens.

Cefixime and azithromycin haven't been studied as post-exposure prophylaxis (usually it's doxycycline, with or without cefixime) but probably prevented gonorrhea, chlamydia and syphilis, even if one of your partners was infected.

All things considered, I agree there is no need for you to be tested for anything.

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

HHH, MD

Hi Dr. Handsfield,

Thanks for your reply.  Would it change anything if the csw's were Nigerian but incident occurred in Dubai and it was a very lengthy repeated scenario over the night? They took the duo tests the following morning.

Anyway, will be rest assured and not take any further tests.  Does this also mean I can resume to have unprotected sex with spouse without any HIV risk?

Finally, I think perhaps you may have not seen the earlier question regarding hepatitis.  Am I at risk for any type of hepatitis due to the anal sex and bleeding (the foreskin was indeed swollen for 5-6 days thereafter and bleeding occassionally, so it was not a "minor cut").  If so, which ones and when can I test reliably?  And if I were to get herpes, by when would I have symptoms (or by when could I rule it out if no symptoms).

Thanks!

Viral hepatitis risk:  Still zero for HBV if you were vaccinated, or if the CSW was vaccinated. Hepatitis C virus is not sexually transmitted between men adn women, or so rarely the chance can be ignored. HCV is a sexual risk only for men having potentially traumatic anal sex with other men. That said, given possible blood exposure I cannot say your risk is zero for HCV.

New herpes symptoms (blisters, sores of exposed sites) usually start within 5 days, but it can take a couple of weeks. HSV is very unlikely if no symptoms after 2 weeks.

All in all, your risk for HIV and other STIs is very low, and I would put the chance at very nearly zero -- and truly zero if you used a condom.  However, the setting puts you in a high risk category and this forum cannot guarantee you are not infected and can safely have sex with your spouse. I advise you see a knowledgeable health care provider or clinic, i.e. a provider who has intimate understanding of STI/HIV issues in Dubai, which I do not. (As indicated above, there is at least one expert clinic there.) It seems likely they would advise a urine test for gonorrhea and chlamydia and blood tests for HIV and syphilis. 

Hi Dr. Handsfield,

Thanks for your reply.  No, I stupidly did not use condoms. I am under the care of a specialist but wanted to get your views on the following:

1.  He made me take DUO test at 14 day mark which came back Non Reactive. I was having some symptoms in the few days prior to the test, so would my understanding be correct that the symptoms could not have been related to HIV?

2. He advised me to take PCR RNA test anytime after 15 days post incident and no further testing required.  Do you concur or is my Non Reactive Duo result coupled with the Non Reactive Duo result of partners sufficient to stop testing now?

3. Regarding STIs, he felt the prophylaxsis I took was sufficient to kill all incubating bacterial STIs and no further testing is required.  However, I could do a ToC if I wanted at the 3 week mark.  Do you feel I need to do a ToC or can I put this behind me as well?

4. For Hep C, he advised waiting for 6 weeks to test.  But I have read 12 weeks is required.  What is correct?

5.  No herpes symptos at 14 days, so am going to move on from that.

Thanks!

2. I agree that with both your and your partner's negative AgAb tests, PCR RNA testing is optional. But since your doctor advises it, why not do it for the additional reassurance it will give you?

3. I agree the bacterial STI prophylaxis was highly likely to prevent any infection adn that test of cure is optional. Here too, however, why not do the TOC for reassurance if you still are worried?

4. There was no risk for HCV, which is very rarely sexually transmitted between males and females (if ever), despite lots of beliefs to the contrary. I've always advised 6 weeks.

5. I agree herpes isn't an issue.

Hi Dr. Handsfield,

Thank you for your reply.  I will follow your recommendations.  Have made a serious mistake, and will surely learn from this and never put myself in such a situation again!  Just to clarify, the partner negative Ag/AB was done on the day of the incident and mine was 14 days post (in case that changes your opinion).  I believe the 3 questions have been submitted so the thread may be closed. 

Incidentally, if you feel it may be good information to share, could you explain why theoretically U=U does not apply to p24 (which I thought was a marker for the virus and if there was enough virus to be infectious, there would surely be enough p24 to be detectable).  Just trying to understand the science.

Thanks!