[Question #1351] hiv risk in my situation

48 months ago
40yo male who recently received unprotected oral sex and I think protected (condom didn't break, but unsure if it was touched w/ her vaginal secretions on the inside) vaginal sex from a HIV+ female who also has active/shedding HSV2.    It has been 5 days since the exposure & I have had chills/night sweats the past two nights.  I alsohave mild burning in my urethra.  Chlamydia & gonnorhea tests were negative as was my rapid HIV.  Is it even possible for the chills/ night sweats be due to HIV within 5 days of exposure?   I had been prescribed PEP and started 67 hours after the exposure but I only partial filled the prescriptions for now.  Should I continue with the PEP (cost is not an issue, but what about side effect risk -truvada & isentress)?  I've received mixed messages from healthcare providers, some saying my risk is very low & to relax & another provider prescribing PEP.  Please help, I'm very stressed and confused.  Thank you.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
Welcome to the forum. Thanks for your question. The news is good:  little or no risk for HIV, no worries! Here is why.

This was a very low risk situation. In the US HIV remains rare even among the most sexually active women. Even among sex workers, on average well under 1% (usually fewer than one in a thousand) have HIV. And condoms work, so the vaginal sex was low to zero risk, and skin contact with vaginal secretions of a woman with HIV, with or without HSV2, is no risk for practical purposes. (The risk of sexually acquiring HIV is elevated in people with HSV2. However, there is no documented increased risk of transmission when the HIV infected person is the one with HSV2.) The oral sex also was near zero risk. Even without condoms, there has never been a proved case or oral to penile HIV transmission, and CDC estimates the risk (if the oral partner has HIV) at 1 in 20,000. That's equivalent to receiving BJs by infected partners once daily for 55 years before transmission might be likely.

For those reasons, I would not have prescribed PEP had you come to my clinic, except in unusual circumstances -- for example, maybe if your partner were known to have HIV (and even then I would recommend against it).

As for your symptoms, I have to be skeptical you really had chills or night sweats. Did you take your temperature? If no fever, chills and night sweats are not evidence of infection. (Both of these symptoms occur only in people with high fever.) They also  were too early to be caused by HIV from this event, as you seem to already know. Acute HIV symptoms cannot start sooner than 8-10 days after exposure. So even if you really have an illness with fever, it isn't HIV from this exposure.

As for other STDs, I'm guessing your "mild burning" in the urethra was psychological due to your anxieties over this event. In any case, mild burning alone (without discharge) generally is not evidence of STD. In any case, your negative gonorrhea/chlamydia test is reliable, so you also can put that concern aside. (On top of which your risk for both of these was low based on your exposure history.)

At this point, the main decision you need to make is whether or not to continue PEP. The drugs you are taking carry little risk of important side effects -- not completely risk free, but not likely to cause any problem. However, without PEP you could have a conclusive HIV test (4th generation, i.e. antigen-antibody test) 4 weeks after the exposure. With PEP, the recommendation is to delay testing to 3 months for a conclusive result. So one effect of continuing treatment probably will be to prolong your anxiety to 3 months instead of one month. Since your risk of having caught HIV is zero for all practical purposes, I would advise you to consider stopping it. However, we do not make definitive treatment recommendations on this forum, so you should not follow this advice without first discussing it with the prescribing doctor.

I hope you find this information as reassuring as I intend it. Let me know if anything isn't clear.

Best wishes--  HHH, MD
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48 months ago
Thank you so much doctor.  I've been dealing with uncontrolled stress for the past five nights and was hoping the night sweats were unrelated to HIV.  I will put my HIV fear to rest and discontinue the PEP, as I would prefer the earlier testing you suggested.   I have not taken my temperature but I will tonight .   My skin & sheets were so drenched with sweat that I had to use a towel to dry off & change the sheets.  I agree that it could be anxiety, but if I am febrile would you consider a new HSV2 infection likely, especially if she was actively shedding?  I have been urinating frequently & have the burning sensation but no other symptoms (I am HSV1+).   Again,  I can't thank you enough for your expert advice.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
As I said above, you should not stop PEP based on my comments. Discuss it with the doctor who prescribed it and follow his or her advice.

Your symptoms sound a lot like true night sweats; if they are continuing, take your temperature a few times and also discuss this with your doctor. Although allergic reactions to medications don't commonly behave this way, sometimes they do (i.e. drug fever), conceivably due to either of the PEP meds. Again, this is something to discuss with your doctor.

No STD causes urinary frequency and rarely cause burning, except in the presence of discharge. HSV (of either type) is also a very unlikely cause of these symptoms. And the chance of initial infection with HSV2 from this exposure is exceedingly low, since HSV2 is rarely carried in the mouth and so oral sex isn't a risk for it; and condoms are effective in preventing genital transmission. Also, herpes rarely if ever cause fevers, sweats, etc without also causing very obvious oral or genital blisters and sores.

We really can't go further on this forum in addressing the cause of your symptoms or next steps in testing or treatment. All this needs to be addressed with your doctor.

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