I was recently with two male crossdressers. They mainly performed oral on me and both offered me methamphetamine which I I took. I was quite high during both encounters and found it difficult to ejaculate from the oral sex. They both digitally stimulated me anally. I am almost certain that both tried to at least rub their penises against my anus for an unspecified period, probably not that long but hard to remember I was not looking down but laying back. I almost certain the first person was on PreP and I do not think there was any penetration anyway so I am not worried about the frottage there. The second and more recent person I was with I am more concerned about as I was highly intoxicated at the time and don't recall everything clearly. They did mention later that they did penetrate me which I found surprising as I do not recall this at all. It is not something I have done before and was not curious to try. Fine with fingering but no penetration, I would have stopped them if I knew they were doing that. If they did, I am not sure for how long they did or if there was much precum or any ejaculate. It is all a bit hard to know my memory is hazy,. I don't even think any lube was used for fingering or otherwise but not 100%. I am not on PreP I rarely hook up with men or trans women. I have not been able to contact the second person since  the encounter to find out about their HIV status or whether they take PreP which is hugely frustrating. I started PEP maybe 50 hours after the encounter. (1) What would you give your risk assessment for HIV from this type of activity? (2) Same but for other STIs? (3) How effective is PEP (3 drug combo) 50 hours post encounter? (4) Would you refrain from having unprotected vaginal sex with a regular partner for the time being and if so, how long? (5) Would you recommend delaying fertility treatment if this was being planned with a regular female partner? Thanks in advance!

1) You're obviously the only one who can judge the details of these exposures. But I agree that if penile-anal penetration may have occurred, it raised the risk of HIV and other. STIs. Oral sex is close to zero risk for HIV and low risk for other infections (gonorrhea being the most common STI of serious concern), and anal fingering is zero risk for all. Even with entirely unprotected receptive anal sex (bottom) to completion (i.e. with ejaculation), no more than 1% of exposures result in HIV transmission, if the insertive partner has HIV and is not on treatment. Given the brevity of that event, if penetration occurred at all, your risk of HIV was probably well under one chance in several thousand.

2) Other STIs are greater risk -- gonorrhea, chlamydia and syphilis are the main concerns -- but still low. When you see a doctor or clinic to consider HIV PEP, also discuss doxy-PEP -- i.e. single dose doxycycline 200 mg, which is highly effective in preventing chlamydia and syphilis, and also reduced gonorrhea risk by about 50%. You also should have urine and swab tests for PCR testing for gonorrhea and chlamydia (urethra/urine, anal, throat).

3) The effectiveness of HIV PEP at various intervals after exposure is difficult to study and good data do not exist. But most experts would judge ~80% effectiveness at 50 hours (close to 100% within 24 hr).

4) Probably it would be best to refrain from sex with your regular partner at least until you've had doxy-PEP and you have the results of gonorrhea/chlamydia testing. Probably they will be negative, but better safe than sorry. 

5) We are not experts in fertility or its treatment. In general, STI testing is routine for sperm donors. If your gon/chl tests are negative, I see no reason for delay beyond those test results.

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

HHH, MD

I suppose your chance of having HIV could have been as high as 0.2% (1 in 500). However, the large majority of HIV providers with lots of experience using PEP report they have NEVER seen a patient in whom PEP didn't work if taken within 72 hours. All in all, it's likely more effective than in the animal (primate) studies of its effectiveness.

The 3-drug might be slightly more effective than the 2-drug regimens, but again the research is very imprecise. From a scientific standpoint, it's a difficult thing to study. It's essentially impossible to conduct studies in humans with sufficient numbers to provide the levels of statistical certainty that such figures imply.

The bottom line (pun slightly intended) is that is is exceedingly unlikely you have HIV. If somehow I were in your situation, I wouldn't be at all worried about it.