Hello Doctors,

I am a heterosexual male from Puerto Vallarta, Mexico, and had an encounter with a female sex worker approximately 6 hours ago at a regulated establishment in Puerto Vallarta.

Vaginal intercourse was condom protected from the beginning. I did not ejaculate at any point before the event in question.

Near the end of intercourse, I withdrew my penis from her vagina and immediately noticed that the condom was no longer on my penis. At that same moment, the woman told me that the condom had just come off. The condom was visibly hanging from the vaginal opening when I saw it. I removed it and immediately put on a new condom before continuing.

There was no visible blood, trauma, or rough sex. The woman stated that there had not been any unprotected intercourse and that the condom came off at the moment I withdrew. Based on what I observed, that seems plausible, although I cannot know with certainty exactly when the condom detached.

The woman appeared to be approximately 30 years old and was working at a regulated establishment. I do not know her HIV status.

My questions are:

1. Based on this description, would you consider this a meaningful HIV exposure?

2. In your opinion, would HIV PEP be recommended, optional, or unnecessary?

3. Beyond HIV, would you consider this a significant exposure for other STIs such as gonorrhea, chlamydia, syphilis, herpes, or hepatitis B?

4. Given the circumstances, would you recommend doxycycline PEP?

5. If you were counseling a patient with this exact exposure, would you recommend any HIV or STI testing at all?

6. If HIV testing is reasonable for reassurance, would a negative 4th-generation HIV test at 4 weeks be considered conclusive or sufficiently reassuring?

Thank you very much for your time.