I am a 34 year old heterosexual male living in NYC and am in a committed relationship with a heterosexual woman. With that said after a night of heavy drinking and MDMA usage I obviously wasn't thinking clearly and went online to solicit sex. I came across an ad posted by a pre-op Asian transsexual (MTF) who is not from America and had what I believe to be a Filipino accent and was curious. I reached out and arranged for her to come to my apartment. This was in the very early morning hours of Friday November 25th. She arrived at 6am and admitted that she too was on a substance "GHB". I was not thinking clearly at all and stupidly didn't even think to ask about her HIV status and she never mentioned anything about it either so I do not know whether or not she is HIV positive.

After arriving at my apartment she proceeded to give me unprotected oral sex for a while before I put on a latex condom and had anal sex with her for about 5-10 minutes. I had not ejaculated so pulled out and removed the condom, it was still intact. She went back to giving me unprotected oral sex for another few minutes and we then decided to again try anal so I put on a new latex condom and proceeded to again have protected anal sex. After another few minutes it was apparent I was not going to ejaculate so I stopped, removed the condom which was also intact and put a stop to whole thing. After she left my apartment I actually filled both condoms with water to make sure they hadn't broken, and neither had any leak.

Something worth noting is that I had unprotected anal sex with my girlfriend about 4 days before and had a bit of a rash on the left side of the shaft of my penis (I believe from friction), it was very red and appeared to look like little dots/bumps that weren't very raised - but no open wounds. I noticed before the Trans sex worker arrived that the rash looked very dry and the skin on the shaft of my penis was flaking. 

Anyway, after the Trans woman left my apartment I was so ashamed I immediately deleted her phone number and any trace of our communication. After thinking about things and starting to freak out I looked for her ad online that I had found her through and saw she had deleted that as well, as I wanted to ask her status. So unfortunately I have no way of getting in touch with her to ask. So given all that background I have a few questions. 

1. How likely is it that she was HIV positive? Again, she is not from the USA and I believe to be Filipino or of a similar Asian decent. Obviously given her profession and the fact that she had admitted the usage of "club drugs" I am very concerned.

2. Even though we used a condom for anal sex given the rash on my shaft, which definitely wasn't fully covered how likely is it that I would have contracted HIV through that if she was positive? 

3. The whole experience with her last from 6am to 7am on November 25th, it's now 3pm on November 26th so well within the 72 hours, do you recommend that I try to get PEP? 

4. In regards to testing, I have been reading about the HIV RNA test that an be given about 10 days after exposure. Would you recommend that? 

5. Finally my girlfriend got a new job and is traveling for a month so I will not see her until December 28th. I plan to get an antibody test at the four week mark, on December 23rd. I will be praying that comes back negative and if it does can I deem that conclusive and resume unprotected sex with my girlfriend? 

My main response is that despite your anxiety over your decision about such a sexual experience, you did it safely. Condoms work, as long as they don't break wide open. (The notion of small leaks you wouldn't otherwise notice, they almost never happen and "water testing" is a useless exercise. Even if you found a drop of water oozing through, it would not mean the sex had any lesser protection.) On one hand, this was a high risk situation:  regardless of trans status, you had sex with an anatomic male (or once anatomic male) who likely has had sex with other men who have sex with men. So although there are few data on HIV prevalence in transgenders, many or most MTF transgenders probably have risk characteristics and STD/HIV prevalences simliar to MSM in general. OTOH, you used condoms carefully for the only exposure events that matter in regard to HIV transmission. There is a small risk of STDs from unprotected oral sex (mouth to your penis), but little or none for HIV.

Further, although you don't know her HIV status, I suspect most trans sex workers know the score, get tested, and if HIV positive, are likely to be on effective treatment. In that case, there is little or no chance of HIV transmission, even without protection.

To your specific questions:

1) I can't judge the chance she had HIV, or uncontrolled HIV (untreated), any more than my comments above. Her national origin and use of club drugs are less important than her sexual behaviors and lifestyle, which are high risk.

2) While in theory skin rash or inflammation could increase the risk if exposed, it probably makes little important difference in your risk, especiallly with the dry and flaky appearance you describe. I wouldn't worry about that aspect.

3) PEP decisions always are local, i.e. best made by providers who understand local epidemiology (more info than I have about the chance your partner had untreated HIV); plus the patient's level of nervousness. If I were in your situation, I wouldn't seek PEP, but I'm not you. If you want to consider pursuing it, find a local physician or clinic with experience in HIV -- the health department, an infectious diseases specialist, etc. (Urgent care clinics are OK in a pinch, but in my experience tend to pretty automatically give PEP if requested, regardless of genuine understanding of the risks and benefits. After all, they're not saddled with follow-up, repeat testing, ongoing reassurance, etc.) Also, don't forget one major downside of PEP:  in theory, if it fails, in could prolong the period to conclusive testing. So instead of 4 weeks of uncertainty until conclusive testing, you would be on the emotional hook for 3 months.

4) I would not recommend RNA testing in this situation. Instead, a 4th generation (antigen-antibody, duo) test at 10-12 days and against at 4 weeks. A negative RNA test at 10 days would be no more reassuring, and neither is conclusive at that time.

5)  As just implied, make it an antigen-antibody test. Negative results at 4 weeks are conclusive.

Finally, although you don't mention other STDs, consider a urethral (or urine) gonorrhea/chlamydia test. These are conclusive any time more than 3-4 days after exposures. (You really don't need chlamydia, rarely transmitted by oral sex -- but almost always done automatically along with gonorrhea testing.)

I hope this information is helpful. Let me know if anything isn't clear. Best wishes and stay safe--  HHH, MD

Thank you for your thorough response,  given your advice I have decided to not pursue PEP and will wait the four weeks for the antigen-antibody treatment. I have  a  few follow up questions that I would really appreciate your help with:

I understand there isn't enough data for you to weigh in on the  prevalence of HIV amongst trans (MTF) women, and that risk characteristics would be similar to the MSM population. Given that, and knowing it's NYC, along with her lifestyle of being a CSW how likely is it she even has HIV?  Knowing the circumstances how concerned about HIV should I really be? 

Also, while the rash seemed to have been drying up and resolving before our encounter the next day it was back to looking a bit red, but still not open wounds or sores. I presume this was again due to the friction but now it looks even better than before our experience together. Should I take that as a good sign? 

You also mention the risk of other bacterial STI's. Given that, in your professional opinion should I be more concerned about other STI's over HIV? Knowing the circumstances what are the odds/likelihood of each? How risky was this whole thing really? 

Finally,  by going through my mobile phone provider I was able to obtain her phone number and spoke with her about everything. She said she gets tested regularly and that she is clean,  would that affect your opinion of things at all? I want to trust in what she said, but given her profession I feel she would say that regardless of whether or not it's true. 

As I am sure you can imagine I am freaking out and want to know just how serious this is as I still have a a number of weeks before I can know for sure one way or another and I can't help but assume the worst. I want to go back to living my normal life but it's already starting to consume my mind and time spent alone. 

Thanks again for your time and thoughtfulness! 

PS - would it be possible to keep this thread active for me to come back toward the end of December after my antigen-antibody test results come back? 

I understand there is a limit to follow ups, so if you can address my previous response and this I would really appreciate it and consider this closed and will not post again.  But another thing I should have mentioned but forgot and I am scared could increase my risk of HIV infection if she was positive is that I have Herpes Gladatroium (Sean confirmed HSV-1), from my days of competing as a wrestler. I have only ever had one outbreak and it was on my jawline. I know herpes can increase the risk of HIV as well, so if she was infected would the presence of the herpes virus in my body increase my risk of infection; especially with the rash on my penile shaft and despite the use of condoms? 

Sorry for the double follow-up, if you can address I really would appreciate it!!

Thank you so much again for all your service! 

Genital HSV2 increases the risk of sexual acquisition of HIV, if exposed. HSV1 does not, whether genital, oral, or anywhere else, e.g. arms, legs etc in herpes gladiatorum. The biological reasons for risk with only one of the two HSV types are not fully understood, but they have been rigorously documented in several good research studies. So your past diagnosis HSV1 doesn't change anything.

That will have to be the last comment until and unless you want to post your test results in a few weeks. In the meantime, you can count on negative results. So stay mellow while you wait.

Happy holidays, I hope you've had a great weekend. As suggested I had a panel of tests for HIV, chlamydia, and gonorrhea run at 11.5 days post potential exposure and all came back negative.

I was then restested for HIV via 4th generation antigen/antibody: 26 days, 3 hours after potential exposure and I just got the results; again negative. I went a bit earlier than recommended due to the holidays. I know you recommended waiting until 28 days, but how conclusive would you say my results are?

I will be reuniting with my girlfriend in 2 days as well, and we have been engaging in unprotected sex previously. Would it be alright to continue that? I have had no other risky exposures. 

Finally, should I plan to retest and if so, when? 

Thank you for all your help! 

Thanks for the thanks. Best wishes and happy holidays--   HHH, MD