[Question #1697] HIV Risk

55 months ago
I am currently in Thailand and I had sex with a commerical sex worker. I used a condom for oral and vaginal intercourse and during the middle of vaginal intercourse the condom broke.  I felt it immediately and pulled out. I must have been exposed for no more than 1 second.  I went to the shower and washed with soap and water, put another condom and finished.  My questions is, what is my risk for HIV transmission? I know the odds are in my favor but does this happening in Thailand have any increased chances? Also, does the short duration of unprotected exposure matter or is it the same as having unprotected sex? I went to an infection specialist the day after and he stated that my chances were low but still prescribed PEP of Truvada and Rilpivirine.  I'm wondering if this is the proper course of action.  Please help.  Thank you. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
55 months ago
Welcome to the forum. Thanks for your confidence in our services.

Congratulations for having safe sex. Too bad the condom broke, but it happens sometimes.

You are correct that the odds are in your favor -- overwhelmingly so. That the exposure occurred in Thailand slightly elevates the risk compared with, say, western Europe or the United States, because of differences in the likelihood a sex worker has HIV. Still, HIV has been dramatically controlled in Thailand compared with 10-20 years ago, and there probably is under a 1% chance your partner had HIV. And even with entirely unprotected sex, the average HIV transmission rate from vaginal sex averages around once for every 2,000 exposures -- and your risk was a lot lower than that, given the brief exposure after the condom broke. All things considered, I would calculate the chance you caught HIV at under well under one in a million.

Decisions for post exposure prophylaxis (PEP) are always best made on a case by case basis, and with understanding of details of risks in the immediate geographic area. Although my analysis above suggests a very low risk, perhaps the doctor or clinic where you were treated has more detailed knowledge suggesting higher risk; or perhaps for entirely unprotected sex. Decisions for PEP are easier than they once were, given the low toxicity and side effects of the drugs. Still, it's not a decision to be made lightly and I doubt I would have prescribed it in this situation. And there is another downside to PEP that you and the doctor might not have considered:  without treatment, you could have a conclusive 4th generation (antigen-antibody) HIV test 4 weeks after the event. With PEP, positive blood test in theory might be delayed if treatment doesn't work, and it is recommended that testing needs to be extended to 3 months. So if you continue PEP, you're looking at an additional 2 months of uncertainty, perhaps worry, and avoiding sex other partners.

But I cannot make the decision for you and I am not recommending you stop PEP. This is something to discuss with a physician in person, ideally the one who prescribed it.

I hope this has helped. Let me know if anything isnt clear. Best wishes and stay safe--  HHH, MD

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55 months ago
Thank you for the prompt and thorough reply.  It makes me feel much more at ease especially with all the reading I've been doing online and all the conflicting information out there.  You seem to be a foremost expert in this field so I trust your response.  I've been on Truvada and Rilprivirine for 5 days now.  If I decide to stop with PEP treatment now, would I still be about to get the 4th generation HIV test? Also, I recently had a urine test to check for other STDs.  I'm waiting for the results but if I test positive for gonorrhea or chlamydia, does that increase HIV transmission chances? It's been 6 days since the broken condom incident, is it too early to test for gonorrhea and chlamydia? If so, when should I do a follow up of all other STDs? Thank you.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
55 months ago
Gonorrhea and chlamydia testing are accurate and valid any time more than 3-4 days ater exposure, so go ahead with it. Absence of symptoms is strong evidence you didn't catch gonorrhea, less so for chlamydia -- but given the brevity of unprotected exposure, I expect both results to be negative. If positive, it might suggest a higher HIV risk, but still the odds would be very strongly against it.

There are no data at all on the effect of brief courses of PEP -- i.e. early cessation of planned one month treatment -- on delaying HIV test positivity. I suspect an antigen-antibody test would still be conclusive 4 weeks after exposure. However, despite your kind statement about my and Dr. Hook's expertise (thank you), I'm really not a true HIV testing expert; my expertise is greatest in non-HIV STDs. The doctor treating you (apparently an infectious diseases specialist?) may have more experience with HIV infected patients and HIV testing than I do. Don't hesitate to ask; you could even consider printing out this thread as a framework for discussion.

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