[Question #1714] HIV / STD Risks

44 months ago

Dear Doctors,

On Friday 27th January 2017, so 9 days ago I picked up a Colombian women in a bar in the Caribbean.

We went back to my place, where she performed unprotected oral sex on me, I rubbed her vagina and she played with my penis for a while. 

We decide we were going to take it further so I then put on a condom and had fairly rough sex with her, which consisted of kissing, fingering, and numerous sex positions; I did not climax and we stopped after a while.

We moved to the bedroom, I put on a new condom and we had another bout of fairly vigorous sex; again consisting of kissing, fingering, rubbing of genitals and various sex positions, this time however I did climax inside the condom.

When I checked the condoms in the morning they were both unbroken, tied and airtight which would suggest to me that they had remained in tact.  I subsequently untied them both filled them with water and again none came out, which would again hopefully suggest they had remained unbroken.

It was in the morning however when I was checking the condoms that I discovered that the woman was on her period, there was blood on the outside of both condoms, a little on the bed-sheets and a little on my hand, she also confirmed this.

As mentioned 9 days have passed, yesterday I started feeling a lump in my throat, I feel like I have a bit of a sore neck and there is one individual sore on the inside of my lower lip which is red in colour, almost feels and looks like a cut or that I have bitten my lip.

I have now totally convinced myself I have contracted HIV having read the early symptoms online and am totally freaking out.  I am having hot flushes when I think about it, keep swallowing which is making my throat feel tighter and every little pain in my neck and shoulders is super evident.

What would be your professional opinion?  Was the fact she on period likely to have increased her viral load?  If I had her blood on my hands from fingering her and then played with myself would I have put myself at risk?

I look forward to hopefully your prompt reply.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Welcome to the forum. Thanks for your question.

My first thought is to congratulate you for having safe sex for this event. But with or without protection, this was not nearly as risky an exposure as you think, and your symptoms are in fact not at all suggestive of a new HIV infection. The symptoms that matter are sore throat, skin rash, enlarged lymph nodes, and fever. Your symptoms really don't come close to the usual ones in newly infected persons. But more important, the odds are that your partner didn't have HIV; and if she did, even with entirely unprotected sex, the odds of HIV transmission if the woman has HIV average once for every 2,000 exposures. HIV is no more risky in vaginal sex with a woman who is menstruating, and the minor blood contact you report does not elevate your risk. And you had protected sex with a condom that didn't break. All the other details -- fingering, minor blood contact, oral sex -- are all trivial risks and don't change the overall picture.

That said, of course I cannot say the risk was zero. But the odds are very strongly in your favor. I would guess the odds you caught HIV are under one chance in a million. You should plan on being tested for HIV, but you'll need to wait a while. About 2 weeks after the exposure, a 4th generation (antigen-antibody) HIV test would detect 80-90% of new infections; and a 100% concluisve test could be done at 4 weeks.

In the meantime, stay relaxed. It is exceedingly unlikely you caught HIV from this event.

I hope this information has helped. Best wishes and stay safe--  HHH, MD

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44 months ago

Thanks for your reply and for putting my mind more at ease.

 

If you think my chances are one in a million, do you recommend testing just for psychological reasons?

 

Can you explain in layman’s terms why it is no more risky when a woman  is menstruating?  It would seem logical (to me at least) that the presence of blood would significantly increase the chances of infection. 

 

I appreciate you are a sexual health expert not a psychologist, but in your time you must have come across many people who had worked themselves up into a frenzy about HIV / STDs; are my symptoms of a lump in the throat, hot flushes that come and go when I think about it and sore neck consistent with this sort of thing?  I am perhaps not sleeping as well as normal as a result which probably isn’t helping.

 

The symptoms that matter as per your list above are a sore throat, skin rash, enlarged lymph nodes, and fever. 

Sore throat - As mentioned I have a bit of a lump in my throat, I don’t think I could describe it as sore as I have no trouble swallowing, eating, talking ect and there if no accompanied cough.

Skin rash - I do not have a skin rash. 

Enlarged lymph nodes - How can you tell if you lymph nodes are enlarged? 

Fever - What temperature would suggest a fever?

 

Does the presence of one individual sore on the inside of my lower lip which is red in colour suggest nothing?  I only ask again because a quick google search (granted probably a bad idea) would suggest it does.

 

Thanks again for you earlier reply, I can start peeling myself off the ceiling.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Yes, testing is often a good idea for anxious persons even when the risk is zero or close to it. Most anxious persons probably are more reassured by negative test results than by expert opinion based on probability and statistics.

We know that having unprotected sex during menstruation doesn't elevate risk over sex at other times. Probably it's because levels of HIV often are just as high in genital fluids as in blood, so adding blood to the mix doesn't significantly raise risk.

Sore throat with HIV would be just like any sore throat with a cold, not appearing as a "lump" feeling. Swollen lumps in the neck, under the armits, etc, are difficult to miss. DO NOT start poking those areas; repeated searching for enlarged nodes can enlarge them all by itself, causing confusion and anxiety. ARS fever usually is 101F or higher.

A single oral sore like this is not suggestive of HIV. When oral sores occur with HIV, usually there are several throughout the mouth. And it's uncommon anyway.

Thanks for the thanks. I'm glad to have helped!

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44 months ago

Doctor,

 

Having re-read your first response I am staggered at how low you say the chances are for totally unprotected sex - “odds of HIV transmission if the woman has HIV average once for every 2,000 exposures”.  How can it possibly be so low?  Is this statistic based on her taking medication and controlling her viral load?  What would the odds be if the woman was unaware or recently infected, I imagine significantly higher?

 

I still have a lump in the throat, the odd hot flush, a stiff upper back / back of the neck & shoulders, a sore jaw and oddly an itchy back of the head all of which seems to come and go / vary in severity throughout the day.  I am having a hard time concentrating and my vision is giving me a bit of a headache.

 

I don’t have any pain swallowing or any rash to speak of and the sore on the inside of my mouth appears to be healing and is almost gone.

 

I return home from holiday in the next few days and will do as you suggest and get a test for peace of mind.  In the meantime should I abstain from intercourse with my regular partner?

 

I appreciate this is my last follow up question so would like to take the opportunity to thank you once more and comment on what a good service you offer.  

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
That's a reasonable question, and I'm taking the opportunity now to write another blog-like reply I can use in future replies to similar questions. A lot of people find such a low per-exposure risk counterintuitive. But the data are quite strong. Two kinds of studies have been one. In one, people with and without HIV are interviewed about their risks, i.e. how many exposures of various kinds, and these results are analyzed with knowledge of the approximate chance their partners had HIV in the geographic area where they were exposed. In the other, couples in which one person has HIV and the other does not kept diaries to record every time they had sex. Below I have pasted a Table from CDC, based entirely on the first kind of data. It's from 2005 (CDC. Morbidity and Mortality Weekly Report 54 (RR-2), January 21, 2005). The data from both kinds of studies are for unprotected sex with partners not taking anti-HIV treatment. (With treatment that lowers HIV levels in the blood to undetctable levels, transmission risk is near zero for all kinds of sexual exposures.)

A third kind of study applies only to men having sex with men. The study showing nearly 100% protection by anti-HIV treatment included some men on placebo. The study was immediately stopped (long before originally planned) when the benefit of treatment became apparent. For what it's worth, all the infections in MSM occurred through anal sex, with few if any by oral sex. Of course no data on vaginal intercourse.

The risk of 5 in 10,000 is equivalent to 1 in 2,000. Note the risk is twice as high for the woman in vaginal sex, i.e. penile to vaginal, but still only 1 in 1,000. These are averages, and actual transmission risk also depends on viral load in the infected person and perhaps with other factors. Whatever the exact reasons, the fact is that exposures like yours always are relatively low risk. The vast majority of people with new, sexually acquired HIV infections were exposed repeatedly to infected partners, i.e. they catch it from their regular partners, often only after several years. It is extremely rare for anyone to be infected after any single exposure. The risk isn't zero, and I'm not implying a cavalier attitude toward protection. And the risks for other STDs typically is higher than for HIV, and of course condoms should be used for non-monogamous sexual events.

As for your continuing symptoms, they remain atypical for HIV and do not change my opinions or advice. Difficulty concentrating of course is almost always psychological, not physical (unless maybe you're resting poorly and are sleep deprived due to these anxieties).

There is no black and white answer to having sex with your regular partner. If somehow I were in your situation, I would continune unprotected sex with my wife without worry. The main thing is that your exposure was condom protected. But of course nobody can give a guarantee you weren't infected with HIV or other STD. You'll have to make your own decision -- while considering the implications of explaining things to a partner who might expect sex on your return home.

I'll leave this thread open for a final comment in case you have reactions or questions about this rather detailed reply.


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44 months ago

Doctor,

 

Thanks for your very detailed and informative response, and for leaving the forum open (I really have had my money’s worth).  The table is incredibly informative and somewhat surprising, but makes for an excellent read.

 

I am far calmer about the episode than I was previously.  Oddly when I was a younger man I would have protected sex and not really give it a second thought, I wasn’t “putting it about all over the place” but I has my fair share of one night stands / short term romances. Now I am older and in a relationship I suspect anxiety and guilt are the principle cause of my symptoms, I truly feel terrible about having done this.

 

As for the symptoms,

 

1)   If they were to occur would you expect to see the sore throat, skin rash, enlarged lymph nodes, and fever all happen together?

 

2)   If a rash were to occur how long after exposure would you expect to see this, would it be an all over body rash, how long would it normally last? 

 

3)   Would swollen / enlarged lymph nodes be viable to the eye, both on the neck and under the armpits?  What about the lymph nodes on the back of the head, would you expect these to flare up?

 

4)   How severe would a sore throat normally be?

 

5)   Would headaches or a feeling of being hot be in line with the fever?

 

6)   Would symptoms come and go or would they be constant for a for days / weeks?

 

I feel much less ignorant about the virus having raised my question, and really glad I did.

 

I called a clinic back home to arrange a test but they wouldn’t do one before 6 weeks, they said they offer a quick finger prick and blood test combination!  I don’t really want to wait that, short of lying about when the incident took place what other options do I have?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
You describe an entirely normal and expected sex life for the modern era. Don't beat yourself up over a behavioral pattern that applies to most people.

You are seriously overthinking the symptoms business. Many (most?) people with new HIV don't have noticeable symptoms. And when all these symptoms appear, they almost always are due to something other than HIV, even people at high risk. And you were at almost no risk anyway from the exposure described. This is mental masturbation and this line of thinking won't get you anywhere.

1) All together, and would have started by now.
2) All symptoms last 1-3 weeks.
3) Easily felt and noticed. If not, nothing is wrong.
4) Anywhere from trivial to horrible, usually somewhere in the middle.
5) Headache usually isn't involved and most fever doesn't cause headache.
6) Continuous, not come and go.

It shouldn't be difficult to find a clinic or doctor to do a 4th generation test at 4 weeks. If I were in your circumstances, however, I would not be tested for HIV at all and would be continuing unprotected sex with my wife.

That completes this thread. Do your best to mellow out and move on. You didn't catch HIV. Assuming you go ahead with testing, you can expect a negative result. Best wishes and stay safe.

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