[Question #1989] HIV Risk/STI

50 months ago
Good evening,

I am currently stationed in Bahrain for work, and two weeks ago I met with a Transexual CSW. The night consisted of unprotected oral to both parties without ejacualtion multiple times. It also included both receptive and penetrative anal sex which was protected.

My concern comes from the fact that when she ejaculated she pulled out of me, removed the condom, and finished on my back side. While I know protected anal is very low risk, the fact that her seaman could have made it's way back down to my ass is of considerable concern.

I have also found the last week that I have been incredibly nauseous, as well as had multiple bouts of diarrhea which was yellowish in color. As well as some lower back pain, which I'll admit could be work related.

I am aware that in order to come to Bahrain you have to be tested in order to receive a visa, and she has only been here about 4 months. However, since you will be automatically deported I feel as though their lack of sexual health reporting here makes it hard to gather what the statistics really are. 

So please let me know what I should do, and what my risk really are. I also plan on ordering a couple Oraquick test to take in the coming weeks once I reach the window to be able to be useful at all.

Thank you
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
50 months ago
Welcome to the forum. Thanks for your question, which came in shortly before I logged in. Most users don't get such quick replies!

First, for the reasons you state, it is statistically unlikely your partner has HIV. Second, even if she does, semen on the back or buttocks is not going to transmit HIV, even if it comes in superficial contact with the anal area.

As for your symptoms, they don't concern me. New HIV infection doesn't cause the symptoms described. (It can be associated with diarrhea and nausea, but never as the only or primary symptoms. And back pain doesn't fit at all.) If your gastrointestinal symptoms continue, I would be more concerned about a sexually acquired bacterial or parasitic infection, which could be related to the exposure described. It's probably unlikely and in any case wouldn't worry about it unless your symptoms continue.

The oral fluids HIV tests are the least reliable and most to be avoided in your situation. They give more false positive results (which can be highly disconcerting) than lab based tests and take longer for seroconversion. Although modern lab based tests (4th generation) are conclusive any time 4 weeks or more after exposure, that time is 3 months for oral fluids. I definitely recommend against oral fluids testing sooner than 4 weeks after exposure.

As for testing in Bahrain, UAE, or other middle east countries that attract ex-pat workers, I think the concerns about HIV testing are overblown. Admittedly I have no experience with Barhain in this regard, but I know people are more concerned than necessary in Dubai. I doubt anybody is being deported just for being tested, and in Dubai (and probably in Bahrain) there are clinics that keep such information highly confidential. Deportation undoubtedly is a risk if HIV positive, but that's very unlikely in most situations, including yours; and if positive, you need to be promptly evaluated by an HIV expert and started on life-saving treatment. So newly infected people have to leave anyway. I suppose it makes sense for people truly at high risk to have their work and personal affairs in order before being tested, in case deportation is immediate. But for most people at low or average risk, it seems to me that these fears do not justify delaying testing for HIV.

Final advice:  Your partner may be transgender and from a personal relationship standard, she is female. However, it is obvious she is anatomically male, and she performs anal sex both insertively and receptively. That places her at especially high risk for HIV, and your sexual contacts with such persons at similarly high risk. Condoms sometimes fail -- so while of course they are necessary for anal sex both top and bottom, they are not foolproof. That said, probably HIV remains rare in most transgenders in the urban Middle East. But if such sexual exposures continue, you should consider yourself at high risk for HIV and get tested from time to time (e.g. yearly) even if there are no obvious lapses in sexual safety. A word to the wise!

Don't interpret these comments as undercutting my advice above. The chance you caught HIV from the event described still is zero or close to it.

I hope these comments are helpful. Best wishes and stay safe.

HHH, MD

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50 months ago
Thank you for the quick reply.

Quick follow up, haven't you and your colleagues in the past said that the oral swap test would be about 95% accurate at the 6 week mark. I ask this only because of the nature of my job, and obviously if I were to receive a positive (flase or actual) I would then go to get it confirmed.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
50 months ago
Yes, that has been our advice. And 95% probably is about right. But that still leaves 5% that won't be positivve until 3 months. And the false positive problem remains -- not frequent, but a lot more common than with blood tests. In addition, I am aware of a coming publication -- not yet in print -- that discusses that oral fluids test interpretation (color and density of the lab strips, as observed by medically untrained persons testing themselves) is not always as certain as for lab based tests. All experts increasingly agree the oral fluids test is OK for people generally at risk and want reassuring test results covering their lifetime risks, they are the least suitable of all tests following any single exposure of concern. That said, you seem to have a level head about it and would get follow-up testing if there were any doubt about the result, so feel free. Just be aware of the cautions.

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49 months ago
Good Evening Doc,

I was also curious about what risk you can perceive from my encounter/symptoms for other STI/STD's? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
49 months ago
Condoms are highly effective in preventing STDs transmitted through genital fluids (gonorrhea, chlamydia, HIV, hepatitis B) but less so against those transmitted skin-to-skin (herpes, HPV, syphilis). Oral sex is relatively low risk for all STDs, but not zero. But I have no way of judging the likelihood that a particular transgender woman in Bahrain might or might not be infected; and there are no data on which to base a numerical risk estimate. But there is at least a small chance of exposure and infection with one or more of these STDs. To be maximally safe, I would recommend a urine test for gonorrhea and chlamydia, and a throat swab to test for oral gonorrhea (not detectable by urine testing) -- these tests are accurate any time more than 3-4 days after exposure. Also a syphilis blood test at 6 weeks -- although the chance of syphilis is very low if you don't develop a sore at an exposed site within 3 weeks of exposure. There is little point in any other tests aside from these:  the risks are too low and the available tests imperfect.

That completes the two follow-up questions and replies included with each initial question, and so concludes this thread. I hope the discussion has been helpful. Best wishes and stay safe.

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