[Question #2090] Oral Sex & HIV/STD - Risk Level.

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83 months ago
I am a 30-something "straight" married man who met a 40-something "straight" married man anonymously on Craigslist last week.  I have HSV-1, and have since I was a child.  He claimed to be drug and disease-free, but his STD and HIV status is unknown to me outside of that.  I've had no prior homosexual encounters, but was intoxicated and my lack of judgment at the time led to me pursuing this.

We performed unprotected fellatio on one another for a brief period of time, and he rimmed me for perhaps ten seconds or so.  He did not ejaculate into my mouth, in me, etc...

I am on a regular dose of 200mg Doxycycline for a dermatologic condition.  In addition, given my paranoia surrounding the situation, I took a 1000mg dose of Cefuroxime that I had on-hand.  Two or three days after the encounter, I began having itching/discomfort on/in my anus, and a slight burning sensation in my penis when urinating. In addition, I have fear surrounding potential HIV transmission. 

Given the circumstances, I am quite anxious about my status, and am refraining from any sexual contact with my wife until I gain further understanding of my potential exposure here.  From what you've read, what am I at risk for from an STD standpoint?  Is HIV possible here?  If not an STD, what could potentially be causing this anal and penile discomfort? Thank you for reviewing this.
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H. Hunter Handsfield, MD
83 months ago
Welcome to the forum. Thanks for your confidence in our services. Your question popped up while I was logged in:  most users shouldn't expect nearly real-time replies!

Oral sex should be viewed as safe sex. It's not entirely risk free, but the chance of all STDs is far lower than for anal or vaginal sex (unprotected oral probably is even safer than condom-protected vag/anal). Some STDs are virtually never transmitted by fellatio, and that includes HIV; and others are rare. The biggest potential disease risk from this encounter was for your partner, specifically the risk of getting genital herpes from your oral HSV1 infection; that was a low risk in absence of an overt cold sore outbreak, but not zero. (Presumably you told him of your history of oral herpes, right?)

The insertive partner in fellatio is at measurable risk for only 4 infections. In your case we pretty confidently dismiss all of them:  1) Gonorrhea, but extremely unlikely in view of being on doxycycline. 2) Syphilis, ditto -- potential risk in men having sex with men (much more rare in strict heterosexuals), but 100% prevented by doxycycline. 3) Nongonococcal urethritis (NGU), which in oral sex isometimes may be due to entirely normal oral bacteria -- but this too is normally treated with doxycycline, so probably you also were protected against NGU. 4) Genital herpes due to HSV1 is a possibility, but only in people without prior HSV1 -- so no worries there either (except maybe for your partner, discussed above).

To expand on the low risk of HIV, there has never been a proved case of oral to penile transmission and there is also little risk in the other direction. Estimates by CDC peg the approximate risk for fellatio as 1 in 10,000 for the oral/receptive partner and 1 in 20,000 for the penile/insertive one. These rates are equivalent to giving or receiving BJs with infected partners once daily for 27 or 55 years before transmission might be likely. In other words, zero for all practical purposes. And it seems very unlikely your partner has HIV anyway.

As for your anal irritation, probably you have a yeast infection. Many antibiotics predispose to yeast, and doxycycline and broad spectrum cephalosporins like cefuroxime are among the most potent in this regard. (Most people on chronic doxycycline therapy, e.g. for certain skin conditions, take only 100 mg daily, so you might have been even more susceptible to yeast than many people would be.) This probably doesn't explain the slight discomfort in urination, but my guess is that this is mostly psychological -- i.e. anxiety elevating your awareness of a minor symptom or even entirely normal body sensations you otherwise would ignore or not even notice. Should you develop severe urethral pain or abnormal discharge, you'll need to get it checked out, but for now I don't think it's necessary.

Ideally your anal problem should be professionally evaluated. The doctor who prescribed doxycycline should be a good choice for this. But I think yeast is sufficiently likely that you could first try an over-the-counter antifungal cream, e.g. clotrimazole. (Most such products will be in the women's health section of the pharmacy shelves -- or ask the pharmacist.) If that hasn't helped after 3-4 days, you'll definitely need to be examined.

Bottom line:  I don't recommend any testing at this time, but get checked if new symptoms develop or any other doubts about it.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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83 months ago
Thank you for the prompt reply, Dr. HHH.  Follow-up question for you - ironically, I was prescribed the doxycycline regimen by my dermatologist the day after my encounter.  Does this change your thoughts related to my STD risk?  I am slated to take 8 days worth of the 200mg doxycycline, and as I mentioned before, took a 1000mg dose of cefuroxime the day after my encounter.  I believe that gonorrhea/chlamydia/NGU are eradicated with doxycycline after 7 days (guessing that the additional cefuroxime would reduce the gonorrhea risk), but am unsure as it relates to syphilis and exposure there.

In addition - I realize my HIV risk is minimal, but had read about HIV RNA tests and their ability to diagnose within a 9-11 day window.  Are these tests reliable, or known for false positive/negative results?  Thank you again for your clarification.
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H. Hunter Handsfield, MD
83 months ago
This doesn't change my opinions or advice. Taken so quickly after exposure, these antibiotics would prevent the STDs I described, or would abort them before symptoms ever start.

The plasma RNA test for HIV detects about 90-95% of infections at 9-11 days. As an indication of how good they are, these tests are part of the basis of all blood bank routine testing of all blood donations, and are largely responsible for the fact that there have been no transfusion related HIV infections in the US in recent years. That's how good they are, when combined with antibody testing as you had. And as I said, there is no realistic chance you were infected from this exposure anyway.
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