[Question #306] Risk of STD Transmission, especially Herpes

35 months ago

Hello, what great work you do - and you do while giving dignity to us who find ourselves stressed and anxious, thank you. I had my first (and only!) sexual encounter with a sex worker on November 21/22. We had very brief unprotected moment of oral sex when she placed her mount around my penis. I immediately stopped her and demanded a condom. I put it on, and we continued to have oral sex. We then had vaginal sex, protected, though the condom rolled down a bit. The head and opening on my penis remained fully covered. I took off the condom, she fingered herself vigorously, and gave me a vigorous hand job. I asked her afterwards about her status, and she claimed to be "very negative" for it all. No noticeable blisters or sores on her mouth.

 

I am partnered. I seriously regret this decision, tremendously, and am eager to return to a normal sexual life with her. But I don't want to give her anything, but I also don't want to wait six-twelve weeks for conclusive tests for STIs that I was not at real risk of contracting anyway.

What is my real risk of Herpes given that this is my second partner and it was (mostly) protected sex? It has been 11 days with no symptoms. I know that you can have HSV1/2 and be asymptomatic, but not with first, initial outbreak right? How common is it? How likely is it that I, 11 days later, would have symptoms if I were newly infected with 1 or 2? Is it likely enough that in the absence of them I can assume I am negative and get back to my life?

 

Finally, someone at ASHA P2P said it was 50% likely that I contracted HSV and 50% likely that I am asymptomatic, I do not know if I should believe those numbers - based on what I have read Drs. Handsfield and Hook say to others in a similar scenario.

 

http://www.medhelp.org/posts/STDs/Unprotected-Oral--Visible-Sore/show/1428742

http://www.medhelp.org/posts/STDs/Possible-HSV-2-Exposure/show/1616016

http://www.medhelp.org/posts/STDs/STD-Risk---Receiving-Unprotected-Oral-Sex/show/1200596

 

I will get tested but the waiting period is so long (12 weeks) for conclusive results. But if there is not real risk of having contracted STIs, do I have enough reasons to worry about them to hold off on resuming normal sexual practices with partner until I have conclusive results?

Thank you.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
35 months ago
I don't know who is responding on ASAH P2P but they are way out in left field on this one. 
Perhaps they are thinking that you may already have HSV  infection from acquiring it as a child or through kissing and may not know it?  I'm thinking maybe that's what is going on here, in regards to their comments.  Do I think you acquired genital herpes from receiving a moment or two of oral sex from this CSW?  No!  I think it is extremely unlikely, just so very very unlikely.  Have you ever in your life had a cold sore on your lip or in your nose?  If yes, then you already have HSV 1, which is what you would most likely get from oral sex.  Obviously we can't give you a guarantee about this, but  if I was in your situation, I would not worry about this.

Terri
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35 months ago
Nurse Warren, thank you very much for your response. No, I have no had a core sore or fever blister on or near my mouth or nose, even as a child (at least as I can recall). Does this change anything for you? know that you cannot provide me with an exact percentage of risk here, I do. I also promise I will not badger you with multiple follow ups. :) 

1. The other point of concern for me, I think, is that the condom rolled down a bit during vaginal sex. Most of my penis remained covered, however. I know that this may raises the risk of genital HSV2 slightly, correct, but is it enough to register more concern about the chances/likelihood of transmission in this case? Dr. Hansfield, when responding to an inquirer who had protected sex/broken condom with a HSV2 positive partner, said that "the average transmission risk for genital HSV-2, when one partner is known to be infected, is under 1 in 1,000 for each episode of unprotected sex.  Your risk probably is lower than that, since the unprotected exposure, after condom breakage, was brief." Do you agree that this is close to my own risk? 

2. It is day 12 and no lesions, sores, or blisters. I check myself multiple times a day with no changes. I know that HSV can manifest itself anytime between 2-21 days, but in a recent Medhelp post, Dr. Hook advised an inquirier with possible exposure to HSV1 during oral sex that "If you did acquire genital herpes from this exposure, you should develop penile lesions within 14 days of the exposure at the site of exposure. If you do not develop lesions by 14 days, you do not need to worry."  Do you agree that in this situation, with the possibility being HSV1 (momentary unprotected oral sex) and/or HSV2 (condom rolling down), that if I am still clear in 14 days or so, I do not need to worry? I ask this because I know that it's possible to be infected with HSV2 and be asymptomatic, but especially considering that I have no memory of having a core sore or fever blister as a child, do you agree that it is very likely that I would present with herpes symptoms if I have been infected? In a nutshell - at day 21 or so, should I take my lack of herpetic symptoms as a reassuring sign that I was not infected? 

Finally, do you think I should get tested for HSV? Hook and Hansfield repeatedly advise against herpes testing in low risk situations like mine - mostly because of unreliable tests and false positives. You seem more convinced of its helpfulness. But I am concerned about the possibility of a false positive, which seem to happen a lot .  Do you think the risk here is low enough to forgo testing (especially without symptoms) or do you still think I should get an type specific IGG test at 12 weeks? I am less interested in getting for my own peace of mind, but more about whether or not I have reason to think I really got infected - and so should test for it. 

Forgive my loquaciousness. Thank you. You do really important work here, giving dignity and grace to those of us in vulnerable situations. 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
35 months ago
While condom do offer a great deal of protection, no they are no perfect.  But your situation with a condom that rolled down slightly is quite different, in my opinion, than a situation in which a condom breaks.  I don't know the exact number that can be applied to your risk but around 1 in 1,000 seems a little high to me for this particular situation, though honestly, these are rough estimate that we give you.
I am less certain that if you don't have symptoms in 14 days you are not infected.  If we know that about 80% of those infected with herpes don't know it, I'm not clear how we can say after X number of days, you are not infected.  I can say that if you don't see symptoms within 14 days, as hard as you are looking, that infection is unlikely - you certainly wouldn't miss symptoms, that's for sure!  And if you truly are not infected with HSV 1 or HSV 2 already, you would be more likely to have significant symptoms that would be noticeable. 
As far as testing goes, yes, I am more inclined to suggest that people test than are Dr. Hook or Dr. Handsfield.  We don't do STD testing at our clinic without including herpes testing unless someone specifically declines testing.  The literature and our own studies have shown us that there is a range of index values in which we can find false positives.  There are outliers on that, as well, but not many.  for those people who test positive in the low positive range or for whom the results just don't fit, we reflex testing to the herpes western blot which we feel is very good.  In other words, we can usually work out test results that are unclear or are suspect of being false positive.  In our clinic where we do the screening test about 80 times a month, about 5.5% of people's results fall into that low positive range.  The rest are either strongly positive or negative.  So I'm pretty comfortable working with these tests.  Having said that, I'm not clear that testing in your situation is necessary since I believe your situation was so low risk.

Terri
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