[Question #3490] Recieved Oral from high risk partner

35 months ago
Dr. HHH,

I have gotten myself into a situation that has been bothering me immensely. I am a 36 years old uncircumcised male of east Indian descent living in the US.  I recently visited Thailand and received unprotected oral and protected vaginal sex from a very, very high-risk female sex worker. I call her very high risk because after 3-4 minutes of protected sex she told me that for an extra tip, I can go unprotected. I was shocked to hear that and immediately ended the session. I asked her if she has any std. She told me she didn't have anything . But I don't know if I can believe her.  I read somewhere that in certain segments of female sex workers in Thailand, HIV prevalence is as high as 20% to 45%. Because of her inconsistent condom use, I am sure she falls into the high-risk segment. I will really appreciate if you can answer the following questions. 

(1) I received vigorous unprotected oral sex for 10-15 minutes. I understand that saliva is not infectious but what if she had blood in her mouth? She works in a massage parlor and probably sees several clients a day and performs oral sex on them. So it's likely she had some trauma and therefore blood in her mouth. Will that increase the risk of transmission to me? 

(2) Will the fact that it happened in a Thailand increase the risk for transmission? I only ask because studies have shown different rate of transmission in high vs low income countries. For example, according the website aidsmap, the average rate of transmission to male from female in high income countries is around 1 in 2380 whereas in low income countries it's almost 10 times higher at 1 in 263!

(3) I got tested for gonorrhea and chlamydia around 4 days after exposure which came back  negative. I will test for Syphilis after 6 weeks. Do you recommend testing for other STD's?

 It's been only a week so I have a few more weeks to go before I can have a conclusive HIV test.  What are my chances?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Welcome back to the forum, but sorry you found it necessary.

I agree that your partner's offer of condomless sex marks her as higher risk for HIV. Still, it remains statistically unlikely she has HIV, and your risk of HIV from this event is zero or close to it. I can't comment on "certain segments" of Thai sex workers, but in general Thailand has had great success in controlling heterosexually transmitted HIV, and I believe the overall proportion of female sex workers with HIV is far lower.

1) But more important, as we discussed in your earlier thread several months ago, oral sex is low risk, with no scientifically documented cases of HIV transmission oral to penis. Could blood in the mouth make a difference? I suppose so. OTOH, blood in the mouth is quite common, e.g. from bleeding gums, so there must have been billions of oral sex events by HIV infected persons, and still no known transmissions. In any case, I disagree with your assumption that if she had recently performed oral sex on several men, she therefore had been traumatized and was "likely" to have blood in her mouth.

2) You cannot safely generalize such broad data. If tthere really is a higher per-exposure risk of HIV in low income countries, it probably results from higher proportions of recently infected persons in the population, with a higher viral load than otherwise. 

3) I'm glad to hear your gonorrhea and chlamydia tests were negative. You can expect the same for syphilis and HIV. For HIV, I would recommend testing primarily for reassurance, not because you are really at significant risk. You are not. In any case, I would suggest an AgAb ("4th generation") lab-based blood test about 2 weeks after the exposure:  although too soon for conclusive results, at 2 weeks a negative result will be around 80% reliable, which should be reassuring. Then have a final, conclusive test at 6 weeks.

I hope this information is hlepful. Let me know if anything isn't clear.

HHH, MD
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35 months ago
Thank you for your very reassuring response Dr. HHH. I will follow your testing recommendation. My anxiety is probably making this situation far scarier than it really is. I only engage in this kind of behavior 2 or 3 times a year and I feel anxious every time I do it. My anxiety is especially worse this time because of the higher likelihood that the women was infected. I have decided to never engage in this kind of behavior ever  again because of extraordinary anxiety and grief it causes me.  I also need to address my anxiety issues as it has caused a lot of trouble in my life including divorce.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Thanks for the thanks. However, I would suggest you be cautious about pledges that may be impractical. Rather than completely swearing off commercial sex exposures, you might find it wiser to set limits (for example, you can ask ahead of time about condom policies with other clients). I'm not a psychologist, but I can see a pretty serious vicious cycle of temptation, giving in, recrimination, worsened anxiety, and back again to temptation. Also, if your anxiety and/or other mental health issues (it may not be anxiety alone) are serious enough to have caused a divorce, there's a clear need for professional mental health care. I suggest it from compassion, not criticism!

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