[Question #3832] Possible brief (five minutes maximum) exposure to precum HIV risk

34 months ago
I have a question about HIV risk. I tested negative about eight months ago and only had one encounter after this past January. I had a one night stand with a caucasian transgender (well transitioning male still not full transgender) and something happened that's been freaking me out. So I was the receptive partner (anal) and we were safe (using a condom and condom-friendly lube). We switched positions and I checked to see if the condom was still on, and it was, after continuing for another two-four minutes, she pulled out because her penis became soft, and before she put it back in I checked to see if the condom was still on and it wasn't, so I started looking for it under me and it was nowhere to be found, and she pulled it from my ass and said it was hanging outside of it and laughed. Well penetration stopped there and we ejaculated (so no ejaculation occurred during penetration). The whole episode lasted  My question is if the condom slipped out while we having sex and there was brief (let's say five minutes at maximum) unprotected penetration, is that a considerable risk? (considering if any fluid was exchanged it would only be precum as she was far from ejaculating when we stopped.) Also five-six weeks after the incident, I came down with a lung infection, but it was winter time and people all around me were getting the same so I didn't think much of it.
34 months ago
The whole episode lasted about 10-15 minutes (from start of penetration to the condom issue) 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Welcome back to the forum. Thanks for your continuing confidence in our services.

When the penis withdraws from the condom, with the condom left behind in the rectum (or vagina), protection is still considered complete. So on one hand, this was a low risk exposure. However, by another analysis, it was high risk:  you had receptive anal sex (bottom) with another male. (She was anatomically male and must be viewed in the same risk category of all men who have sex with men, i.e. the highest risk category for sexual transmission.) Even with a condom, such an exposure can be considered high risk for HIV. And if there was continued penile insertion (and thrusting) without condom coverage, the risk could have been quite high.

Did you ask your partner about her HIV status? People rarely lie when asked directly, and safety is far higher with partners who say or believe they don't have HIV or, if infected, on anti-HIV drugs. So asking about HIV status is always a crucial part of sexual safety with new or commercial partners and is especially important for men having sex with (anatomic) men, including transgenders. Since you don't know, we have to consider the possibility she has HIV and that this was perhaps quite a high risk exposure. You definitely should be tested for HIV, and it also would be a good idea to have a syphilis blood test and rectal swab testing for gonorrhea and chlamydia. 

Having a "lung infection" (bronchitis, pneumonia, etc) does not suggest you had HIV. That part of your history can be ignored.

Don't get me wrong:  I strongly doubt you caught HIV, and most likely no other STDs as well.  Even with entirely unprotected receptive anal sex with a known infected partner, the average transmission risk is around 1 in 250, probably lower in your case, since there was no ejaculation in the rectum. However, it definitely was high enough risk that you need HIV testing.

In your discussion with Dr. Hook a few months ago, you worried about HIV testing because you were in a country that deports HIV infected persons (UAE, maybe?). But even if you're still there, you should be tested. Such countries do not deport or reject new arrivals simply because of being tested, only if positive -- and almost certainly your test will be negative. And in the slight chance it's positive, you'll need to leave the country soon anyway in order to receive proper treatment. So you may as well do it now, as well as the tests recommended for other STDs.

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

HHH, MD
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34 months ago
I did get tested last time, and went through a mini nervous break down, but was very relieved when the results came back negative. I will get tested again, but I am curious about this event. Because I've even read a research study that showed the viral load in precum even in individuals with a high viral load is extremey below that of semen. So I guess I just wanted some peace of mind, and she said she was negative. Would you prescribe PEP in an incident such as this if I was in the window period for it? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Indeed, HIV viral load is lower in pre-ejaculate fluid than in semen. But the data show that anal sex remains risky whether or not there is ejaculation in the rectum. As I said above, your risk is lower than it would have been with ejaculation. But there are no data to know just how much lower the risk might be.

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34 months ago
So in your opinion, would this be a situation that if I were to be put into it again, I should seek out PEP? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
PEP could be a consideration, yes. But also see my advice above about asking your prospective partner(s) about their HIV status. If the likelihood s/he is infected is low, PEP probably wouldn't be recommended. But all PEP decisions should be made on a case by case basis, by a physician or clinic with lots of experience in HIV prevention and with understanding of local epidemiology of HIV, i.e. the likelihood particular kinds of partners are infected. It's never a decision to be based on advice from a distant online forum.

The other reassuring information -- which I forgot to emphasize until now -- is that in general you are trying hard to be sexually safe, with consistent condom use. That probably implies you're also selecting your partners with some level of care, seeming good health, etc. While these things are never solid guarantees against catching HIV or other STDs, these approaches and attitudes mean you are at low risk in general terms. Keep it up!

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

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