[Question #398] HIV Risk assessment please

34 months ago
I had an MSM encounter on 12/21/15 at a video store, in a booth which is separated by partitions. I was in the insertive role throughout this encounter. It began with oral through the partition which was rough/too close to my head (sensitive in that area) and didn't feel good. I pulled out, both to take a break from that and to get a better look at the guy. 

I resumed and put my penis back through the hole in the partition where I finished in what I believe to be his mouth. The confusion I am having is that i recall the smell of feces, however the feeling on my penis wasn't of anal but of a mouth (they're distinct sensations for your penis). 

As I was leaving, I went into the restroom to look at my penis. I did not see remnants of feces on my penis like one would imagine with that smell and having been the insertive partner, however I noticed 3-4 dark marks on the head (circumsized) which I believe to be bite marks; as it was rough in the beginning. My skin didn't break during this encounter, and over the next few days they expanded a little bit then faded and are hardly noticeable now. 

What has been giving me anxiety is: I know if it was simply oral, then I have no risk (although the dark bruise marks were quite alarming), but if it was anal then it would have been unprotected. I cannot explain the poop smell, unless he just had really terrible breath?? I realize the risk for STI's and I will be testing for this and will continue to monitor any symptoms. Since those are manageable, my concern is HIV. I spoke to an HIV counselor over the phone earlier this week and explained the situation and he didn't believe the encounter was anything but oral, and set me up with an appointment for Monday 1/4/16, which would be the 14 day mark. I know this facility has the resources for this type of testing that soon. 

This might all sound a little funny because how can I not tell the difference, and I admit that my nerves are getting the best of me here. But I'm interested in other people's take on this. 

Also curious about reliability of testing at this point. Did some homework and learned that HIV is detectable at this point with a follow up at the 28 day phase; do I have this correct?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Welcome to the forum. Thanks for your question.

I cannot be the one to judge whether your exposure was oral or anal. The mechanics of sex through a small hole in a partition would seem to make anal less probable, but you'll have to rely on your own judgment and that of the HIV counselor. You are correct that anal would be a lot more risky than oral. If it was oral, there is essentially no risk for HIV. But even if anal, and even if your "partner" (I'm not sure I would dignify it with that word) has untreated HIV, the odds remain in your favor -- probably an average of one transmission per 200-500 such exposures.

You could be tested for HIV at this time with a 4th generation ("duo", "combo") test, which probably would detect somewhere around 80-90% of infections at 2 weeks; and assuming negative, a repeat conclusive test at 4 weeks. For the reasons above, whether the exposure was oral or anal, you can expect negative results. You should also be tested for gonorrhea and chlamydia (urine or urethral swab, valid any time) and syphilis (blood test after 6 weeks).

Finally, although it is unlikely you caught HIV from this particular event, if this event reflects your sexual lifestyle, I think there is a high chance you can expect to catch HIV someday. (If your HIV counselor is doing his job correctly, you will have heard the same thing from him.) If all you ever do is have insertive oral sex with other men, the chance of HIV will remain near zero. But most men who participate in such highly anonymous exposures with multiple partners do not limit themselves to one kind of exposure -- and in general such persons are among the highest of the high risk for HIV. I would strongly encourage you to consider your sexual lifestyle going forward. I trust it's clear that this is pragmatic advice, not moralistic.

Best wishes and happy new year--   HHH, MD

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34 months ago
Thanks Dr. Handsfield for the reply and the stern advisement. I am not taking your reply as anything but pragmatic. This encounter is not representative of my sexual lifestyle, which is why I have great worry about it, and thus decided to turn to this forum.

As I had observed in your past replies to posters, I wrote my post devoid of any feelings of regret/morality. So please believe that I am aware that this was not my finest hour, and that your warning is not falling on deaf ears.

Thus far, I have not observed any objective symptoms indicative of STI's (burning sensation when urinating and/or the formation of a chancre).  My only 'symptoms' have been nausea and anxiety which I am taking as have stemmed from my worry and regret over the situation and the unknown. However I will be proceeding with the respective testing as you advise.

Would the marks/bruising I observed on the head of my penis have any bearing or influence on any 'worst case scenario'? I still don't believe my skin broke as no blood was observed on the paper towel I used to check the area. I didn't see it addressed so I presume not, but I'd like clarification on that.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
It's good to hear this was a one-time event. Thanks for your understanding of my perspective on it.

Since your penile skin wasn't apparently broken, I don't see it as an issue in changing risk. For that matter, even with broken skin I wouldn't be worried. HIV transmission by oral sex is so rare, even though tooth injuries probably are not uncommon; and HIV has never known to have actually been transmitted by biting -- one of those theoretical risks people sometimes worry about but a minimal real-world concern.

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34 months ago
Dr Handsfield. I proceed with with the 4th gen HIV duo test yesterday afternoon as discussed and received a Non Reactive result. I have set up an appointment for a follow-up confirmation test in 3 weeks; this would be 5 weeks post encounter. 

At that time, I intend to proceed with the remaining STI testing for chylamidia and gonorhea, including syphilis (doing it all at once for insurance reasons, don't want to bill my carrier with multiple visits in rapid succession). That, however, would be a week shy of your stated 6 weeks for syphilis testing. Could I conclude a confirmation of syphilis at the 5 week mark? 

I also read in a past response from Dr Hook (#381) that syphilis almost always presents with a chancres or I think he called them lesions at the infection site in the first phase. Is this correct?  I know you can't speak for Dr Hook, and I don't ask in attempt to forego testing, but I want to keep an eye it for things the mean time.

Ready to put this unpleasantness behind me. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
34 months ago
Glad to hear of the negative initial result. It should be very reassuring, and you can expect future test(s) to remain negative.

There are no solid data on time to positive blood tests for syphilis. Six weeks is a consensus, and I think it is accurate. But I cannot vouch for 5 weeks. Probably it's valid, but difficult to be certain. But I agree exactly with what you say about sypmtoms (I have said the same thing as Dr. Hook, innumerable times).  The combination of no symptoms plus negative test at 5 weeks probably can safely be considered conclusive.

That completes the two follow-up questions and replies covered by the initial posting fee, so that ends this thread. Stay mellow as you wait for final test results for HIV, syphilis, and other STDs. It is very unlikely anything will turn up positive.

Best wishes and stay safe.


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