[Question #4154] HIV Risk

31 months ago
DR.

2 nights ago while in Las Vegas I had an encounter with a transexual escort.  We engaged in unprotected oral both ways, and protected anal, me being the receptive partner.  Which was painful.   However, while switching positions for me to be insertive partner she removed her condom.  I was unaware she removed her condom.  I was not ready yet to top, so she performed oral on me to and inserted her penis inside me half way, I realized the condom was off and immediately removed her.  She did not thrust or cum but she was inside my anus for about 20 seconds.  I freaked out, she was very upset saying she thought I knew it was off.  She said she was negative on test in July and showed me a read out of the voicemail from her doctor.  Though it really didn't specify what tests just said all were normal.  

The next day I went to a clinic got tested for apparently everything, Hep and HIV were neg, on rapid test.  Waiting on the GC.  The clinic said I had a significant risk and prescribed PEP. this is 12 hours post exposure

I asked her to go to clinic and get tested, she did 12 hours after our encounter and sent me the results, NEGATIVE.  

I can't believe this happened, and I am also living with my girlfriend so don't want her at risk.  

Do you think there is a significant risk for me, do I continue the PEP is my girlfriend at risk???

Thank you
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
31 months ago
Welcome to the forum. Thanks for your confidence in our services.

The odds are very strongly in your favor, i.e. low risk for HIV from this event. First, your partner's negative test is nearly 100% proof she isn't infected. Yes, it's possible she was in the window period, but statistically it's very unlikely. Second, even with more prolonged anal sex, with ejaculation, the average risk of HIV transmission, if the insertive (top) partner is infected, is around once for every 200-500 exposures. That's not trivial, but your risk would be much lower given the brief exposure without ejaculation.

Should you continue PEP? That's not a decision I can make for you. But I have to wonder if the doctor or clinic who prescribed it was aware your the involved partner has tested negative. It's also reasonable to consider a downside that you and the clinic may not have thought of. If PEP doesn't work, it could prolong the time to know, i.e. it lengthens the testing window. Most experts recommend testing 3 months or even 6 months later. For anxious persons, this means 3-6 months of uncertainty, rather than just 4-6 weeks without PEP. Please discuss all this with the clinic where PEP was prescribed before you make a decision either to continue or stop taking it.

As for other STDs, the risk could be higher. Presumably you had a rectal swab test for gonorrhea, right? Problem is that it might take 2-3 days before testing is reliable. And maybe 4-5 days for chlamydia (which you don't mention). You also could have been exposed to oral gonorrhea, through unprotected oral sex with your penis. It might be wise to be retested a week or so after the exposure. Syphilis also is a concern; a blood test at 6 weeks would make sense.

However, the chance you have any of these is low. All things considered, it might be wise to avoid sex with your girlfriend for 10 days or so, then go ahead if no symptoms and your tests up to then are negative. This is not a guarantee, but it is how I would advise someone close to me, like a family member, or what I would do myself if somehow I were in your situation.

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

HHH, MD
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31 months ago
Thank you DR.

I should clarify.  I did tell the doctor that she tested negative in July and that she was taking the test again that day.  His response was "even if she has negative test she could be in a window and that is an even more dangerous time to have been the receiving partner  in this situation.  Thus his recommendation for PEP.  I must say the second day on it, it is kicking my ass.

Your statistic of 1 for every 200-500 was for the (top)?  In this instance I was the bottom, which I think is why the prescribed the PEP.   Do you still feel that the odds are so small?  Could there be a chance of the window period be active and not detected?

I have been in contact with her and she continues to maintain that it is fine she has been doing this for 13 years and she is fine and safe. She still responds when I reach out to her so I think that is  a good sign or she is just doing it so I will pay her (since I panicked and asked her to leave after)

As for the other STI's they treated me for all at the visit.  But took tests as precaution.

Thanks again
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
31 months ago
I'm not going to indirectly debate the doc you say. However, I stand by my comments above. Had you been my patient, and if I knew your partner had a negative current HIV test, I would have refused to prescribe PEP. Even with only her previous history and no recent test, I would have advised against it -- or at least counseled you to consider PEP very carefully.

That 1 in 200-500 is for the the receptive (bottom) partner. These odds are from an estimate by CDC.

There is always "a chance" of infection during the window period, i.e. before a positive blood test. And during that period, it is true that transmission risk may be high. However, the odds any person at risk -- even someone at extremely high risk -- is in the window period at any particular moment is extremely low.

Your partner's self assessment of her risk and her infection status sounds reliable.

Bottom line:  i stand by my advice above. If you were my patient, you would not be on PEP.

Glad to hear you were treated for other common STDs. Would you like to tell me what treatment(s) you received?
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31 months ago
Dr.  Handsfield,

Thank you again for your reply.  It really helps.  As for the treatment I recived it was a Rocephin shot and 1g of azithromycin  orally.  Both were administered with in 12 hours of the encounter.  

You mentioned you would hold off on sex for at least 10 days and check tests, was that for the Syphilis and gonorrhea, chlamydia?  Given the current information of treatment do you still recommend that I refrain from sex with my girlfriend for 10 days?  

Also, I assume that you would suggest that I get a HIV test done at 4-6 weeks post exposure if I were to stop PEP.  Would taking PEP for 3 days change the results of the test taken at 4 weeks?  Do you recommend that I not have sex with my girlfriend until after the test at 4-6 weeks?

Could there be any chance that the escort actually has HIV but is taking a medication that would make her test results show negative?

Thank you again, your input is much appreciated.

31 months ago
Sorry last question....

When you mention that if I were your patient you would not have prescribed PEP, is that because you feel it is unnecessary because of risk assessment, or is it because of the statement you made in the delay in finding out if PEP did not work?

Thanks again,  those are all the questions I have.  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
31 months ago
My suggestion to avoid sex for a few days was before I knew you had been treated. Those antibiotics for sure would have prevented gonorrhea, chlamydia, syphilis, and nongonococcal urethritis. Having been treated, there also is no point in being tested for them. Even if you had been exposed, treatment before onset of symptoms mean all tests will forever be negative.

You're seriously overthinking the HIV aspects. There are no medications, including HIV treatment, that make HIV tests falsely negative. If your escort partner had HIV, she would have tested positive.

Avoid sex for 4-6 weeks? I cannot answer any better than I already have. As I said, if I were in your situation, I would continue unprotected sex with my wife without worry. I cannot say there is zero risk you are infected, with or without PEP, but in my opinion it is low enough to take the chance. With or without PEP, the likelihood you have HIV is probably under 1 in several million.

I would advise against HIV for both reasons you state:  low chance of infection plus the inconvenience and potentially prolonged anxiety because of the need for delayed testing.

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


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31 months ago
Thank you Doctor.  You are very much appreciated.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
31 months ago
I appreciate the kind words. Take care and stay safe.---