[Question #4198] STD and HIV Risk

29 months ago

Dear Dr. Handfield/Hook,

 

Would really appreciate your advice on my situation as follows:

 

I had mainly protected vaginal sex and unprotected oral for a long duration with multiple csw’s in London on night.  There was a brief period of unprotected vaginal (maybe 15 seconds), but I asked her and she said she was clean.  I am not circumcised and afterwards, my penis and foreskin was quite red from abrasion.

 

The very next day I noticed a discomforting sensation in my urethra, and a clear sticky discharge from time to time from the third day onwards and often not noticeable upon waking up.  Once, I did notice a yellowish stain with a little bit of brown (around day 4-5), but mainly it was clear and sticky.

 

Other Symptoms:

 

Day 9 – Sore throat at night and remained mildly sore the next few days.

Day 11 – On/Off pain in right leg (near vertical lymph nodes in groin) and on/off stiff joint where right leg meets hip.  This continues on and off till this day.

Day 12 – Diarrhea for a day.  Strange chest and abdomen burning at night

Day 13 – Feeling very cold at the office even though it wasn't cold – hands were frozen and this lasted 1-2 hours.

Day 16 – Sore throat at night again and did salt water gargle the next morning and felt better

Day 19 – Strange burning and pain in left armpit at night for a few hours

Day 20 – Sporadic pains in groin and armpits for 2 days

Day 25 – Started getting a hacking dry cough in the evening

Day 26 – The cough persists but woke up with pain behind the eyes, and a fever of 100.  Don't feel well.

 

 

Testing:

On day 11, I gave a urine sample for PCR DNA for chlamydia/gonorrhea which was negative.  But, since they run the tests only weekly and it happened to be a holiday the day they were to run it, it was stored for a week before testing.  And normally they do not test for gonorrhea on urine – they do it on exudate, but they said it was ok.  Thereafter, I took 2g Zithro and 800mg Cefixime.  The discharge is still as infrequent, but present and noticed mainly when removing underwear as it feels like a sticky separation.

 

On day 23, I took a HIV Duo test and it was negative.  But three days later, I started developing a dry cough, pain behind eyes, and a fever of around 100 – I don't feel very well.

 

Questions

  1. From a bacterial STD point of view, it seems too soon for it to be NGU/Chlamydia, but gonorrhea was negative.  So what to do now?
  2. Will the long storage duration of the urine specimen or the fact they normally don't use urine as specimen for gonorrhea mean results could be inaccurate?
  3. Was the 23 day Duo test too early to meaningful and since I developed a fever at day 26 – should I be concerned about HIV and test again now that I have a fever too or is it more likely a normal viral and too late for ARS?

 

 

 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Welcome to the forum. Thanks for your question.

You don't mention any visit or opinions from a doctor or clinic. Were you tested and treated on your own? If so, that's unfortunate for two reasons. First, personal, professional exam by an expert is often important in diagnosing urethritis, determining best tests and treatment, and so on. Second, it would seem you may be hoping this forum could be a substitute for such direct care. However, we do not provide medical care, and I will make no attempt to diagnose your problem or treat it. We are not direct medical care providers and can only provide general information and probabilities.

You have been at low risk for STDs (congratulations for generally having only safe sex for your commercial sex encounters). In addition, 15 seconds is quite brief and inherently low risk for that reason; and most CSWs' self assessment they are not actively infected probably is accurate. In addition, most of the symptoms you list are not possibly due to any STD. If they are related to the exposure described, it's most likely you just caught a garden variety minor virus, like a common cold. Most likely they aren't related at all to that event.

I'm unclear whether your gonorrhea/chlamydia tests are negative or you're still waiting for results. Based on your exposure history, my guess is they are (or will be) negative. If positive, it could be you were infected prior to the particular exposure you have mentioned. (STDs sometimes are acquired during apparently well protected vaginal sex exposures, or from unprotected oral sex.)

Now to your specific questions:

1) I agree the symptoms started too soon to be from an STD acquired during the event described. If related to that event, perhaps just physical irritation. Or, as noted above, perhaps urethritis from a previous exposure.

2) Nucleic acid amplification tests (NAATs, i.e. all DNA/RNA tests like PCR and others) are extremely hardy, for all STDs and virtually all other infections. Specimen can be stored weeks, months, or even years with little or no effect on test performance. (DNA is very hardy stuff. Remember all those media stories about recovering DNA from long dead organisms and even fossils?)

3) The chance of HIV in this situation is under one in a million, based on both the rarity of HIV in UK (or at least London) CSWs and the low risk of transmission for any single episode of unprotected vaginal sex (average one in 2,500). In addition, your negative test is reassuring. Although the duo test requires 6 weeks for 100% certainty, around 90-95% of infected people would have positive results by 23 days. Have another test at 6 weeks (along with a syphilis blood test at that time), but stay mellow in the meantime. It also will be negative. And by the way, your symptoms are not at all suggestive of a new HIV infection.)

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

HHH, MD
---
29 months ago
Dear Dr. Handsfield,

Thank you for your reply.  Sorry for the delay in posting this follow up as I have not been well.

A few clarifications may help in your further advice:
  • I have been sexually abstinent since my last health check up, where I tested negative for all STDs.  
  • The chlamydia and gonorrhea PCR DNA urine results were both negative
  • While this incident happened in London, I am not from there and therefore did not know where to go for medical assistance.  Upon returning home (where we do not have STD testing centers), I showed my doctor the CDC treatment guidelines, and he basically doubled the dose of azithromycin (2g) and cefixime (800 mg) and gave it to me and told me this would be a prophylaxis against all potential bacterial STDs.

At first, I was concerned about an STD which then morphed into concern about HIV due to the strange symptoms.  The negative Duo test at 23 days gave me a sense of relief that whatever symptoms I had till then were not related to HIV in any way at all and the higher dosage of azithromycin and cefixime led me to believe that any bacterial STD would have been resolved as well.  

Unfortunately, three days after my duo test, I came down with a bad dry cough, fever (up to 103), sore throat (felt like razor blade cuts in my throat when swallowing), body pain, fatigue, etc.  Its just about clearing up now (about 6 days).  But it has been a severe illness.  This has gotten me worried that maybe ARS symptoms may have started late for me and the Duo test was negative because potential ARS symptoms started 3 days later.  On the other hand, it may also be the flu, as my wife got a fever and bad throat 2 days after me and my son got it 5 days after me (though in both their cases, it was not as bad as mine).  The doctor thought it was a viral but still gave me a three day course of cefuroxime 500 (twice a day).

My questions are:
  1. If there is still occasional discharge, I assume this would be non chlamydial non gonococcal urethritis - are there any specific tests for this?  Is ncngu something to worry about or will this clear on its own over time - basically do I need to address this before having unprotected sex with my wife?  The other option is to follow the CDC treatment guidelines and take a course of doxy and tindazole.
  2. Does the flu like illness sound like ARS or just a common viral and would taking another duo now (i.e. before 6 weeks) rule out ARS if negative?
  3. Do you still suggest I take syphilis test even though I took the zithro and cefixime?  Do I need to test for Hep B, or anything else?
Thanks!





H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Thanks for the clarifications.

1) If "occasional discharge" indeed is continuing, it should be examined to assure there are increased white blood cells. If so, urethritis is oonfirmed; and that would mean you indeed have NGU (nongonococcal, nonchlamydial). Most such infections indeed may clear with time, but it is also possible you have one of the less common causes of NGU, such as Mycoplasma genitalium, trichomonas, or others. Your treatment with azithromycin takes care of most such cases. If it does not, the standard recommendation is to then treat with a combination of doxycycline and metronidazole (or tinidazole). I suggest you discuss these options with the doctor or clinic where you were treated with cefixime and azithromycin.

2) Your respiratory viral illness "around the time of the duo test" was obviously rather severe, but it was not ARS and had nothing to do with the sexual exposure or with your previous urethral symptoms. It is not possible to have HIV/ARS symptoms and also have a negative duo test at about the same time.

3) There is no point in syphilis testing. If you had been exposed and had syphilis that had not yet caused symptoms at the time you received cefixime and azithromycin, they would abort the infection and you would never develop a positive test. The chances of hepatitis B or anything else are too low to warrant testing after any single exposure.

---
29 months ago
Dear Dr. Handsfield,

Thank you for the information and apologies for the delay in this follow up.  You had mentioned that HIV prevalence in UK and London in particular is very low for CSW and low transmission probability and therefore, the risk is minimal and less than 1 in a million.

I have studied the BASSH guidelines on PEP for the statistics on HIV prevalence (https://www.bashhguidelines.org/media/1027/pepse-2015.pdf).  

On page 4, it says HIV prevalence is 7.1% in black heterosexual women and 0.06% for non black.  That is even more than the overall rate for MSM which is 5.9% (granted its higher in London).  But a few pages later (page 9), they indicate that overall rates in CSW is low.  So, I dont understand - is the 7.1% for non CSW, and black CSW have lower infection rates or does the 7.1% apply to all black ethnic regardless of whether they are a CSW or not?

I just wanted to understand more about the epidemiology of HIV in London with regards to this and for the future, whether it is low risk regardless of the ethnicity.  It seems that if 7/100 black ethnic women are infected by HIV in the UK, this is a very high risk group.

Also, BASSH says the odds for insertive vaginal is 1/1219.  Based on an australian study (for insertive anal), if not circumcised, this increases risk by a factor of 5.6, so the risk for me is 1/218 x 7.1/100 = 1/3070.  This seems fairly high -is my math correct?  At this high a risk, it would seem that PEP would be warranted for something like this as well.

Thanks.





H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
You're being unnecessarily argumentative. You can find research and surveillance to support almost any number you like. Trust me, there are plenty of data beyond the single studies you cite to support the rates and risks I have cited. My comment about the HIV rate in London area sex workers was for overall rates, not race based; and most such surveillance is inherently biased toward higher risk sex worker groups. 

It's fine with me if you want to consider your HIV risk to be as high as 1 in 3 thousand. I would point out that this is equivalent to having daily exposures and likely having HIV (or maybe not) after 8 years. Whatever the actual risk, you're obviously going to need HIV testing to assure you weren't infected. You can expect a negative result.

That concludes the two follow-up comments and replies included with each question and so ends this thread. Keep using those condoms. Good luck.
---