[Question #4268] Syphilis and HIV

29 months ago
Dear doctors

I am a 37yo married male who gave another married a blowjob (unprotected) and bottomed for him (protected) about 8 weeks ago. Two days later he told me he had tested positive for gonorrhea and syphilis. I went to an after-hours clinic and got azithromycin and an injection to treat possible gonorrhea, but couldn't see a sexual health specialist for another week (9-10 days post exposure). She said she couldn't see any mouth lesions and said I "might not need" treatment for syphilis, but I got a penicillin shot anyway.

The day after I got the treatment I noticed a small anal fissure (I got diarrhea from the antibiotics, and some anxiety, so figured it was from that), but it cleared up in a few days.

An HIV rapid test at 4 weeks came back negative, and the counsellor I saw said he wouldn’t worry about further HIV testing if he was in my situation, given the low risk.

A syphilis EIA test at almost 7 weeks came back negative.

I’m keen to move on from this and had a few questions:

- if the anal fissure had been a syphilis chancre, or if I'd had any other lesions the doctor and myself had overlooked, I would have tested positive at 7 weeks, yes? 
- is the EIA test as reliable as any other at 7 weeks?

- would you recommend any more testing for HIV or can I move on with my life, including unprotected sex with my wife?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Welcome to the forum. Thanks for your question.

You were treated exactly according to standard guidelines in industrialized countries (CDC in the US, BASHH in UK, Australasian recommendations, etc): it is normal to treat persons exposed to gonorrhea and syphilis as if they were infected. The treatments are 100% effective:  if syphilis or gonorrhea had been transmitted, you can be 100% confident they were eradicated. Your sexual health specialist was correct that syphilis treatment likely wasn't necessary, because the gonorrhea treatment (ceftriaxone injection plus azithromycin by mouth) is nearly 100% reliable against incubating syphilis) -- and the subsequent syphilis treatment (benzathine penicillin) also is 100% reliable. Because the gonorrhea treatment is so effective against syphilis, you can be confident the anal fissure -- showing up some days later -- was not a syphliitic chancre. In addition, because of the effectiveness of your treatments, you will never develop a positive blood test for syphilis. There is no point in any additional testing for it.

To your specific questions:

1) If somehow the treatments weren't effective against syphilis, your 7 week blood test would have been positive. But there was no chance of that anyway.

2) Yes, EIA is 100% reliable in this context.

3) It is for sure safe to continue or resume unprotected sex with your wife. Indeed, you could have done so safely several weeks ago. You don't mention your partner's HIV status, but my guess is he was tested and documented negative after your exposure, i.e. when his gonorrhea and syphilis were diagnosed. Right? In addition, the gonorrhea treatment made you non-infectious for either gonorrhea or syphilis within 24 hours, so you could safely have resumed sex with your wife at that time. Of course it would have been wise to hold off if the HIV situation was not clear at the time, but for sure there was no need in regard to gonorrhea or syphilis.

That said, 4 weeks is slightly early for definitive results for your own HIV test; most experts and clinics consider 6 weeks conclusive, although 4 weeks is very nearly so. In any case, if your partner was HIV negative, that fact plus your own test result, taken together, are definitive.

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

HHH, MD
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29 months ago
Thanks Dr Handsfield for the reassurance. I really appreciate the wisdom that’s shared on this forum.

Unfortunately I don’t know this man’s HIV status; he didn’t mention it when he told me about his other diagnoses online, and he blocked me when I started asking him more questions. Admittedly I was probably a little bit hysterical/over the top when I was questioning him.

I will go for another HIV test, but do you have any comments about how worried (or not) I should be?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Receptive anal sex (bottom) between men is the highest risk for HIV of all sexual activities, and unwillingness to reveal HIV status is a potential sign your partner was infected. OTOH, a condom was used and oral sex carries little risk for HIV; and you have already had a negative test that is 98-99% reliable. So almost certainly you were not infected with HIV. But for 100% certainty, it would be smart to be tested once more, 6+ weeks after the event, this time with a lab based (not rapid) antigen-antibody HIV test. You definitely can expect another negative result; and in the meantime, the chance you have HIV is low enough that you should be comfortable having sex with your wife.---
29 months ago
Thanks doctor Handsfield. I have to admit, I was a bit spun out to think of my sex partner as an HIV risk; he’s a married man with a kid and he checked that I had condoms before we met up...but I guess testing positive for gonorrhea and syphilis might suggest he’s not committed to safe sex?

I’ve done a bit of googling and was wondering if you had any thoughts about what increased the risk for HIV from oral sex? He didn’t ejaculate in my mouth (there was probably precum) and my oral hygiene is pretty good. I can see that on average the estimated risk is 1:10000, is that right?

I’m on holiday at the moment so won’t be able to get tested for another two weeks; even though I’ve made my bed and have to lie in it I’m still pretty stressed out.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Sometimes people who are very committed to safer sex nevertheless are infected. He may have another partner who he trusted, but perhaps mistakenly. This gets to the simple fact that men who have sex with other men, as a group, are at high risk for STDs. There are exceptions, of course, and many gay men are as safe as Snow White. But on average, it's always wise to be safe with other men. In any case, you used a condom for your receptive anal sex event, so your risk was low, despite his infection.

I don't know that anything "increased the risk for HIV from oral sex". HIV is virtually never transmitted by oral sex. The quality of your oral hygiene makes no known difference one way or the other. The 1 in 10,000 estimate is the standard one, which is equivalent to giving BJs to infected men once daily for 27 years before infection might be likely. Since condoms aren't perfect (unrecognized failures sometimes occur), your risk from the protected rectal exposure probably was higher than for the unprotected oral. That's not to say you shouldn't be tested. But the odds are very strongly in your favor, even if your partner has HIV. You definitely can expect a negative test result.
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29 months ago
Thanks Doctor Handsfield. I’m almost certain the condom didn’t fail, at least not in a big way (when he pulled out of me I could see his cum contained in the tip and it didn’t seem to be leaking anywhere), but I will get tested ASAP for the safety of my partner and my own peace of mind. Thanks again.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Thanks for the thanks. I'm glad to have helped.---