[Question #4340] HIV Risk

29 months ago

Dear Doctor,

 

I was not in my senses and made a big mistake.  I was in London and had multiple vaginal intercourse with two female csw’s that were of black ethnicity (one was born in the UK and the other was born in Kenya and moved to the UK).  These were not high end escorts – it was incall at their place near Paddington in London.

 

The intercourse was protected except for a few times while rubbing, my penis was inserted without protection (this may have happened 4-5 times during the night and each time the exposure was about 10 seconds).

 

I am not circumcised, and the next day my penis was red from all the activity the preceeding night.

 

As I was travelling back the next day, I was only able to visit my doctor upon my return and started PEP at 48 hours.

 

A few days after the exposure, I noticed red spots on the glans which went away after a few days.  I also took a urine dna test for chlamydia and gonorrhea on the 5th day post exposure, and the results were negative.

 

However, about 10-11 days post exposure, I noticed a large red splotch on the outside part of my foreskin and very dry white scaly skin adjacent to it (near the tip).  The redness went away after a day, but the dryness would not go away even with coconut oil.  After 2-3 days, it has mostly gone.  But during the time I got this, I also got a sore throat, dry cough, bad heartburn at night, feeling hot (but never checked my temperature), and diarrhea.  This has been going on for a few days now and still there as I write this.

 

Questions

  1. Would you have taken PEP if you were in my place?
  2. I have read that many places (including NY and countries in Europe) PEP cutoff is 24 or 36 hours.  Is 48 hours practically too late even though CDC has a window of 72 hours?
  3. What are my chances that I became infected with HIV? Especially as I am not circumcised and the csw ethnicity?
  4. Do the symptoms I describe seem like ARS and would a rash in ARS be restricted to the penis outer foreskin or be more widespread?
  5. If it indeed is ARS, would a duo be reliable (assuming that if it is ARS, PEP has failed).  Would a negative duo now mean this is not ARS or is it meaningless in the face of PEP?
  6. Is the chlamydia/gonorrhea test at 5 days reliable or too soon?

 

 Thanks!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Greetings. Thanks for your question and your confidence in our services. 

1) Decisions on PEP are best made locally, by a provider who understands HIV epidemiology in the area. Where I live and work (Seattle), the frequency of HIV in female CSWs is very low overall. I believe the same is true in London, OTOH, there is a recent heterosexual HIV outbreak going on in one part of Seattle, and exposure there would be considered higher risk. But it might have been reasonable if you're in an area where such an exposure would be high risk. Probably I would not have taken PEP if somehow I had personally been in your situation.

2) I am unaware of any data that would dictate cut-offs shorter than 72 hours. There are no good data on how well PEP works, except to know that few if any persons who take PEP later are found to be infected. To my knowledge, this applies for any PEP timing up to 72 hours.

3) HIV risk for a single episode of unprotected vaginal sex with an infected woman has an approximate risk of 1 in 2,500. If there is a 1% chance your partner(s) had HIV, that comes to 1 in 25,000. Being uncircumcised roughly doubles the risk for any single exposure. "Double" sounds dramatic, but really isn't much. Would it really matter if your risk were 1 12,500 instead of 25,000? 

4,5) Your symptoms do not even hint at ARS. The rash of ARS is body wide, and is pretty much always accompanied by other symptoms (fever, sore throat, enlarged lymph nodes). And ARS is very unlikely to develop while on PEP. If PEP fails, symptoms and blood test positivity would come later, after finishing treatment. A negative test now would be meaningless. (One downside of PEP, often not remembered by patients or providers, is that testing must be extended to at least 3 months after exposure -- and some experts suggest 6 months. So the period of anxiety to know for sure that someone isn't infected is 3-6 mo. instead of 6 weeks.)

6) Gonorrhea testing is valid any time more than 2-3 days after exposure, chlamydia probably 4-5 days. Your negative results are reliable.

I hope these comments are helpful. Let me  know if anything isn't clear.

HHH, MD
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28 months ago
Dear Dr. Handsfield,

Thank you for your reply.  I am relieved to note that the symptoms do not seem like ARS but at the same time I'm still very worried about HIV.  My symptoms lasted one week and have gone away, except for the skin rash and dryness on the penis, and the diarrhea which still persists now for 8 days.  I would appreciate your thoughts on the following:

  1. Would side effects of PEP generally be experienced from initiation of the medication, or could it also happen after 10 days (I did not have any side effects for the first 10 days at all)?  I would imagine that it would be difficult for PEP side effects to start so late, but am trying to see if the diarrhea (which started 10 days after initiating PEP) could be due to the PEP.
  2. Is there any STD that can cause the symptoms I am noticing on the outer foreskin (i.e. red patch the size of a quarter and white, extremely dry skin adjacent to it near the tip of the foreskin?  I thought it might be a fungal infection, but after 1 week of applying bifonazole cream, there is no respite (when I apply the cream, it goes away, but if I dont apply for a day, it comes back).  And I never heard of getting psoriasis or any other dry skin from unprotected sex, so am baffled by this.
  3. From what I have read, PEP would not delay antibody production, but would delay RNA or P24 due to suppression of virus by the PEP (is this true?).  My understanding is that antibody is normally detected on average within 25 days (or 10 days of onset of symptoms if any), wouldn't an antibody test at 28 days be over quite accurate?
  4. I have read that a proviral DNA test could be considered at the end of PEP as opposed to RNA to see if PEP has failed.  Is this true?

Thanks for your time.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
28 months ago
Thanks for the additional information. FYI, my odds calculation for your HIV risk was off tenfold:  1% of 1 in 2,500 comes to one chance in a quarter million, not 25,000.

1) Drug side effects can develop any time while taking a drug -- hours, days, or even weeks into treatment. However, your symptoms are not typical for PEP side effects. 

2) No, I cannot think of any STD that would be a likely cause. Fungal infections aren't sexually transmitted, and in any case I agree non-response to an azole cream is good evidence against yeast. Correct that psoriasis is not an infectious disease and not acquired by contact with other persons, sexual or otherwise. However, there are many causes of genital rash, and STDs are among the least common causes. (I have a Color Atlas of Genital Dermatology. As the title implies, it is full of photos of genital skin problems. Of its 300 pages, only 15 are devoted to STDs.) See a doctor if it persists, and in the meantime, stop treating it, which will just make accurate diagnosis more difficult. In any case, I also am 100% confident it isn't due to HIV.

3,4) I am unaware of data on how testing evolves if PEP is unsuccessful. I suppose it is theoretically possible the tests would evolve as you suggest, but I don't know of any data on it. In general, no testing is done while persons take PEP, only after treatment is complete -- with the uncertainties I noted above on timing of specific tests. I recommend following the advice of the clinic or doctor who prescribed the PEP -- or if that was a general walk-in clinic or emergency department, with an HIV specialist, e.g. an NHS GUM clinic.
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28 months ago
Hi Dr. Handsfield,

Thank you for your mail.  

I have been under some more stress as around day 20 post exposure, I had developed small round flesh colored bumps on my forehead which a dermatologist said was molluscum contagiosum.  After researching this, I found that molluscum is rare in adults (except when transmitted sexually) and rarely manifests on the face unless one is infected with HIV.  The bumps are still there and the only reassurance I'm getting is that the dermatologist said he could not guarantee it was molluscum and after looking at countless magnified photographs, I cannot see a central dimple.  But this has got me very worried.

I took the Duo test at 27 days post PEP (still will take it for one more day) and the results were non-reactive.  I know it does not mean much given the PEP, but quite frankly, any negative test is reassuring at this stage.

In closing this thread, just had a few more questions where I would greatly appreciate your insight.  Thank you very much for your time.

  1. Is molluscum associated with ARS or early days/months after infection, or is it associated with late stage infection?
  2. I think that I should take re-assurance from the odds (1/250,000 or 1/125,000 for being uncircumcised) and that is before PEP, so adding a 80% chance of PEP success would make the odds 1/1,250,000 or 1/625,000 for being uncircumcised.  Is my math and reasoning correct?

Thanks!

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
28 months ago
My guess is that it's not molluscum. If it were, within a few days it would be quite obvious, not only because of dimples but because of the typical smooth, shiny, pink appearance. (Google MC for photos.) And you cannot possibly be immunodeficient from HIV while on PEP or this soon, or with negative duo test at 27 days. Continue to work with a dermatologist (preferably in person) if the bumps persist, but probably this has nothing at all to do with your sexual exposure or HIV.

1) I've never heard of MC occurring with ARS. It's an issue only in people with advanced AIDS.

2) Yes, your math seems fine, except I would estimate the likelihood of PEP success at 90-95%, not 80%. The exact numbers don't matter -- the point is that the odds are exceedingly low. (By comparison, if you live in the US, National Safety Council data show that there is 1 chance in 1,756 each year of death by traumatic accident. In other words, the likelihood you have HIV is hundreds of times lower than the possibility you'll be gone within a year due to an auto accident, a fall, drowning, etc, etc. So maybe the main take-home message is to stop worrying so much about HIV and be sure you wear your seat belt and check your smoke alarm batteries!

Also, perhaps it will help to know that in the 14 years I have been doing this and a previous online forum, with thousands of questions from people concerned about catching HIV, not one person ever reported they had in fact become infected. If and when that happens, undoubtedly it will be from someone with a true high risk exposure, like unprotected sex with a known infected person, probably in a man having sex with another man.

Really, do your best to mellow out and move on without worry. There is no realistic chance you have HIV.

That concludes this thread. All my comments are meant to be reassuring. I hope they help. Best wishes and stay safe.
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