[Question #5075] HIV Risk - Now what?

23 months ago
Hi Doctor,

Am in a dilemma. I was in Dubai earlier this week and had unprotected vaginal sex with two different Moroccan csw. I am not circumcised. 

The first episode was last Monday. I am a bit hazy about the events and not sure if it was penetration or rubbing or combo. She did not seem to have any issues with it but in the middle I remember she said to use condom so I got worried and asked if she had hiv. Language barrier so showed her the word aids on the phone and she said no. But not sure if she understood. Later I tried to think logically - if she asked me to use a condom afterwards then probably prior to that was rubbing?  Why ask half way through?  I feel some penetration occurred because for next few days I noticed penis was moist (I don’t think discharge and no pain) but the smell was also bad. 

Second was Thursday morning. I specifically asked about hiv status and she said no problem and she tested in November 18. She wanted additional money for this so worried she does this with everyone. But this literally lasted a minute. 

On coming back, I started pep. But this is 36 hours after second event and way outside timeframe for first event. 

So, I want to look at this logically to see if I should continue pep or test rna in 1 week. 

I figure if both had it, then it’s not looking good for me. If first had it and not second, pep is no use anyway. If second had it and not first, would such low duration warrant pep. Would appreciate if you could let me know what you’d do if in my position. 

Also what could cause penis to smell badly after first event?  No rash or fungus visible and just seems little damp with very minimal clear dampness on glans and foreskin. 

Thanks. 
Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
Welcome to the Forum.  I'll be glad to comment with some general information which I hope will be helpful.  First, the frequency of HIV among Dubai CSWs is low.  Second, even if one of your partners had HIV, HIV is transmitted through unprotected genital sexual intercourse on average only about once in every 1200 acts of intercourse, thus the odds that you were infected are low.  Finally, as you point out, your PEP would have no effect with respect to CSW 1 (for whom it sounds like their was rubbing/frottage followed by protected sex and thus was very low risk) but would substantially (90-95%) reduce the already low risk for HIV if she was in fact infected.  As for whether or not to continue the PEP, that is a personal decision.  Had you asked before starting I would have said the exposures were low risk and stated that I probably would not taken it if I were you but it is a personal decision.  Having started it and I presume, purchased the medications, if you opted to continue that would be understandable.  having started, it becomes a toss-up as to whether or not to continue.

Regarding the odor, it is difficult for me to think of an STI which would cause unusual penile odor, particularly which then went away.  Any chance you are just looking more closely than might be usual?  Since the odor has apparently resolved, I would not worry further unless you develop further symptoms which are obvious and do not need to be looked for.  

Hope this helps. EWH


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23 months ago
Dear Dr. Hook,

Thank you for your reply. Would like to provide following clarifications/questions:

1. There was no protected sex with csw 1. It was frottage and unprotected  insertive, though I am not sure about duration and intensity of unprotected insertive. 

2.  The smell and dampness on penis happened after csw 1. It is not resolved and still there albeit lesser. Could very minimal discharge that is not so noticeable be causing the odor? Or possibly a  mild fungal infection I cannot see?

3.  I am not circumcised, so wouldn’t the risk be more like 1/200?  I forgot to mention that csw 2 had her period and I unfortunately found out after the event when tissues she used to clean up had blood on them. I was very upset but she said she was unaware as it just started. Would the menstrual blood change the risk levels?  I didn’t really notice blood on my penis but it was there when she was wiping her vagina. 

4. If I stopped pep after a day, would the pcr rna test be accurate at 7 days?  I know it’s not a diagnostic test, but seems far more sensitive than p24. 

5. You mention hiv prevalence among Dubai csw is low. My understanding was that they are all transient from other countries arriving for a short while on tourist visas and then returning to their native country. So would I have took at hiv prevalence in native country - ie Morocco or does this not matter. 

6.  Would any of the above clarifications/questions  change your opinion in any way that if you were in my place you probably wouldn’t have started pep? 

Thanks!
Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
1.  Thanks for the clarification.  There is no risk for infection from frottage.  You were unclear whether the insertive sex was protected or not.  If it was unprotected, the same risks I mentioned on my original response apply.

2.  Neither STIs, nor fungi typically cause odor.  I see you are you uncircumcised.  Sometimes the bacteria under the foreskin can cause odor.  My advice is simply to keep the area clean and dry.

3.  Sex during an infected woman's period is no more risky than sex not on a period since there is the same amount of HIV in genital secretions as in blood.  The average risk of infection may be somewhat higher, if exposed, for uncircumcised men but the 1 in 1200 figure I quoted above was for circumcised and uncircumcised men combined. Estimating your risk, in the unlikely situation, as 1 in 200 because you are uncircumcised however is too high.

4.  The impact of taking any anti-HIV meds on subsequent early tests is difficult to say.  There are just no good studies of this.  If you stopped taking PEP after one or two doses, conceivably it could delay a test becoming positive but there are no firm estimates of how much.  You are correct, RNA PCR tests however do become positive before the p24 tests.

5.  Certainly, the country of origin would impact the likelihood that a person was HIV positive but that said, experience is that few people have acquired HIV from CSWs in Dubai.

6.  No.

Hope this helps.  I can see you are concerned and some of your questions reflect trying to process your situation.  Having started PEP, if you have the full prescription and are not experiencing side effects, the path of least resistance is to keep taking it.  EWH
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23 months ago
Hi Dr. Hook,

Thanks for the information. I have decided to discontinue pep as it seems the risk is low and the hiv prevalence is low.  

I do have pep supply for another week and can always get more as cost in not the issue. The main issue for me is the added timeline for testing if I did finish the pep course and would have to wait till 8 weeks post exposure to really know. 

As it is I figure that I have a risk with csw 1. Pep would only have a benefit with csw 2 so if the risk is so low as you state, then may not be a point in taking it.  In other words it’s taking a very low risk and making it even lower. 

I did have some follow up questions:

1. If I stop Pep today and take a rna test 7 days from today would it give me a good idea of status?  What would be the soonest I could take rna test?

2. If I were your patient, would you be ok with me stopping pep?

3. On a separate note, I keep seeing risk of insertive anal as quite high. But there are no genital fluids exposed so why is it high?

Please wish me luck that I made the right choice to discontinue. 


Thanks 


Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
I happened to be on line at the time your follow-up questions arrived so you are getting a faster than usual response.  

1.  The time parameters for when RNA tests are conclusive are less well established than for other, more widely used tests.  Most experts agree that somewhere in the range of 11 to 14 days after and exposure, if a person has acquired HIV, their test will be positive.  PEP could delay this somewhat but precisely for how long is undefined.  I would wait two weeks after the last dose until I was confident of the test result.  Many experts also suggest taking a standard HIV antigen/antibody (4th generation) test at six weeks for a totally conclusive result (in your case, this would be six weeks after your last dose of PEP) but to be honest, I have never seen someone whose two week RNA test was not confirmed as having been accurate by the six week test.

2.  I would not have recommended starting it so I would also be OK with stopping.

3.  Anal intercourse is inherently a more traumatic event than vaginal intercourse.  For that reason insertive anal intercourse is thought to be a somewhat higher risk sexual act than insertive vaginal intercourse with receptive rectal intercourse being the highest risk sexual activity with transmission occurring, on average, about once in every 200 acts of receptive rectal intercourse.

This is my 3rd response to your questions.  Thus, as per Forum guidelines, this thread will be closed shortly without further responses.  Take care.  EWH
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