[Question #5554] Two protected incidents - risk or (virtually) no risk?

20 months ago

Incidents took place in a western European country with low HIV/Syphilis levels. Both cases with CSW:s of Asian origin. First was condom protected oral + vaginal sex, condom seemed intact and I saw seamen gathered at the tip after. I thought of not testing because of condom use and no symptoms but after googling about condom effectiveness etc. I decided for a 4th gen ag/ab HIV test. Test was at day 49 post exposure. I had a slightly sore throat two days before the test and two days after the test my sore throat got a lot worse. Also some cough and headache, especially when putting my head down. Sinus infection I hope, not ARS.

Second case (no testing after), condom protected oral, hand job, brief frottage (gliding penis on her butt) and I also did some vaginal/anal fingering. I made sure that there was no penetration. A slight flu afterwards. The oral sex and hand job were a bit rough and I had some redness on the penis that went away in a few days. But after 10 days I saw a small bump on the shaft of the penis, on the top side, close to the hairline. To me it looks like folliculitis. Googled “syphilis sore” and mine is not an open sore at all. And the part where the spot is did not touch her, apart from her and my hands. During oral, the spot was maybe under the condom, if not could her oral fluids have reached over the condom, don’t think so but can’t be sure. Timing wise I read that 10 days is possible for syphilis but a bit later is more common. My theory is that the rough hand job might have contributed to folliculitis.

1.       Any chance that my 7 week ag/ab had missed HIV1/2 after the first incident, given symptoms a few days after test.

2.       Any reason to believe that the second incident could have resulted in syphilis?

3.       My eye hurts a bit, could be sun/wind, but any chance of getting anything in the eye after fingering and maybe later touching your eye?

Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
Welcome to the Forum and thanks for your questions. Congratulations as well on your commitment to safe sex- it will keep you healthy.  I'll go to your specific questions in just a moment but first a few background comments.  Among CSWs, there is a hierarchy of likelihood that a CSW is infected.  In general, a partner recruited from off the street is somewhat more likely than a CSW from a brothel or recruited through other means to have other risk factors in their life such as drug use and as a result may be more likely to have STI's including HIV.  Nonetheless, the majority of such "higher risk" CSWs still do not have STIs, including HIV.  Further, the risk for infection from any single exposure is low - only a minority of unprotected exposures lead to transmission.  Adding condom use to the exposure reduces the risk to virtually zero as long as the condom is used throughout the sex act and does not break.  When it comes to risk, google is not your friend and much of what is found through internet searches of topics like STI risk overstate the risk as well as the risk of condom failure.  The encounters you describe above were safe sex with no meaningful risk for infection.  Had you asked if you needed testing for either encounter, my advice would be that testing is not needed.  With this background, let's address your specific questions:

1.       Any chance that my 7 week ag/ab had missed HIV1/2 after the first incident, given symptoms a few days after test.
No, you can be confident of the results of this test. The results are conclusive and your symptoms around the time of testing were due to something other than HIV.

2.       Any reason to believe that the second incident could have resulted in syphilis?
Among STIs, syphilis is a relatively rare infection.  Today in Western Europe, about 75-80% of all syphilis occurs in men who have other men as sex partners.  The location of the lesion you describe is far more consistent with folliculitis than syphilis and had it been syphilis, the bump would be expected to form an open sore in a day or two after its initial appearance.  For all of these reasons, I would not worry that this was syphilis.  

3.       My eye hurts a bit, could be sun/wind, but any chance of getting anything in the eye after fingering and maybe later touching your eye?
No, could be sun or wind or perhaps a non-STI, community acquired viral illness.  STIs are not transmitted through transfer of infectious material on a person's hands to other parts of the body.

I hope this information is helpful.  EWH
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20 months ago
Thank you for a quick reply. I am very impressed on how you, expert MD:s in your field, take the time to answer questions by worried people. Yes, the internet has too much conflicting information and I have been spending way too much time learning of HIV transmissions, test performance etc. 

My take aways:

1. I will believe my test results after 7 weeks after the first incident. Frustrating that there are still so many conflicting advice, for example, official advice for conclusive HIV tests in Europe, Denmark 4 weeks, Sweden 6 weeks, Finland 12 weeks, UK 4 weeks for low risk etc. But I understand that 6 weeks is the norm, regardless of symptoms and risk.
2. The small pimple on the shaft of my penis has been the same for three days, unless it turns into an open sore, I will, together with low risk (protected oral and masturbation) and other considerations, conclude that it is not Syphilis and will not even be tested. Apparently the prelevance of syphilis in my country is 3/100.000, more than half of them acquired by men abroad, some in their partners, and also some in men who have sex with men. I understand that you cannot confirm anything online but would you agree with this assesment?
3. Ok, I remember reading somewhere that genital-hand-eye contact could transmit some STD:s but maybe it is mostly theoretical.

Once again, thaks for this service and if you could just comment on mainly point 2 above?
Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
Your summary is right on target.  I'm pleased that my comments were helpful to you.  Take care.  EWH---
20 months ago
Last questions. Still, after four days, no open sore, it looks like a small pimple and hurts slightly when poked. I read that syphilis sores do not hurt. Does syphilis always cause an open sore and would the description alone be strong evidence against syphilis, regardless of risk? And also timing, 10 days after the event, many sites state that it usually takes 3 weeks

Also, is syphilis commonly transmitted in oral sex? And how effective are condoms in prevention of syphilis? I can understand that there might not be any studies on this and it is not easy to measures but common sense says that condoms should still provide decent, if not full, protection. 
Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
This is all strong evidence that this is not syphilis and makes folliculitis much more likely.  

Syphilis is transmitted through oral sex but occurs this way very, very rarely.  A condom which covered the site of exposure would prevent syphilis acquisition.  In studies of condoms and syphilis risk, condom use reduces risk of infection by about 80%

Hope this helps.  At this point I really would not be worried about syphilis as the cause of the lesion you describe.  As per Forum Guidelines, since this is my 3rd response, this thread will now be closed.  EWH
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