[Question #581] STD Confusion

108 months ago

· Day 0 - I had unprotected oral sex and protected sex with two different csw’s in the red light area in Mumbai. For the penetrative sex portion, as I was greatly intoxicated, I could only manage penetration a few times briefly and the rest of the time was spent attempting penetration due to flaccidity. This went on for an hour or so, and I am not sure of the condom quality as it was local and provided to me. I do not have access to a proper STD clinic here.

· Day 2-4 – As prophylaxis, a doctor here gave me 2 grams azithromycin and 800 mg cefixime which I took daily for 3 days. He also gave me 2 g tinidazole the first day.

· Day 3 – Noticed clumping of yellow material on tip of penis the morning after I started the medicine. This was the only time I noticed this.

· Day 4 – Noticed scant clear sticky liquid on penis upon waking and discomfort in urethra (no pain while urinating) and occasional itchiness.

· Day 5-10 – Same symptoms as day 4, but discharge seems to be greater and less sticky and prevalent throughout the day as well. I also noticed slight stain on underwear upon waking (only on day 4) and a little more discharge if I milk the penis.

Questions

1. Could this be gonorrhea or chlamydia? I thought the medicine was overkill and would have cured all incubating STD’s including syphilis, LGV, etc.?

2. Would starting doxycycline now be the correct course of action?

3. Would a negative urine NAAT for chlam/gonor after treatment (i.e. now) mean that I don't have these infections?

4. I thought this was safe sex, but since I obviously got infected with something, am now worried about HIV. I’m beginning to think that perhaps the condom came off or broke or something like that. Am I at risk for HIV and do you feel I would need to test? I know pcr rna qualitative test is not advised for diagnosis, but in your opinion, would a 10 day negative test give enough certainty that I was not infected?

Edward W. Hook M.D.

108 months ago

Welcome to the Forum. I will try to help. Straight to your questions.

1. The medications you took should be effective for prevention of gonorrhea, chlamydia, LGV, syphilis, and trichomonasis. These are high , effective doses of these medications.

2. Doxycycline would not add anything to the medications you have already taken.

3. Yes, a negative gonorrhea/chlamydia NAAT at this time would be proof that you were not infected.

4. HIV rates are high in Mumbai but your encounter was very low risk. Tthe odds that you were infected are quite low. There are no proven cases of HIV acquired through receipt of oral sex and if you condom appeared intact it almost certainly was. When condoms fail, they break wide open. Despite claims to the contrary by those who sell them, PCR assays for HIV at 10 or even 14 days after exposure, while strong evidence that you were not infected are not definitive. Testing at 28 days/4 weeks would do this.

I hope these comments are helpful. EWH

---

108 months ago

Hi Dr. Hook,

Thank you for your reply. I would appreciate if you could clarify the following:

Since I continue to have discharge and discomfort even a week after taking the medication, would that imply that despite the prophylaxis, I still got infected with something (e.g. NGU) that is resistant to azithromycin/cefixime? In this case, wouldn't the recommended course of action be to take doxycycline or some other medication? Are there any other tests I should be doing (urine culture, urinalysis, etc.)?

For the chlamydia and gonorrhea tests, they offer a PCR Qualitative test here on first morning urine sample. Is this the same as NAAT and the correct test to take (https://www.lalpathlabs.com/pathology-test/chlamydia-tracomatis-and-neisseria-gonorrhoeae-pcr-qualitative?q=chlamy)? And does first morning urine really matter (the lab is quite far away and am not sure if I can get there in time for a first morning void)!

Are there any chances of a false negative for these PCR tests on urine given my circumstances (i.e. already taken medication and timing of tests)? My understanding is that a false positive could occur if the test is taken prior to one week after completing medication - is this correct?

As there is no std professional I can visit here, would the next best option be a urologist or infectious diseases specialist?

Finally, do you know if azithromycin, cefixime, or doxycycline is bad for someone who has a fatty liver?

Thanks!

Edward W. Hook M.D.

108 months ago

Straight to your questions. It would be unusual for you to fail the combined therapy youdescribe. Rather than presuming you failed, I would suggest the following:

1. See an infectious diseases specialist if there in no STD/sexual health expert easily accessible.

2. Get tested for gonorrhea and chlamydia. If you have one of these and failed therapy, the test will be positive. The qualitative PCR is the same as a NAAT. The terms are synonymous.

3. It is not absolutely necessary to have your test performed on the first void of the day but it is helpful to have not voided for at least an hour before the specimen is collected. The specimen should be urine collected as you begin to urinate, not collected in midstream.

4. None of the medications you list would be a problem for someone with a fatty liver in the doses used to treat STIs. EWH

---

108 months ago

Hi Dr. Hook,

My last set of questions:

A clarification on the medication taken – the 800 mg cefixime was only taken the first 2 days and not the 3^rd day (rest of the medication is as I had mentioned earlier). Would this change your opinion on effectiveness of curing any of the incubating STD’s you mentioned?
I did have a lot of alcohol 2 days after the 3rd day (i.e. last day) that medication was taken – would this lower/change the effectiveness of the medication?
As suggested, I did the PCR urine test for gonorrhea/chlamydia and it was negative. Does that mean I definitely don't have these infections or is there any possibility its a false negative as I had read on an earlier post by your colleague, Dr. HHH, that the sensitivity of these tests is not 100%.
If it wasn't gonorrhea/chlamydia, what could it have been? NGU? Do I need further testing or medication, or should I just forget about it and move on?
What are the correct tests and timeframe to take for Hepatitis A/B/C, HSV, and syphilis? Is it advisable to screen for these?
I did the HIV PCR RNA Qualitative (up to 20 copies/ml) test 12 days after the exposure and it was negative. I know only the Duo at 28 days is definitive, but Dr. HHH mentions in the following post that HIV RNA always becomes positive 5-10 days later. Do you agree with that and do I need further HIV testing? http://www.medhelp.org/posts/HIV---Prevention/RNA-and-oraquick-swab-test-/show/1891685
Finally, can I now have unprotected sex with my wife without worry of infecting her with anything?

Thanks!

Edward W. Hook M.D.

108 months ago

As per Forum guidelines, these will be final answers to your rather repetitive question. You seem fixated on the possibility of STI despite the very, very low risk nature of your exposure. In my opinion, you would be far better served by seeing an STI or Infectious Disease specialist than persisting in the course you seem to be following. :

A clarification on the medication taken – the 800 mg cefixime was only taken the first 2 days and not the 3^rd day (rest of the medication is as I had mentioned earlier). Would this change your opinion on effectiveness of curing any of the incubating STD’s you mentioned?

You took twice the dose (800mg) of cefixime that was previously recommended for gonorrhea treatment by the U.S. CDc and took it twice when the CDC recommended that only a single dose was needed. further, biologically it requires less antibiotic to prevent infection than to cure it. No change in my opinion- you did not need the medication in the first place and the medications you took would be effectivein preventing gonorrhea, chlamydia and NGU as well as the other STIs I mentioned earlier

2. I did have a lot of alcohol 2 days after the 3rd day (i.e. last day) that medication was taken – would this lower/change the effectiveness of the medication?

No!!!

3. As suggested, I did the PCR urine test for gonorrhea/chlamydia and it was negative. Does that mean I definitely don't have these infections or is there any possibility its a false negative as I had read on an earlier post by your colleague, Dr. HHH, that the sensitivity of these tests is not 100%.

The absence of a positive test, particularly when considered in the context of your negligible risk for STI is strong evidence that you did not have gonorrhea or chalmydia and should be believed.

4. If it wasn't gonorrhea/chlamydia, what could it have been? NGU? Do I need further testing or medication, or should I just forget about it and move on?

The medications you took would prevent most NGU as well. I suggest that you forget about it and move on.

5. What are the correct tests and timeframe to take for Hepatitis A/B/C, HSV, and syphilis? Is it advisable to screen for these?

You are not at risk for syphilis, the medications you took it would have prevented it. Your risk for hepatitis is likewise low but you could be tested at 4-6 weeks and expect accurate results. Please note that unless you have tested before, testing may detect infection that you had before the low risk exposure you described.

6. I did the HIV PCR RNA Qualitative (up to 20 copies/ml) test 12 days after the exposure and it was negative. I know only the Duo at 28 days is definitive, but Dr. HHH mentions in the following post that HIV RNA always becomes positive 5-10 days later. Do you agree with that and do I need further HIV testing? http://www.medhelp.org/posts/HIV---Prevention/RNA-and-oraquick-swab-test-/show/1891685

Dr. Handsfield and I agree that PCR testing for HIV DNA soon after a sexual exposure (typically more than 10 days after exposure) is strong but not perfect evidence that a person was not infected. A negative DUO test at 28 days however is definitive.

7. Finally, can I now have unprotected sex with my wife without worry of infecting her with anything?

I see no reason for you to worry about unprotected sex with your wife related to the exposure you described.

There will be no further answers to your questions as part of this thread. If you have more questions you will need to start a new thread. EWH

---