I have a question about a previous risk and a recent one.

I am a 42 y/o gay male who last May 2019, performed oral and was recipient of anal sex [briefly without a condom] with another male. He did state he was on PrEP.  I tested at 4, 6, 8,and 10 weeks with a 4th Generation Test. Three of those tests [weeks 4,6,8 were lab tests done via Quest]. The 10th week test was a POC test via Alere Determine [20 minute test].  All tests were NEGATIVE.  

Sunday, August 18th, 2019 I made out [French kissing] and performed oral twice on a 22 y/o male. He did not perform on me.  He ejaculated on his chest. I am sure pre-seminal fluids were involved.  I did not have any "Gaping" wounds in my mouth, but I have gum recession that requires intermittent dental appointments. He stated he was negative.

Going forward, I'd rather be more comfortable knowing my partner's status for future risks in regards to anal sex. [Getting them tested with me as well as using condoms]. I also want to start PrEP as additional layer of protection, but feel the latest risk on August 18th has now "restarted" the clock before I can start a PrEP regimen. 

1. Am I in the clear with the May 2019th incident? [in regards to HIV]

2. Do I need to retest for HIV for the August oral incident?

3. Do I need to delay starting PrEP because of the August incident?

4. In your experience, have you seen many men [or women] become HIV+ from performing oral? [I understand that it is a 1/10,000 risk?] Do these variables still exist or is there new data on oral sex as much higher risk than perceived?

Thank you for your time.

As for the earlier exposure, obviously you were not infected. You were seriously overtested. Your negative 6 week result was conclusive; all tests after that date were superfluous.

3) I also see no need to delay starting PrEP. The Aug 18 event was too low risk for such a precatuion.

4) I have never seen or hear of such a case. Not that it can't happen -- rare events still happen rarely (e.g. being struck by lightning). But as noted above, the 1 in 10,000 risk is still the best estimate available -- and again note that's for a know HIV infected partner. Your partner almost certainly did not have HIV.

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

HHH, MD

As a last follow up. ....

1. Would it be safe to say that if I stuck solely with kissing, mutual masturbation and oral [giving and receiving] ...that HIV would not be on the radar for these risk activities?  [ That is to say that I avoid anal sex completely as well as being on PrEP.]

2. And if I go on PrEP, was exposed, does PrEP delay seroconversion?  Could someone be HIV+ and not know it until they are off PrEP?

Thanks for these concluding questions. 

2. If you are confident your sexual activities with non-monogamous partners will be limited as described, you don't need PrEP at all. That said, sexual intentions often go by the wayside in the heat of the moment, so on that basis PrEP probably is OK. PrEP works extremely well; I'm not aware of any cases of HIV acquired despite PrEP, so there are no data on whether it would delay blood test detection if it fails. But probably there would be a risk of delayed positivity. In theory, it might be possible for someone to have an incubating HIV infections and not know it until seroconversion after stopping PrEP. However, such a person would not be infectious for partners, and would have no health effects from HIV, until the tests become positive. This question also implies you would be tested following individual exposures. I recommend against that strategy. Smarter to just ignore the miniscule risk (assuming no episodes of unprotected anal sex) and have a routine HIV test from time to time, like once a year.

I was tested for oral, rectal [via swab] and urine for gonhorrea on Friday 8/29.  Would these swab/urine tests have given me a clear indication of any STI of Gonhorrea from the oral incident in the past [from the 8/18 incident]?  They also tested for syphilis.  

Unsure if I was ever vaccinated for HepB in the past, but I would need a AB/Ag test to see if I was infected in past? If so, should I follow up with a HepB series if I was infected? I was tested for Hep C via a rapid POC test they offered. It was negative. 

Thanks for your time.  

The hepatitic C test result is condlusive, and anyway the risk of hep C was zero from the exposure described. The chance of hep B also was extremely low. And you are corect that a blood test for hep B would show whether or not you have been vaccinated and whether or not you ever were infected with hep B. Or you can just be vaccinated now:  it isn't harmful to receive re-vaccination.

That completes the two follow-up comments and responses included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes and stay safe.