[Question #5914] Condom broke with one night stand - HIV risk

18 months ago
Dear Dr,

I am a straight white male, I had a one night stand with a white female (age about ~28-35) I met at a bar in California 10 days ago. When we were having protected intercourse, after about 5 minutes I realized the condom was broken. 

I was quite anxious about potential HIV risk, and I asked her multiple times, to which she answered she didn't have any and in fact she said she works as a high end CSW from time to time and she gets tested. The fact that she mentioned she works as a CSW from time to time as a casual thing made me quite nervous and I asked her to do  an Oraquick HIV test the next day. She agreed and took the test in front of me, which showed negative. 

However, 7 days after the encounter, I had itching when urinating and got tested for Chlamydia and Gonorrhea -- It returned positive for Chlamydia, and my doctor prescribed a single dose antibiotic which I took on day 9. 

All of this put the HIV risk again into my head and I went and took a PCR test and a 4th gen ag/ab test as well as a syphilis test today on day 10. I don't have any other symptoms other than the urination one. I am waiting for tests which will take couple days probably but I am very anxious. 

Can you evaluate the risk given CSW persona, positive Chlamydia, and her negative Oraquick HIV test the day after encounter? Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
18 months ago
Welcome and thanks for your confidence in our services.

First, congratulations for using a condom in this situation. Too bad it broke, but it happens from time to time and your intentions were good. The bottom line is that there was little risk for HIV and almost certainly you were not infected. That said, the risk wasn't zero and you should have another HIV test to confirm you don't have it.

The frequency of HIV in women like your partner, including sex workers, is very low in the US; the chance she is infected probably is under 1 in a thousand. And her negative Oraquick test is very strong evidence she doesn't have HIV. She would have to be in the window period for that test, i.e. would have had to acquired HIV within a few weeks before your contact with yer. This isn't impossible, but it is statistically very unlikely. On the other hand, she obviously does not consistently have safe sex, otherwise she would not have had chlamydia. Still, when a woman has HIV, the average transmission risk for a single episode of unprotected vaginal sex is 1 chance in 2,500. Your risk could be  higher, because transmission risk is highest during the testing window in persons with newly acquired infection; and chlamydia raises HIV risk if exposed.

But still, the odds are very strongly in your favor. You can expect negative results for the HIV tests underway:  RNA (PCR) testing probably picks up 80% of infections at 10 days, but the negative AgAb test means nothing that soon. So was the syphilis blood test, which takes up to 6 weeks for positive results. Assuming the current HIV test results are negative, I would recommend another AgAb test at 6 weeks; that result will be conclusive. If you should develop symptoms typical of a new HIV infection (sore throat, fever, rash, enlarged lymph nodes) -- which almost certainly you will not -- you should immediately see a doctor for repeat testing at that time. 

Your chlamydia treatment was azithromycin. It is nearly but not quite 100% effective for male urethral infection. It is recommended that all persons with chlanydia have a follow-up test about 3 months later to detect delayed treatment failure (or new infections, which are not uncommon in that time). You also should be in touch with your sex partner, if you haven't done so, to make sure she is aware of your chlamydia and gets treatment and testing.

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

HHH, MD
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18 months ago
Thanks for your comments Dr. 

I was told not to engage in sex for 7 days after the antibiotics. provided that the current HIV tests return negative, do you see the risk low enough to continue unprotected sex with regular partner? would you yourself continue unprotected sex with your regular partner in that circumstance? 

For the repeat tests, do you think it makes sense to get a PCR at 13 or 14 days? Would that be conclusive enough since you mentioned 10 day is 80%?

For the ag/ab repeat, I was reading 4 weeks to be conclusive but your suggestion of 6 weeks makes me confused a bit.

Thanks in advance for your answers.


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
18 months ago
Seven days is standard advice for return to sexual activity after treatment of chlamydia. If I were in your situation, I would do exactly as you suggest:  wait 7 days then resume unprotected sex with my wife without worry. The chance of other infections, like HIV or syphilis, is not zero, but it is extremely low and I would not defer sex with my wife for that long -- and all the explaining it would require. That is, I would take the very miniscule risk of having to address it with her later if something turns up; or in the rare case that the chlamydia treatment fails.

The HIV PCR tests detect nearly 100% of infection by 14 days. If you do that and have a negative redsult, that would also be good enough (for me) to resume sex at home without worry.

On this forum we used to advise 4 weeks for conclusive results for AgAb testing, but about 1 ½ yr ago a comprehensive review showed that it takes 6 weeks in 1-2% of cases. At that time, we changed our advice to 6 weeks. However, 4 weeks will be fine in your case. The combination of negative PCR at ~2 weeks and AgAb at 4 weeks also is 100% conclusive.
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17 months ago
Hi Doc, 

wanted to update here because things got more interesting (but arguable safer) for me. So, on the same 10th day of broken condom exposure, after I wrote to you my questions here, I called the lady and she agreed to take a full panel test. I paid for her tests over stdcheckcom, and took her to the labcorp facility myself as well. All of her results for Chlamydia, Gonorrhea, Syphilis, HIV Ab/Ag, and HIV RNA PCR came back negative. 

My Gonorrhea, Syphilis, HIV Ab/Ag, and HIV RNA PCR also came back negative. 

She says she didn't use any antibiotics since 6 months, and after this much cooperation I don't have a reason to not believe her. This in turn means that my Chlamydia was from an earlier exposure, which is a bit confusing because I do not recall any unprotected sex or condom accident in the last year. The previous sexual encounter with a different female before this particular lady was about a month or more before this lady. So, even if that one was where I got the Chlamydia from, The ~1 month PCR + Ab/Ag combo for that "assumed" exposure is I believe quite good enough. 

So, I am gonna put this to rest in my head, but still thinking who I got the Chlamydia from, which should have happened in the last 9 months because that was my last full panel annual Std check point where everything was clear... 

Anyways, thanks for all the responses. Just wanted to share this conclusion. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
17 months ago
Like most infections, chlamydia is cleared by the immune system over several weeks or months, even without treatment. In addition, the chlamydia tests are not perfect, missing up to 5% of infections. The timing of your symptoms also was much more consistent with this, as opposed to your partner a month earlier (and certainly much more likely than being infected 9 months ago.) So it remains likey your recent partner was the source. For these reasons, all recent partners of infected persons should e treated, regardless of their own test results. The partner a month earlier also is a possible source -- not higly, but enough so that she also: should be informed of your infection, tested and treated. But not the one 9 months earlier. (Feel free to print out this discussion; they could take it to their own doctors if they the need for treatment.)

As for complications, if you ineed had a prolonged infection, don't worry about it. There are no complications in men that do not cause obvious symptoms.

Finally, you are correct about your negative HIV test results. They are conclusive.

That concludes the two follow-up comments and replies included with each question and so concludes this discussion. I hope it has been useful.
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