I apologize in advance if this question seems repetitive, but I was hoping you could provide a little more context or clarity.

I acquired an NGU from oral sex recently. I understand that you have consistently stated that there have never been any proven cases of female-to-male HIV transmission from such activity.  I've also read on this forum that: All you need to know about HIV avoiding HIV is to select partners with care, do not have insertive vaginal or anal sex with new or unknown partners except when using a condom, and do not share drug injection equipment with other persons.

In a "normal" scenario, I would likely have never given this event a second thought and moved on.  The fact that I acquired an STI from a $500/hr escort, however, has me a bit spooked and wondering if your advice still applies.

1. Is this still a "zero" or "virtually zero" risk event? Fwiw, there was zero evidence of bloody gums or visual ulcers, etc...

2. Am I seriously overthinking this? If it were you, would you just move on without a worry?

To clarify, I am only concerned about HIV. I received the treatment (shots, pills) for gonorrhea, chlamydia, and syphilis and am vaccinated from Hep B.  I also had a Hep C test (not worried) and HIV test at 18-19 days. However, the test was only 3rd generation, so while it may slightly improve my odds I realize it was not very informative.  

Thank you.

The implications for HIV for NGU from oral sex are not the same as for most STDs. Most NGu acquired by oral exposure is believed to be caused by entirely normal oral bacteria (including the meningococcus, which at any time is present in the throat of a few percent of healthy people). The chance of acquiring such NGU is probably no higher from the most sexually active, unsafe partners than from someone who never had sex at all. For these reasons, there are no data to suggest an increased HIV risk in association with orally acquired NGU -- unlike acquring other STDs like chlamydia, gonorrhea, or especially genital herpes (the STD with the strongest association with catching HIV).

Those comments pretty well cover your questions, but to be explicit:  1) Yes, this was still a virtually zero risk event in regard to HIV.  2) You're not overthinking it -- i.e. these are reasonable questions. But I think you'll agree my comments above are favorable. Indeed if I were in your shoes and I would "move on without a worry".

I disagree your 3rd generation antibody test was "not very informative".  Around 75-80% of newly infected people would have positive results by 18-19 days, so it should be at least somewhat reassuring.

Does this help? Let me know if anything isn't clear.

HHH, MD

1. You would treat/analyze this oral exposure like any other "typical" unprotected blowjob from a risk perspective, correct?

2. The cumulative risk from the fellatio, brief cunnilingus and protected intercourse is too remote to be concerned with.

3. You note that my risk is not increased from NGU-acquired oral.  Is the reverse also true? That is, is the female's risk of HIV acquisition also uncorrelated with this specific bacteria in her throat? In my mind, I had essentially doubled or tripled her hypothetical odds of being infected to 5-10% or more given her country of origin and presence of STI.

4. A little off-track i think, but I have never had an outbreak of genital herpes (or oral for that matter) in my life. That said, I have not been tested for that since probably late in the Clinton administration. Is that something that is recommended?

5. For educational purposes:  I had tinkered with the idea of trying to contact this lady and informing her of my experience, whether out of moral obligation or to seek assurances. Had she gone to a doctor or clinic, however, it sounds like she may have been asymptomatic and any tests on her throat would likely have returned negative.  So mentioning this could have caused things to blow up in my face in a way? 

All the best.

2) True. Not zero risk, but very low.

3) Nothing about this story indicates any special risk for HIV for either you or your partner.

4) Most experts, including I and Dr. Hook, recommend against HSV testing except in people with suspicious symptoms or contact, meaning the regular sex partners of persons known to have HSV, especially genital HSV2. I don't recommnend testing for you.

5) How to manage partners of men with orally acquired NGU is a dilemma. Standard practice is that partners are treated with an NGU-type regimin, i.e. single dose azithromycin or 7 days of doxycycline. OTOH, there are no data that this makes any difference in the partner's health or in preventing transmission of NGU to other partners (or back to the original partner with NGU, if they continue a relationship). These guidelines for NGU were derived before it was known oral sex was a risk, i.e. it was originally assumed that the partners must have a genital infection with chlamydia or other bacteria causing NGU; and no official guidelines have updated the recommendations since orally transmitted NGU was more generally recognized.

So what to do? I would advise telling your partner of your NGU, and suggest she see her doctor (or perhaps better, an STD specialist or clinic, e.g. Planned Parenthood or the local heatlh department). But the ultimate choice to treat her or not should be between her and her doctor or clinic -- knowing that treatment likely would make no difference in her health. That said, if the shoe were on the other foot, wouldn't you want to know, to make your own choice? If you say nothing, it's essentially denying her autonomy to evaluate the situation.

As much as I'd like to erase this encounter from my mind, I'm not sure my anxiety will allow it. I seem to think about it 24/7, and concoct new "what ifs" every time I think I have turned a corner. (what if she used a lambskin condom? what if I had a blemish on my penis? etc...)  

I realize this is the last reply of the thread, so I was hoping you could help me put "very low" into perspective. If this doesn't help, then my intent is to simply get tested again, as life is simply no fun when you are all tensed up. 

1.  Do you agree with these assumptions? Please adjust as necessary

a. Effectiveness of condom (97%) (was used from pre-entry thru withdrawal with no slips or breaks) 1/.03 = 33

b. Likelihood of partner being infected (3%) (I am simply basing this on a "high-end" Russian escort working in the USA, hopefully this is conservative) 1/.03 = 33

c. Multiple to account for previous 3rd gen test = 3 (assuming 66.7% reliable, a bit lower than the 75-80% you mentioned) 1/.333 = 3

Using these figures (or your revisions), I come up with

a. Protected Vaginal Sex = 2,000 * 33 * 33 * 3 = 6.5 million to 1

b. Insertive Oral Sex = 20,000 (CDC estimate) * 33 * 3 = 2 million to 1

c. Cunnilingus = assume same as for insertive oral but not sure

3. Any final thoughts, assurances etc... would be appreciated

I trust you have discussed the situation with your partner, right?