[Question #600] Unprotected sex with sex workers

42 months ago
Hi Doctors,

I am male, and from Malaysia.  Lately, due to work and marital stress, I have been binge drinking a lot and this has led to two incidents where I had unprotected sex with sex workers in massage parlors.  In the first incident, a condom was put on me at first and I proceeded to have sexual intercourse with the lady. Halfway through, I removed the condom and penetrated her. She did not stop me and it went on for a few minutes before I withdrew and ejaculated outside. She did not seem worried about the lack of protection.

In the second incident, which was three days ago, a condom was put on me and we proceeded to have sex. Due to my inebriation, I could not climax and I requested for sex without condom from the lady. She agreed to do so at a higher fee and she assured me that she did not have any diseases.  I took off my condom and proceeded with sex until i ejaculated in her.

I am now worried about my risks for HIV and STDs. Can you please give me a risk assessment and also advise me on when I should test ? I also know that I should pull the brakes on my drinking and will seek help as soon as possible. Thanks
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
Welcome to the forum. Thank you for your question and for your confidence in our services.

You had sex with two sex workers who do not insist on 100% condom use by their customers, and to my knowledge STDs and HIV are fairly common in Malaysia (but I don't know the details). So these clearly were high risk exposures. However, the odds still are in your favor:  at any time, most sex workers (even unsafe ones) are not infected; and when STDs or HIV are present, they are transmitted a minority of the time. Even if one of your partners had HIV, the transmission risk for any single unprotected vaginal sex exposure averages somewhere around once for every 2,000 exposures. The risk of chlamydia, gonorrhea, and other STDs is somewhat higher.

Depending on local practice and details of HIV frequency in sex workers in your area, post-exposure prophylaxis (PEP) with anti-HIV drugs might have been recommended, but PEP must be started within 72 hours of exposure, so it's too late for that. But you'll need to be tested for HIV and for gonorrhea, chlamydia, and syphilis; and to be on the lookout for symptoms like discharge from the penis, painful urination, and penile blisters or sores. Urine testing for gonorrhea and chlamydia is valid any time more than 3-4 days after exposure. The timing of blood tests for HIV and syphilis depends on level of risk -- definitive testing can't be done until 4-6 weeks after exposure, but local experts who understand STD/HIV risks in your immediate area might recommend earlier testing if they consider the risk to be fairly high.

I would advise you to find a physician or clinic knowledgeable about STDs and HIV, and follow their advice about the details. There are excellent STD services and physicians in Malaysia, at least in major metropolitan areas like Kuala Lumpur.

Let me stress again that most likely you weren't infected. But better safe than sorry, so get it checked out.

Best wishes--  HHH, MD


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42 months ago
Thanks for your response. The doctors here recommend an Elisa test after 3 months from my last exposure. I am feeling very anxious. Is an Elisa test after a 4 week period definitive? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
There are several different ELISA HIV tests. If you have a combination antigen/antibody test ("4th generation", "duo", or "combo" test), it is conclusive any time 4 weeks or more after exoposure. Most stand-alone antibody tests these days are conclusive by 6-8 weeks; 3 months is old news, unless the doctors you have seen are using older tests. That would surprise me in a medically sophisticated country like Malaysia. Still, in some settings public health departments still recommend waiting 3 months, but it really isn't necessary. With any blood test, a negative result at 4 weeks is highly reassuring; few people take longer than that to become positive, if infected.

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42 months ago
Thank you for your prompt response. So far it has been 5 days after my last exposure I have not experienced any symptoms but I will be going for a full screening after 4-6 weeks.  I appreciate your good work and the impact you have on people around the world
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
Thank you for the kind words. That's why we're here. Take care and stay safe.

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42 months ago
Dear Doctor,

Sorry to bother you again. I went to see a general practitioner yesterday and he recommended  that I take a test after 6 months from my exposure.  I am in Kuching, the capital of the state of Sarawak in East Malaysia which is a small city of a population of 500,000.00 and so i am assuming that perhaps the doctors here are more conservative in their decision making. The general practitioner told me that HIV prevalence in Sarawak is 9 in 100,000 persons and that he hadn't encountered STD/HIV cases from the type of brothel i visited.

I have also contacted one of the sex workers who is from China and she assured me that she was clean. The other sex worker is from Vietnam but i have not contacted her. I actually had two previous sessions with the latter and both times, we used condoms. It was only on the third occasion, where a condom was used initially,  that I, in the heat of the moment, took it off. I know I am scraping the bottom of the barrel here to look for reasons to relieve my anxiety.  It is now 9 days after my last exposure and I have no symptoms. Given the extra information above, should I take a combo test at 4 weeks? 

You must have the patience of a saint to deal with worried people like me. Thank you.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
41 months ago
Many doctors and clinics got used to giving advice about conclusive testing at 3 months or even 6 months after exposure, and by habit have not changed even as the newer tests came into use. Others are simply being extra conservative. It truly isn't necessary to wait that long; despite your doctors' advice, even a regular antibody test will be conclusive by 8 weeks, and a combo test at 4 weeks. There are no exceptions.

In my reply above I summarized the low risk of HIV transmission from a single epsiode of unprotected vaginal sex. Absence of ARS symptoms at 9 days further reduces the chance, so at this point I would guess the chance you have HIV to be about 1 in 5,000. Those are awfully good odds in your favor.

If you have access to a combo test, I think you should do it around 4 weeks after the second exposure. If somehow I were in your situation, that's what I would do. After that negative result, you can move on with your life with absolutely no worries about it. You can then decide whether to follow your doctor's advice about still later testing, for additional reassurance. Personally, I would not do so, and once the 4 week test was negative I would resume unprotected sex with my wife, without any worry at all about infecting her.

All this is in regard to HIV only. You also should be tested for gonorrhea, chlamydia, and syphilis, as discussed above.

That completes the three follow-up questions and replies included with each new thread. Best wishes and stay safe.


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