While having vaginal sex with my girl of choice, the condom broke. She noticed immediately, stopped, and changed to a new condom. The duration of the incident may have been a few seconds, my calculation is between 5 and 35 seconds. I am not sure if she gave me oral with the condom before and that may caused it to break (it was a while ago so can't remember). I am circumcised.

After the incident I didn't make any of it. No concerns, no symptoms, nothing. I had sex with a few other CSWs through the next couple of years, always protected and without incidents. A couple of months back came by accident through an article in the web about HIV. That article sparked fears, started to read, remembered this incident and since then have been very anxious about HIV. 

I have a few questions:

1) What is the risk level of this incident? how worried should I be about it?

3) How common is ARS? I do not remember having any ARS-like symptoms and neither my wife. Can it be that we both got infected without symptoms?

4) One lymph node or salivary gland on the right side of my neck seemed swollen a few times in the course of last few years. Can that be attributed to HIV/ARS?

5) I practice protected sex with my wife, but sometimes we do brief initial unprotected before moving on to protection (with condoms). In that case, how big could her risk be?

Thanks is advance for your help, you do fantastic work helping people out there!

First. congratulations on having only safe sex for sex outside your marriage. Good move and very wise. However, there is an obvious answer to your concerns, and I'm rather suprised you don't mention it. Have you been tested for HIV? If not, why not? Given your sexual lifestyle -- "sex with a few other CSWs through the...years" -- you should be getting periodic testing for HIV and other STDs from time to time. In my opinion, you are over-focused on this single incident, without due regard for your overall risks. Even without known lapses in sexual safety, you are clearly at risk and need to recognize that.

Don't get me wrong. I think there is almost no chance you acquired HIV from the particular exposure described. It is statistically unlikely your partner had HIV; and even if she did, the odds are strongly in your favor. To your specific questions:

1) The average HIV transmission risk from vaginal sex, female to male, is around once for every 2,000 exposures. If we assume even a very high risk your partner was infected, say 1%, your chance of having caught HIV would be roughly 1 in 200,000.

2) Irrelevant. What does it matter what cases I have seen personally? It happens I have not, but rare things happen. Does it modify your risk of being struck by lightning if I have cared for a patient who was struck?

3) Depending on how one interprets the mildest symptoms, somewhere from 50% to 80% of people with new HIV infections have recognizable ARS. Certainly it is possible for any two people to have HIV without having overt ARS/

4) ARS never causes a single lymph node to be inflamed. For sure this problem wasn't HIV or ARS.

5) If you have HIV, your wife is at high risk. However, it is unlikely you are infected.

Bottom lines:  There is little chance you acquired HIV from the incident described. There is a higher chance of other STDs, but these also are unlikely. However, anyone having non-monogamous and especially commercial sexual exposures should be tested for HIV and other common STDs (chlamydia, gonorrhea, syphilis) from time to time, and you should do so now. I expect all results to be negative, but better safe than sorry. If your HIV test is negative, then all the above questions really are irrelevant. If you don't have it, obviously the risks at the time, and ARS symptoms, don't matter.

I hope you don't mind the blunt talk. It's just staright talk, which I assume you would want. Best wishes and stay safe--

HHH, MD

Hi Doctor,

Thanks for the reply. This horrible behavior was part of a brief mid-life crisis that I deeply regret and that fortunately ended a long time ago. I still can't believe it happened, but it's a good thing that it ended (the way in which I phrased using "years" may made it seem bigger). 

Over the past weeks I've been able to track the few CSWs that I've been with, called them and asked them directly about their HIV status. In all cases, they answered that they were not infected and that tested recently (after our encounter). Not sure how reliable those responses are. The case that I worry and asked you about is the one where I couldn't call to confirm (and also the most eventful one).

My worries appeared very recently after some random reading in the web. I didn't tested yet. I am trying to learn as much as possible about my risks and expected outcome before the test as I am very scared and anxious about this situation. Reading that based on the info that I provided you expect my results to be negative was quite reassuring.

A few other questions:

1) any recommendation for the test? is there any test that you recommend to get results the same day?

2) any comment on the confirmation from CSW's negative status? is that info somewhat reliable and something good that I can factor in my situation?

4) what are the common symptoms for ARS? is there any symptom that is almost always present?

Thanks for the help, you are a great help to people like me who at some point made very bad decisions that deeply regret.

That some of your partners have assured you they don't have HIV is good, and further reduces the chances you were exposed. But it doesn't change my advice that you be tested for HIV, syphilis, gonorrhea, and chlamydia. And no, that does not change my expectations that the results will be negative. But stranger things have happened, and better safe than sorry. I think your additional questions are in relation to HIV testing and that's how I will respond. But I hope you will also follow through on the others.

1) There are 20+ tests on the market and I can only comment on general types of test, not specific ones. The best and overall standard test these days is an HIV antigen/antibody (Ag/Ab) test, also called "4th generation", "duo", and "combo" test. These are conclusive any time 4 weeks or more after the last possible exposure -- and despite your concern about the condom failure event and reassurances from your other partners, I would recommend waiting that long after your last commercial sex exposure. These tests are lab based and usually will take a few days to get the result. At 6+ weeks, and antibody-only blood test will be conclusive, and some clinics may offer this option. The most common point-of-care (while you wait) test uses oral fluids, and you can purchase it OTC for self testing at home; but is not conclusive until 3+ months.

2) Mentioned above. Most people don't lie about HIV status when asked directly, and you're in a better position than I am to judge the tone of their responses. OTOH, don't forget that people can be in a window period if recently infected.

3) The 1 in 2000 data came from the pre-viral load days and cover all cases. The transmission risk would be correspondingly higher or lower for any particular exposure. But probably never higher than 1% (1 chance in a hundred).

4) The most common symptoms are fever, sore throat, skin rash, and enlarged lymph nodes (always several, not just one or two). Sores in the mouth. Several others. Almost always several symptoms; any of these by itself isn't worrisome. ARS onset is always within 2 weeks of exposure; anything later isn't ARS. But only half of new infections have ARS; presence or absence of symptoms won't help you judge the likelihood you were infected.

Thanks for the thanks. Now do me the honor of following through and getting tested. That's the ONLY thing you need to do. Don't spend any more time or energy worrying about the risk at the times of exposure or symptoms. They now mean nothing; the test result means everything.