[Question #6108] Was I at risk and should I be worried?

19 months ago
I am a caucasian gay male from London, UK and I hooked-up with a random hispanic guy in Southern California, USA 8 days ago.  He told me he was negative when I asked the question before we met.  The only sexual activities we undertook were kissing and oral sex (me giving him oral sex) and a very brief and shallow episode of receptive fingering.  He did not ejaculate.

I have been using "on-demand" PrEP from time-to-time and I had taken a PrEP tablet 3 days before the encounter, 2 days before the encounter and then again about an hour before the encounter.  So I missed the PrEP tablet the day before the encounter AND only took one tablet (instead of the recommended 2 for "on-demand" dosing) about an hour before the encounter (not the minimum 2 hours as recommended).  I did, however, continue to take PrEP for the subsequent two days as recommended as part of the "on-demand" regime.

Since yesterday, so 7 days after the encounter, I have had body aches and pains, extreme tiredness, trouble sleeping and a bad sore throat.  No other symptoms.  

I am absolutely terrified this could be HIV and would be grateful for your assessment.  I am particularly worried since I don't seem to have nasal congestion or other garden variety cold symptoms which would otherwise reassure me this is nothing serious.  I have ordered a comprehensive STD testing kit but I am conscious I probably need to wait another couple weeks to get definitive results.   I am naturally most worried about HIV but I realise I could have contracted any other kind of STD so grateful for your thoughts on probabilities and risk. 

Thank you in advance for your assessment and any advice you can share. 
19 months ago
Also, I'm so confused about risk from oral sex generally ... one UK website I read said that it is estimated that 8-10% of HIV infections were caught from oral sex alone. How can that be the case when the CDC suggests numbers like 1 in 10,000 etc.?    So grateful if you can share your thoughts.
Edward W. Hook M.D.
Edward W. Hook M.D.
19 months ago
Welcome to the Forum and thanks for your confidence in our service.  I'll be glad to comment on your questions.  Let me start by complementing you on your use of PrEP.  While the regimen you took was not the one which has been most widely studied, it is reasonable to assume that it would further reduce the already low risk for infection associated with the encounter you describe.  Let me provide some facts, followed by my advice:

1.  Your partner told you he was negative.  Most people tell the truth.  (I should add, that even if he was infected, if he was on effective therapy, he would be un-infectious as well).
2. Performance of oral sex on an infected, untreated partner is low risk. Even the U.S. CDC which tends to be conservative estimates  that transmission through receptive oral sex occurs less than in in 10,000 episodes. 
3.  You were taking PrEP which would further reduce your risk for infection. 
4.   Admittedly, you do not mention fever but your flu-like illness has occurred at about the time the ARS might occur.  When at risk persons with flu-like illness have been studied, only about 1% of them turn out to have HIV. The remained tend to have other flu-like viral illnesses.  You have been traveling as well which is a circumstance associated with risk of non-HIV flu-like illness.

My advice.  The chances that this is HIV are very, very low - statistically less than 1 in a million (risk from oral sex  X ~1% risk that your partner was infected X your on-demand PrEP) BUT transmission of HIV does occur rarely in this situation.  If you were my patient I would order an HIV PRC on you, anticipating that it will be negative.  When it is, my advice would then be to urge you not worry further and offer my best wishes that I hope that your non-HIV flu gets better quickly.  

I hope that this perspective is helpful.  EWH
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19 months ago
Thanks for your thoughts.  To clarify my symptoms, my sore throat feels like it is on one side only and kind of spreads to my ear.  I have no fever, rash or other symptoms except for tiredness and some muscle pain (although the muscle aches are probably from a long run I did a couple days ago). I’ve been having trouble sleeping and some weird stomach issues but that might be stress.  Does this alter your assessment in any way? Is a PRC really recommended if the risk is genuinely as low as you say?
Edward W. Hook M.D.
Edward W. Hook M.D.
19 months ago
 Thanks for your follow-up and additional information. My recommendation for the PCR test was based largely on your statement that you were feeling "terrified". I reasoned that a negative PCR test would prove to you that your symptoms were not related to HIV and us be reassuring.  objectively I have little concerned that you have been infected.

 In my opinion your risk of being infected is infintesimal and not something to be worried about. If the problem is on your mind however, the most direct way to resolve your concerns is to get tested as suggested. If these are not concerns I would suggest no need for testing or waiting until six weeks had passed for testing  with a fourth generation test. 

Hope this is helpful?  EWH
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19 months ago
Thank you; I appreciate the reassurance and advice.  I would be grateful for your thoughts on three final queries:

(1) I know judging HIV risk based on symptoms is difficult but, in your clinical experience, is sore throat alone ever indicative of ARS? The muscle aches in my legs were definitely a result of my run and have now subsided; the tiredness is because of my lack of sleep. So I literally just have a bad sore throat. The timing and lack of nasal/cold symptoms is what is freaking me out; seems pretty coincidental it came on exactly a week after the event and I don't have a cold or feel particularly unwell.

(2) Do you know if PrEP is effective against HIV-acquisition from oral sex?  I only engage in oral sex so if PrEP isn't doing anything to reduce the already low risk I'd rather not expose my body to the drug unnecessarily.  I've trawled the internet and everything refers to PrEP's effect on reaching "anal and vaginal tissues" and nothing seems to even touch on its ability to offer protection from oral sex exposures.

(3) Putting HIV to the side, is sore throat one week after oral sex possibly indicative of oral gonorrhea/chlamydia?  Is the timing of the symptoms correct?  

Thanks again.
Edward W. Hook M.D.
Edward W. Hook M.D.
19 months ago
Thanks for additional information.  Final responses below:

1.  The classical description of the ARS is a "flu-like" illness comprised of high temperatures,  sore throat, and flu-like muscle and/or joint aches, sometimes accompanied by diarrhea or a faint generalized body rash.  An isolated sore throat without the other components (you apparently have a satisfactory alternate reason for your muscle aches) is NOT the ARS and further greatly reduces the likelihood that your symptoms are due to the ARS.  I would add that when at risk persons seek care for a flu-like illness, 99% of them have the flu or something other than the ARS.  Thus odds are that your current symptoms are due to HIV are very low.

2.  PrEP was studied for HIV prevention irrespective of the type of sexual activity.  HIV following oral sex is so low that this could not be reasonably studied.  There just isn't enough data to comment further.  I would hypothesize that it would have at least some beneficial effect.

3.  Most oral gonorrhea and chlamydia or the throat is asymptomatic.  The only way to know about these infections is with a throat swab test.

Hope this helps.  As you know, we provide up to three responses per question and since this is my 3rd response, this thread will be closed shortly without further responses.  EWH
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