I was making stupid decisions the other day and I came home with a CSW here in SF after a night out.

She gave me a protected BJ, the condom pulled out and reapplied. Then i stupidly had brief vaginal intercourse with the condom on.

It was still on my penis when i pull out like 20-30 seconds later. My anxiety is making me rethink every moment and I don't recall

checking the condom after sex.

Should I go in for a 4th gen test at 28 days? Or is a 14 day RNA PCR. I was last tested a year ago and havent had sex since.

First, the large majority of female sex workers in the US, including San Francisco, do not have HIV. The chance she was infected probably is under 1% or even only one chance in a thousand. Second, when a woman has HIV, the risk of HIV from unprotected oral sex is zero of very close to it; and the risk from unprotected vaginal sex is around 1 chance in 2,500. So even if a condom had not been used at all, the likelihood of HIV from this event is extremely low. WIth a condom, it's even lower. You are uncertain about how correctly and consistently the condom was used, but it sounds to me like you were protected for both the oral and vaginal exposure.

For those reasons, from a strictly medical/exposure perspective I see no need even for HIV/STD testing. However, for reassurance you could have both the tests you mention; those are the right times. However, based on what you have said, I see no reason for PEP. The San Francisco STD clinic is excellent, very highly respected nationwide. Go there for in person professional advice. I predict it will be similar to mine. Perhaps most important, they will be able to predict better than I can the likelihood that CSWs in that city, or in the area where you met your partner, have HIV. (Give them my regards. The clinic director is a colleague and friend of mine.)

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

HHH, MD

Yes. Condom was on during both oral sex and vaginal sex. Its probably my guilt and anxiety that's making me reimagine the scenario.

I have perused the questions on this forum and was trying not to use too much of your time, but here are a few follow ups. May they benefit future readers.

Condom breakage is very apparent? So there is never a scenario where one would miss the breakage?

You generally dont recommend the RNA test, but if negative at 14 days, no need for a follow up test?

Re: 4th DUO tests, i've seen recommendation vary from 4 weeks to 6 weeks. Does this depend on a case by case basis?

Yes, condom breakage generally is obvioius. I don't see how it could be missed.

For most of the past 10-15 years, since RNA testing became widely available, we have urged caution in its use because of uncertainty about how accurately it detected early infection, rare false positive results, and cost. However, demand continues to grow, costs have declined, and false positive results have become vanishingly rare, and many experts now use it more liberally, including testing people at pretty low risk but nonetheless worried. Our advice has started to lean in that direction as well. We still advise that when the chance of new HIV is very low (e.g. in your case, probably under one in a million), often no testing at all is warranted, or to have a single AgAb (4th gen) test at 4-6 weeks. However, a negative RNA test at 14-20 days detects almost all infections, and if cost isn't a limitation, it's fine with us if you get tested. However, RNA testing probably still misses 1-2% of infections, so it usually should be followed by an AgAb test at 4 weeks. That combination of results is 100% conclusive.

As for AgAb tests, in theory they should be conclusive by 4 weeks, but a comprehensive review published 1 1/2 years ago reported rare cases -- around 1-2% -- requiring 6 weeks, and we modified our advice at that time. That's for testing with this test alone. As just noted, in combination with a negative RNA test, AgAb at 4 weeks is conclusive

For all testing, interpretation of results, and especially advice about further testing, is partly dependent on level of risk. For example, if someone has 1 chance in 100,000 of having HIV after a low risk exposure (your risk is a whole lot lower than this), then a negative result with a test that detects 99% of infections makes the odds of HIV 1 in 10 million. On the other hand, if someone say has a truly high risk exposure and typical ARS symptoms, and if prior to testing we figure a 1 in 10 chance he has HIV, a 99% reliable test drops those odds to 1 in a thousand. That's good and should be reassuring, but you'll agree that 1 in 1000 isn't good enough. Same test, different interpretation. The second clearly needs more testing; the first case does not. Does this make sense?

Any time HIV testing is done on account of a sexual exposure, it is appropriate to test for other common STDs. If you visit the SF STD clinic, I would expect them to do a urine test for gonorrhea and chlamydia and a blood test for syphilis; and conceivably a follow-up syphilis test 6 weeks after the event. But every patient is evaluated on a case by case basis. Whatever their advice, follow it!

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