[Question #630] Chances of HSV2/HIV due to a brief protected sexual encounter with a sex worker

92 months ago
Hello Doctor(s), 

I have been in a monogamous relationship for the past 13 years and have oral HSV 1 since childhood (cold sores once in 2 or 3 years). 7 weeks back, I had a brief & protected sexual encounter (under 10 mins) with a young (early or mid twenties) sex worker. There was no kissing or oral sex involved. She did touch my penis with her hands and I touched her ‘around’ her genitals/thighs but not inside her vagina (don't mean to be descriptive but mentioning this as I don’t recall feeling any sores/blisters on her skin with my hands). After minimal fore-play in terms of talking with her and touching her as described above, I had protected vaginal intercourse (condom used from start to end) that lasted for a less than or around couple of minutes. The condom stayed intact throughout the act. I also noticed when I pulled out that the  condom didn’t have any visible vaginal and or any other fluid stuck outside. After that, I washed my penis and the area around with soap and water a couple of times. I was terrified of STDs when I woke up the next day and days / life have been dreadful since then. 

Due to stress and anxiety, I was generally feeling unwell for the first two weeks. On the 17th day (3rd week), I felt itching around my anus (area not exposed to the sex worker for sure) and I guess I ended up scratching it a bit causing some swelling on the anus opening (no blisters, lesions, pain or burning - I know how oral herpes feels so don't think it was a genital herpes outbreak) that went away on its own in about a week's time. The itching did last about a month with improvement starting second week and it’s mostly gone by now (presume it was a mild external haemorrhoid or some other common anus related itching problem but you are better placed to judge/confirm).

2 weeks after exposure, I got tested for Chlamydia, Gonorrea, HIV, Syphilis (VDRL), TPHA, Hepatitis B and all tests came out negative. 

6 weeks after exposure I again tested for HIV (3rd generation? enhanced CLIA), Syphilis (VDRL), TPHA and type specific HSV 2 IGG (test says "torch profile" - not sure why the lab ended up doing that as I had hoped they’d do ELISA but haven’t been able to confirm on what test they used. For HSV 2 IGG, the numerical value was 0.85 with < 0.9 being the negative cut-off and > 1.1 being positive). All these tests came out negative as well.

I have done a lot of reading on the internet (med help, a lot of your posts etc.) but based on my exposure still wanted to ask a few questions: 

1) I hope all my test results (except HSV 2 IGG) should be conclusive at this point? Understand HIV negative at 6 weeks is very indicative and a good sign but still the official time for conclusive testing is 3 months. Do you think there is a probability of the result changing (and if so how much) and should I get retested for HIV at 3 months ?

2) What are the chances that I had contracted genital herpes (HSV 2)? I know I need to wait 4 months for conclusive result but based on the exposure explained above and a 6 weeks negative test result, can I draw some positive hope/comfort here? Should I get retested for HSV 2 at 4 months? 

3) Is 0.85 numerical value (<0.9 for a negative result) a concern? Again, based on all the research I have done, understand numerical result is meaningless and a closer to 0.9 value shouldn't mean I am going towards positive as the value is more driven by how the test is done, varies by control/baseline used by lab etc

4)Should I get retested for Hepatitis B?

My life has been pretty stressful for the past 7 weeks and I really hope that I come clean out of this safe and clean. This surely was the biggest mistake that I’ve done in my life and I can’t stop cursing myself.

I guess HIV/HSV 2 is my biggest worry at his point and I would hate to get it since I already have HSV 1 and I don’t like it :-( 

Appreciate your help and time in this regard.
Edward W. Hook M.D.
92 months ago
Welcome to our forum.  The encounter you describe was essentially no risk for acquisition of STIs, including HIV.  Hand to genital contact is a no risk event, even when genital secretions are encountered.  Similarly condom protected sex is safe sex as well.  If you had asked me about the need for STI,testing, I would have told you that there is no medical need for testing.  At the same time however, I can understand that you might want the peace of mind provided by negative tests.  Your negative tests at two weeks should provide this an, in my opinion, there is no need for testing of any sort.  As for your specific questions:

1.  Considering the nature f your exposure, I see no reason for concern and am confident that the results, including your HIV and HSV results will not change, no matter when and how much you test.
2.  As I said above your risk for acquisition of HSV, like your risk for other STIs is essentially zero.  Further we do not recommend blood tests for diagnosis of HSV acquisition.  In your situation, your chances of having a false positive test are higher than your risk of having gotten HSV.
3.  No, negative is negative.   These numbers may " bounce around" and go up and down.  Still no reason to worry.
4.  I repeat, your exposure was safe sex.  You are not at risk for hepatitis B and do not need testing.

I hope my comments are helpful.  Take care.  EWH
92 months ago
Thank you very much Doc for a timely response. It is very reassuring to read from someone as knowledgable, reputed and experienced as you.

I just wanted confirm a couple more thing explicitly:  

As I briefly mentioned in my post, I was feeling generally unwell (feeling of itching around my body, a lot of stress & anxiety, checking my genitals multiple times during a day with a look as closer as I never have in my life before etc.). 

Do you think and agree that the mild swelling around my anus opening I described below would have been due to scratching / some other reason (my bowels movements weren't completely normal during that time - another stress outcome ?) and same goes for itching (common problem) as well ? There were no blisters or lesions and I think if it had to be the first outbreak of HSV 2,  I would have had burning, tingling, lesions etc. and that it wouldn't have cured (most of swelling) on its own in a week's - 10 days time. I hope Terri (another expert I have known and heard about) being an HSV expert would also think the same?

Can I resume with unprotected sex with my long term partner understanding I don't have STI that I'll pass to her based on your feedback?

It's strange how human mind reacts and starts to think so negative and what stress and anxiety can do to your body.

Lastly I wanted to thank you and the entire team for doing this wonderful service to the people (virtually in the entire world) and humanity. I wish you and the team the very best in your life and everything that you do.

Best Wishes.
Edward W. Hook M.D.
92 months ago

Scratching around your anus could certainly cause swelling and irritation. Further, in general, the closer we look for symptoms, the more likely we are to find them.  The power of suggestion is a huge consideration here.  Your general symptoms are not suggestive of any STI, including herpes.  I am confident that Terri and Dr. Handsfield would think that you may be overthinking this. 

I see no reason related to the exposure that you described for you to worry about unprotected sex with your regular partner related to the exposure you describe.  EWH

92 months ago
Thank you Dr. Hook for your response. I just have a  couple of more questions to put my mind at ease:

1)  HIV testing that I did at 2 and 6 weeks: The name of the test said 'HIV 1 and 2 antibodies' Method: 'Enhanced CLIA'.  I am already following up with the lab to confirm this but could you please share your views on the following:

a) Would this (ECLIA) be a '4th generation test' that would have looked for HIV antibodies as well as p24 antigens (conclusive at 6 weeks) or there are ECLIA tests which are 3rd  generation as well and look for antibodies only (conclusive at 3 months) ? I know ELISA is probably 3rd generation but understand ECLIA is more advanced/newer technology? 

b) Does ECLIA 1st or 2nd generation tests exists at all and if so any longer used ? 

2) Could you please shed some light on the technical details of why a negative HSV 2 IGG index value can range anywhere between anything  over 0 to less than 0.9 for a negative result? Eg: I really hope 0.1 is not 'more negative' than 0.85 as long as it's below 0.9 and we should believe the result.Based on my understanding, a numerical index value doesn't have any significance unless its between 1 and  3.5 where it could either be a false positive or one could genuinely be 'seroconverting' if he/she tested in the window period? Is that an accurate understanding ? 

Thank you again for your patience and help.
Edward W. Hook M.D.
92 months ago
The test you mention is a test (3rd generation) for HIV antibodies only.  It is not a 4th generation, duo test. It is a third generation tests (1rst and 2nd) generation tests are no longer made or used.

Most tests for antibodies have a range of negative values in which one number is no more negative than another.  The numerical variation is due to the chemistry of these tests.  These tests get small amounts of "background" values which are due to the presence of other antibodies and chemicals In the blood which cause the negative number to vary.  All negatives are however negative.

I urge you to believe the results of your negative tests following the low risk encounter that you have described.  EWH
92 months ago
I hope you meant essentially no risk (as per your first response) vs. low risk (last response) ! 

The former statement is much more comforting ... 

92 months ago
And you mention 3rd gen because it doesn't say p24 antigen or duo explicitly in my test ?

Edward W. Hook M.D.
92 months ago

You are overthinking this and making too much of minor variations in wording.  Believe your test results. You did not get HIV from the exposure you described.  Your tests PROVE this.

You are also correct that 3rd generation tests do NOT test for p24 antigen and are not DUO tests.  You were tested with a 3rd generation antibody detection test.

As you know, Forum Guidelines allow for up to three interactions related to questions.  this is my 4th and therefor final response.  This thread will be closed later today.  If you have further questions (and in my opinion, you should not), you will need to start a new question.  EWH