[Question #6473] STI risk from unprotected encounter

15 months ago
I’m a 40 y/o female (nurse) that demonstrated very poor judgement in the past month.  My 10 year marriage has been very rocky as of late and I had 2 unprotected sexual  encounters within last 4 weeks. The 1st involved unprotected oral but no real vaginal intercourse and my partner could not get an erection.  The 2nd encounter involved unprotected oral, vaginal, and brief anal insertion which I quickly stopped. Although I discussed STD risks with both partners prior to my exposures and was told they were clean I have no actual proof.  Both partners are also married as well. 

Eight days following the 2nd encounter and 16 days following the 1st encounter I developed vaginal burning and itching. Saw my doctor who did full STI work up and I was negative for everything but did have yeast infection/BV which I treated. Also did not test for HSV antibodies as I did not have clinical signs of HSV. 

My questions are: 
1. I had neg vaginal swab and urine test for chlamydia and gonorrhea. However since I did have brief anal penetration during 2nd exposure should I have been swabbed separately there? 

2. My HIV antibody was negative as I said 16 days after 1st encounter and 8 days after second. I’m hoping neither of these individuals are high risk but I’m assuming I should be retested at some point. Can I retest at 6 weeks following 2nd encounter and feel confident with results? Should I retest for syphilis at that point as well? 

Thanks in advance for your input. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Welcome to the forum. Thanks for your confidence in our services.

Firrst, don't beat yourself up over a couple of sexual decisions you may regret. Both sound very low risk.

Second, I'm uncertain how to interpret "did have yeast infection/BV". Vulvovaginal candidiasis (VVC, yeast) and bacterial vaginosis are entirely different. They can occur simultaneously, but not often. Burning and itching are typical for VVC but not BV. VVC is not sexually acquired, although anal sex can increase the risk -- candida is normal in both the vagina and rectum and probably can be inoculated into the vagina following anal sex. If you'll clarify the diagnoses and how you were treated, I might have more to say about this aspect. To your specific questions:

1. The large majority of both gonococcal and chlamydial rectal infections in women occur in the presence of genital infection -- that is, isolated rectal infection is rare and is mostly found in women who have had only anal but not vaginal sex. So your negative vaginal swab is reliable. (It was redundant to have both vaginal swab and urine testing, but didn't hurt anything.)

2. The chance of HIV in this setting is zero for all practical purposes, assuming your male partners are not sexually active with other men or injection drug users. Your "hopes" on this score probably are valid! However, you are correct in implying that you were tested too soon for conclusive results. The risk is low enough that from a strictly medical/risk perspective, HIV testing (and syphilis) is optional. But assuming you'll carry through with conclusive testing for reassurance purposes, I suggest an antigen-antibody (AgAb, "4th generation") HIV blood test 6 weeks after the second encounter. The chance of syphilis is almost as low as for HIV, but usually they are done together more or less routinely, and you probably should include a syphilis test at that time -- again, mostly for reassurance, not actual risk.

I hope these comments are helpful. Happy to comment further about BV and VVC if it would be helpful. In the meantime, don't lose any sleep over STD/HIV risks from these events.

HHH, MD
---
---
15 months ago
Thanks so much for your timely response Dr. Handsfield. You are correct re my regret and therefore my anxiety is running high. I sincerely doubt these partners are high risk but since I can’t be certain I will retest for HIV and syphilis at 6 weeks. 

In terms of the vaginitis I should’ve clarified I tested positive for both candida and gardnerella via swab.  I was treated with fluconazole for the yeast and my symptoms have cleared. I was offered treatment for BV with Metrogel but I’m up in the air as to whether or not that’s necessary. I’m not sure if that was just a colonization that was picked up or real “infection”.  Any thoughts on this is appreciated as well. 

Thank you again. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Gardnerella vaginalis is normal in the vagina. It's one of many bacteria that overgrows in BV. The test is calibrated to be positive with larger amounts typical for BV and negative if lower. As you might imagine, that sort of test often gives uncertain results. The best diagnosis for BV is with vaginal pH (sinple and quick -- normal pH, i.e. under 4.5 rules out BV; and wet mount microscopy showing "clue cells". Due to the clinical laboratory improvement act (CLIA), these days many or most providers don't do microscopy. BV is characterized primarily by strong (often fishy) vaginal odor and thin discharge. If you had only vaginal irritation/itching, yeast is likely and BV is not. 

From what you say, I'm inclined to believe you don't really have BV and don't need the metrogel. But you might clarify with your doctor. Either way, actual STDs remain unlikely.
---
15 months ago
Just one last follow up question. Both of my encounters did not involve ejaculation anywhere near my mouth or genitals. Does that lower my risk in any way esp for things like HIV. I realize HSV and HPV may be a different story.  Thanks again for sharing your expertise. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
There are no data on whether STIs like gonorrhea, chlamydia or HIV are transmitted via semen versus from the urethra in absence of ejaculation. In other words, no known difference between penetration with or without ejactulation in a body cavity. If there was penetration, there probably was risk. I imagine it might be higher with ejaculatiion as well, but we just don't know. That said, we do know your vaginal test was negative, so I really wouldn't worry further about it.

Thanks for the thanks. I'm glad to have helped. That concludes this thread. Take care and stay safe.
---