[Question #6543] Potential CSW exposure

14 months ago
Dear Dr Hook/Dr Handsfield

Out of curiosity I recently visited a transgender CSW in the UK for a massage, during which we were both unclothed.  During the massage, contact was made on a number of occasions between the CSW's penis (which seemed at least partially erect - I did not look closely) and the outside of my anus, to the extent that I could feel pressure against it. I assume there could have been 'precum' from the CSW, although I can't say that I have any recollection of physically noticing it.

There was a small cut/s on or around my anus from rough toilet paper; earlier that day, I noticed a small spot of blood on the toilet paper, perhaps around 2-3 mm in diameter. 

I don't think there was any penetration. This may sound like a stupid question but would it at all be possible for any slight penetration (by, say, a centimetre) to occur without me feeling it (the CSW was above average sized down there and no lubrication was applied anywhere at any point)? I have no experience in this department and have no idea what any kind of anal penetration feels like.

I visited a sexual health clinic and was prescribed PEP, due partly to the doctor's concern with my high level of obvious anxiety. He mentioned that the cut/s I mentioned could increase the risk somewhat, although when examining me down there he said he could not see any cuts (i.e. they must have healed by then or been very small to begin with).

I started the PEP about 23 hours after the potential exposure and I'm currently continuing to take it methodically as directed. At the same appointment I was tested for all STDs including HIV, the results of which have since all returned negative. I will return to the clinic for a test once two months have passed since the exposure. 

As you can probably tell, I'm quite anxious about all this. I realise that HIV transmission is probably on the 'unlikely' side of things relatively speaking, but how unlikely, given all the information above?

Many thanks in advance.
Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago

Welcome to our Forum.  Thanks for your question and for your confidence in our service.  I'll do my best to help.

The exposure you describe was very, very low if not no risk.  External rubbing without penetration does not lead to transmission of HIV. Further, if penetration had occurred, I am confident you would be aware of it.  Finally, now that you have made the commitment to PEP, even if you had been exposed to HIV, the PEP would have reduced your risk for infection more than 90% for the less than 1% risk for infection IF your partner had untreated HIV (which is statistically unlikely).  All in all, your risk for HIV from the events is negligible and should not concern you.  I hope that this perspective is helpful.  EWH

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14 months ago
Thanks very much for the response. I suppose what's concerning me the most at this point is the possibility of transmission through the cut/s I mentioned. Almost every official health website I've looked at (NHS, CDC, etc) says that HIV infection can occur via small cuts on the skin. They also say that 'pre-cum' transmits the virus. To what extent does a small surface cut's exposure to pre-cum pose a risk of HIV transmission? Any advice would be much appreciated.
Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago
While the sorts of small cuts you describe have been adopted as theoretical risk factors for acquisition, the fact of the matter is that there are no convincing data to indicate that surface contamination of cuts with genital secretions from infected persons truly represent a meaningful,risk,factor for HIV.  This translates to the statement by even conservative organizations as the U.S. CDC stating that exposure to genital secretions during mutual,masturbation and other non-penetrative activities such as the exposure you describe are no risk events  I have never seen or heard of HIV acquisition through the sort of exposure you describe.  

Regarding the topic of pre-ejaculate, indeed it does contain virus and that is the reason that HIV can be transmitted without ejaculation.  Nonetheless the sort of non-penetrative event you describe remains no risk.  

 No change in my assessment or recommendations.  EWH
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14 months ago
OK, thanks again, Doctor. Much appreciate the help.
14 months ago
Hi Doctor - just one more question if I may. At about 9 days after this possible exposure, I developed high fatigue, a stiff neck and irritability, which have been persisting for about 10 days now. I don't have a rash or a sore throat, but it is possible that I may have had a low-grade fever at some point (no symptoms of high fever, i.e. shaking or the shivers). I'm not sure about enlarged lymph nodes, since I'm not quite sure what they would feel like. The main symptom is fatigue, which is unmistakable and non-psychological, and which I'll see a doctor about if continues for another week or so. 

I could be mistaken but I think I remember either yourself or Dr Handsfield stating that HIV seroconversion symptoms are virtually impossible while a person is on PEP (as I mentioned in my original post, I began PEP at around 23 hours after the exposure - I've been taking it as directed). I just wondered if you would be able to give me your expert opinion on this. Thanks very much.
Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago

Glad to comment further.  Development of the symptoms of acute HIV infection while taking PEP as directed would be close to unheard of.  Further, your symptoms are not at all suggestive of the ARS as both high fever and severe sore throat are part of the hallmarks of the syndrome.  OTOH, fatigue is not.  I am quite confident that his is not the ARS.

I hope this comment is helpful.  EWH

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