[Question #6586] Protected sex and hiv risk

15 months ago
Hello I have a question let me start of by saying that I got checked for everything about a month and a half ago, and all stds including Hiv came out negative.
Well here goes my new encounter, I had an an encounter about 36 hours ago with another male. We both gave each other oral(no ejaculation), and I went on to give protected anal, which lasted for about 3 minutes, I then ejaculated while still inside, pulled out, and checked the condom for about a minute or 2 in the bathroom, and saw no obvious break, or any sort of leakage of semen in the condom, so I beleive it stayed in tact and had no obvious holes in it, now usually if it were a girl I wouldn’t freak out, but since it was a male, I heard that is the highest risk it can get, so I am scared, also I met him online, and he said he just wanted sex, it was a tranny, so it seems the person has a lot of one night stands , as I just did so that is what scares me, so my questions are as followed. 
1) Do you believe that I could have acquired hiv like this? If so how? Or what are the chances(percentage wise) I got it considering this is a high risk situation?
2) Do you think that I should seek out pep since I am still in the 72 hour period?
3) Similar to question 2, I happen to have two pills of pep, from an encounter over a year ago, and they gave me 30, and you only need 28, so I saved them for an emergency, should I take the two doses today and tomorrow, and see if I can get the next course for this encounter on Tuesday at my local clinic?( it’s a bit of a hassle, and I hate taking meds, unless completely needed to) so that is why I want to know what you think, because I will only take it If you think it’s needed, and I mean scientifically not for mental reasons)
4) Am I at risk for other stds? If so which ones?
5) I also have a girl who I am regularly having sex with, who we both tested clean for everything a little over a month ago , and she wants to have sex tonight, would I be able to continue having unprotected sex w
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Welcome to the forum. Thanks for seeking us out.

You correctly understand that anal sex in men who have sex with men (MSM) is the highest sexual risk for HIV. That's because a far higher percentage of MSM than heterosexuals have HIV (in the US and western Europe), and because anal sex is inherently riskier than vaginal sex. However, the HIV risk is a lot higher for the receptive than the insertive partner; the average risk for you wasn't much higher than vaginal sex, if either partner had the virus. But more important, HIV cannot be transmitted through an intact condom -- and it sounds like you had no other risky events. (Oral sex is nearly free of HIV risk.) Once you made a decision to have such a sexual experience, you did it with maximal safety (congratulations for that wise decision!).

Those comments partly answer your questions, but to be explicit:

1) There was little or no risk of HIV from tehse events. If you had had unprotected anal, and if your partner had HIV and wasn't being treated for it, there would have been roughly 1 chance in a thousand you would be infected. If we assume a 10% chance your partner had HIV, and with proper condom use, I would estimate your chance of getting HIV at no higher than 1 in a million.

2,3) PEP decisions are best made locally by doctors or clinics who understand local risks. For example, if there is local evidence that many or most trans women (.e. anatomic males trans to female) have untretaed HIV, and if you remain anxious despite only a one in a million risk, it could be considered. But if somehow I were in your situation, I certainly would not take PEP. But definitely don't start it on your own with leftover pills.

Many persons don't think of a major downside of PEP, and most doctors/clinics don't warn about it either. Normally valid HIV testing can be done 4-6 weeks after exposure, but if PEP doesn't work, it can extend the time to conclusive testing. Most experts recommend final testing at 3 months, so the duration of anxiety until knowing you're in the clear is a lot longer after PEP.

4) All my comments about low risk apply for other STDs, except that unprotected oral sex in this setting has a pretty high risk of gonorrhea and syphilis. It would be reasonable for you to have throat swab and urine tests for gonorrhea (valid any time more than 2-3 days after exposure) and a syphilis blood test in 6 weeks, which also is about the time you might consider having an HIV test.

5) Based on all discussed above, the chance you have any STD is low. However, it isn't zero and there's at least a low risk of transmitting something (especially gonorrhea) to your girlfriend. Once again from a personal perspective, if I were in your situation I would continue unprotected sex with my wife, but I also would be tested as just discussed. 

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

HHH, MD
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15 months ago
Thank you Dr! For your fast, and quick response, you have definitely helped with  my anxiety a lot, so just a few more questions for this, and for some future references, so that I can always look back to this post in case I ever have any more scares( I have a lot of sex so I know it will happen)
1) What is with all the misinformation I see online on different sites for example the cdc says receptive anal sex partner has a 1 in 909 chance of getting hiv being insertive, and with proper condom use , you have a 63 % less  chance of acquiring hiv, 63% is a lot better than not using a condom, but doesn’t 63% seem far too little in your opinion? And also have seen other valid sites that have 70, 80-% effective if properly used, just doesn’t seem high enough for me.
2)What sexual instances do you recommend taking pep for, if not for this with(not including taking iv drug usage, because that would be obvious)
3) Do you believe that I can continue to have protected sex with this person? And as long as I do it protected , I won’t be at risk for hiv? 
4)Have you ever seen a case of some one getting hiv through anal protected sex?(insertive partner)
5) If I told you that my partner had hiv, and wasn’t on treatment, even with proper, non expired condom use, would you ever recommend pep in that situation?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
These are good questions. Directly to them:

1) Condom efficacy is typically expressed in two ways:  biological efficacy, i.e. with proper use and without rupture or other failure; and use-effectiveness, which is efficacy over time, taking human nature and condm fallibility into account. It's actually easiest to explain in pregnancy/conception statistics:  For any episode of vaginal sex, a properly used, non-failing condom is virtually 100% effective in preventing conception. But in couples who rely only on condoms for contraception, the pregnancy rate is reduced by about 80%, i.e. ~20% condom "failure". I'm not sure exactly where you found the 63% statistic, but I'm confident it refers reduced HIV infection rates in people who use only condoms for HIV prevention, without careful partner selection or other prevention strategies. In addition to condom failures, it probably includes people who didn't use condoms at all for some exposures. In other words, biological effectiveness of condoms for HIV prevention probably is virtually 100%. Human failure, not condom failure, explains why use-effectiveness is a log lower.

2) There are no hard and fast guidelines for PEP. Certainly I wouldn't recommend it if the infection chance is 1 in a million or lower; and would always recommend it if the odds were, say, 1 in a thousand (equivalent to the anal sex risk you cite, i.e. anal sex with a known infected partner). Between these extremes, it's clinical judgment and the level of fear, concern, and anxiety felt by the exposed individuatl.

3) I can't advise you on continued sex with the same partner. Seems to me the obvious approach is to ask that person to be tested. If HIV negative, go for it. If not, just be very careful about safe sex. But if he is in fact infected, there is no way for you to continue anal sex and be at zero risk. Condoms do fail sometimes (more commonly with anal than vaginal sex).

4) My experience is irrelevant. The answer is no, but I also have never cared for a patient struck by lightning. That fact doesn't change your odds of a fatal lightning strike. Same deal for HIV risk events.

5) In the circumstance you cite, I would recommend PrEP (pre-exposure prophylaxis):  i.e. that you take continuous anti HIV drugs as long as that relationship and exposures continue.
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15 months ago
Thank you once again I will finish up with this, something in your reply to question 3 kind of freaked me out, and would like if you could explain a bit more what you meant: 1) you said “condoms do sometimes fail”, what do you mean by that? Are you interpreting that even if used correctly, and no breakage I can still catch hiv? If so how? I’ m a little confused by that, because my urethra wouldn’t be exposed, please help clarify what you meant
2)I have been sick since yesterday, runny nose, throat is a bit sore, now cough, and slight diarrhea, do you believe this could be part of ars? (I know symptoms aren’t a good determination, testing is which I will have in 4 weeks, just to be sure) but would you be able to tell me a little bit about ars, when it typically begins etc.
3)probably a broken record question, but what do you think is the percentage I had of having acquired hiv from this?
4)I will test out for peace of mind, “but”if it were you, or if I were your patient, would you even recommend an hiv test for this  one time encounter, even if I got tested a month and a half before this? And I mean for scientific reasons not just peace of mind. 
5) If I had  Gonorrhea in the throat how  would I know that I had it? Does it also cause cold like symptoms? 

15 months ago
I forgot to add that is started about 3,4 days after, and it is gradually getting worst, started with throat itchiness, then slight cough, body aches now, and a horribleeeee headache, and slight swollen nodes under jaw, I’m starting to freak out, i’m 29 and When I get sick I I barely ever get headaches or body aches, I have had a lot of hiv scares before, and never felt this, so I know that it’s not my stress or anxiety causing these symptoms, 1) do you think this could be ars dr?
2) Could it be herpes predome?
3 I also have my left butt  cheek bone on a certain spot is sore, right where the tranny was grabbing(not hard)  while giving me oral, could they have injecting me with something?  And since was tipsy maybe I didn’t feel it? 
Thanks again for the help doc, I was feeling great,
But i’m not one to have these symptoms this bad when I Am sick ever 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Wow -- you're really off the deep end on this, aren't you? Be clear:  if you continue the sort of relationship and exposures as described, you can greatly reduce HIV risk and probably could continue for years without being infected. But you cannot reduce the HIV risk to zero. You need to be realistic about understanding and accepting the risks to expect.

First set:

1) I meant condom rupture, which can occur even with otherwise proper use.
2) New HIV infection symptoms cannot start sooner than 8-10 days; and the symptoms do not include nasal congestion or cough. You caught a cold.
3) Indeed, a "broken record". What was unclear about my guesstimate of 1 in a million?
4) No, I would not be tested if somehow I were in your situation. But testing may have value for reassurance, even in zero risk situations. If you'll feel better with a negative test in a few weeks, feel free.
5) Pharyngeal (throat) gonorrhea rarely causes symptoms at all. The only way to know is to be tested. When it does cause symptoms, it's sore throat only -- no nasal congestion or cough.

Second set:

1) Repeats question 2 above. No reason for me to repeat myself.
2) These symptoms do not suggest herpes or herpes prodrome. 
3) Injected you? Without you knowing? What sort of crazy thinking is that? And you're considering an ongoing relationship with someone you're worried might have tried to inject you with something??? Get real.

How severe your cold symptoms are makes no difference. Most ARS is mild -- so mild that many or most with ARS never notice it.

That completes the two follow-up exchanges included with each question (in a lot more detail than usual) and so ends this thread. The overall tone indicates you are psychologically very conflcted about your sexual choices and risks. Professional counseling might help; I suggest it from compassion, not criticism. 
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