[Question #663] STD Risk, prevention

89 months ago
Hi experts,

Early Sunday morning I received unprotected oral sex and had unprotected vaginal sex with an escort. She was very clean, and not inexpensive. She assured me she tests regularly and presented no risk, but when I asked again later and asked her to get tested this week she at first agreed, and then she became unresponsive. So I'm worried. I'm engaged to be married and want to eradicate any risk.

I want to prevent chlamydia, syphillis, gonorrhea. I visited a clinic and received 2g of azithromycin, which I took. I also received a script for cipro, but research tells me that's not a great help for prophylaxis, so I did not take that one. I visited another clinic today and received a rocephin shot (250mg). 

Given the treatments I've received:

1. Can you assess for me my risks of the three STIs above (given the azithromycin and rocephin), and also for HIV and HSV? 
2. Do I need a penicillin shot to complete my coverage, particularly against syphillis? 
3. Should I look into PEP?
4. Should I take the Cipro (500mg twice daily for 3 days)?

Thank you so much for your help!

H. Hunter Handsfield, MD
89 months ago
Welcome to the forum. Thanks for your question.

My general comment is that you are at very low risk for STDs from this exposure, both because it is statistically unlikely your partner was infected; and all STDs are inefficiently transmitted, i.e. even when a partner is infected, most exposures aren't transmitted during any single exposure. And the frequency of STDs is believed to be low in escorts, i.e. expensive female sex workers by appointment:  most have mostly low risk partners (men like you), use condoms consistently, and get tested regularly.

That said, it is apparent that your particular partner does not use condoms consistently, which is a mark of higher risk. (I would not only advise you to use condoms for similar exposures in the future, but also to avoid sex workers who ever agree to not use them.) Still, on balance the odds are she wasn't infected. I do not interpret her reticence to be tested upon your request as a sign of higher risk. More likely she became defensive, perhaps because of your insistence and her suspicion you don't trust her.) 

To your specific questions:

1) The preventive treatments you had are highly effective: between the azithromycin (in double the usual dose) and ceftriaxone (Rocephin), there is no chance you could now have persisting chlamydia, gonorrhea, or syphilis. The risk of HSV from any particular exposure always is low, probably averaging less than 1 chance in a few thousand both for vaginal sex (for HSV2) and oral sex (for HSV1). But there is nothing available to reduce this already low risk -- i.e. no treatment now. If you don't develop symptoms of herpes (penile blisters/sores) within 2 weeks, that will be further reassuring. HSV blood tests are available, but they are not completely reliable and most experts would not recommend testing after any single exposure of this sort -- and certainly I would not recommend it.

2) No penicillin is necessary; see above.

3) PEP decisions should always be individualized and localized, with advice by an expert who understands risks and probabilities in your area. But unless the local epidemiology of HIV is very unusual in your area, the chance your escort partner had HIV is very low; if she had it, the chance you caught it is under 1 in a thousand. I doubt you need PEP and definitely would not recommend it (and would not do it myself if somehow I were in your situation).

4) You made the right choice. Ciprofloxacin has zero activity against syphilis, little against chlamydia, and doesn't cover many gonorrhea strains. Don't take it.

I hope this has helped. Best wishes. But I do hope you'll get into the condom habit for future events like this!


89 months ago
Thank you, Dr. Handsfield. That's incredibly helpful. Three follow up questions:

1. I didn't receive your reply in time to leave the dr office, so I did get a penicillin g injection. I read your advice when I got home - I wish I'd waited. Are there any drug interactions that make any of the azithromycin, rocephin, or penicillin less effective? If not, am I still safe to assume 100% protection, and therefore do not require testing for chlamydia, syphillis, gonorhhea, NGU?

2. The escort told me she would go get tested today, which I appreciate a lot. If she comes back negative for HIV am I in the clear? (Assuming your answer to #1 is that I am in the clear for the bacterial STIs.)

3. At this time, would you recommend any testing at all? I feel like my bases are covered, but I'm not an expert.

Thanks again and all the best. 

H. Hunter Handsfield, MD
89 months ago
1) I'm a little surprised the doctor gave you the penicillin shot; any basically trained doc should know that the other drugs would have aborted syphilis if you had been exposed. But there are no drug interactions to worry about and no harm will come, except maybe a sore gluteus for a few days. It would be pointless to be tested for any of those STDs after the treatments you had. Yes you're in the clear if the escort's repeat HIV test is negative, which I'm sure it will be. HIV is really, really rare in women like her. I see no need for any testing of any kind -- and certainly would not do it myself if I were in your shoes.

89 months ago
Hi Doctor,

A quick update. It's been 14 days since the encounter. Last night (day 13.5) I noticed a spot on my scrotum. Looks like a blood blister - very dark red. Not flesh colored at all. It doesn't hurt or itch, and it's not scabbed over. It doesn't look like cauliflower. It's barely raised, but not by much. 

Given timing (13.5 days), what do you think that might be? Also, with no other symptoms do you think I'm in the clear with respect to herpes or warts (unless this is one of those two)? 

H. Hunter Handsfield, MD
89 months ago
No STD causes skin lesions similar to this description. I'm confident it has nothing to do with the sexual encounter. For sure it's not herpes; doesn't sound like a wart; and warts don't show up until several weeks or months (up to a year) after exposure. Initial herpes and warts also are most common on directly exposed sites, i.e. those that get friction during sex -- i.e. the penis in men -- not scrotum, thighs, etc. (Your description sounds like a hemangioma, i.e. blood vessel "mole" which might have been present all along.)

You're pretty much out of the woods now on herpes; theoretically could start as late as 3 weeks, but rarely. But as noted above, warts usually become apparent 2-6 months after exposure and can be delayed a year. But the chance you were infected with HPV is low; even lower that you will develop warts, so it is very unlikely this will ever be a problem. In the event evidence of HPV ever shows up in you or your wife (e.g. and abnormal pap) it will not be possible to know when and where the infection came from, and in particular no reason to suspect you had an extramarital exposure. So it shouldn't be a cause of worry.

That completes the two follow-up comments and replies included with each new question, and so concludes this thread. Thanks again for your confidence in our services. Best wishes and stay safe.