[Question #6712] HIV Risk or Not - Totally Confused!

14 months ago

Hi Doc,

 

I had called a low level csw in India to my hotel room and she insisted on protected oral and protected sex. In the end, I just got a handjob inside the condom, so this was a no risk event.

 

Several hours later, I called her back and she was lying on top of me and we were just rubbing around and I was assuming she would only practice safe sex. She held my penis and tried to guide it inside her, but I did not allow it.  By this point, I was very drunk and I am not sure if I was in/out of consciousness at times.  Next thing I remember was her still on top of me and moving her body as if we were having sex.  I recall quickly grabbing my penis to see if it was inside her vagina, but there was no warmth (as one would expect if inserted into a vagina), but it did feel like the upper half of my penis was inside somewhere relatively tight, and in that state of mind, I attributed it to still being outside for some reason.  After that, the next thing I remember was that she was leaving (so don't know if I passed out again at some point).

 

I was planning to not even test or bother about this incident until I showered the next morning and noticed redness on my penis (left side of glans and corresponding side below on inner foreskin - I am not circumcised).  Plus some red spots across glans.  Still did not think much about it.  But about 6 hours after the shower (and about 12 hours since the exposure), the redness was all over glans and foreskin as well as red spots on the glans.  It was not painful, and recall it only having a mild odor once.  I dont think that this could have happened unless my penis was inside her vagina or anus, so I immediately started pep at 19 hours.

 

I'm very confused and dont know what to do as I cant really accurately recall risk.  On one hand, she was insisting on condoms for everything the first time, and the second time seems ok to do it without.  So my questions are:

 

1.     Given the rash on the penis, does it seem logical to assume that insertion did indeed take place?

2.     Given the nature of the rash and the timing, does it seem more to do with friction or fungal?  Today (2 days later), the redness and spots are still there, but less.  I did put on some antifungal cream overnight.

3.     The angle she was on top of me was such that it could have been either anal or vaginal, but since I have never done anal before, would I not have noticed her insert it as there was no lubrication involved (even if I was drunk)?  Wouldn’t I have felt some warmth if it was anal as well?

4.     Would passing out make the penis limp again or could she have continued to have sex while I was passed out?

5.     I’m not even sure what kind of risk this was and how to approach it.  I do know she was high risk as most local csw’s in India are high risk.  If I did have insertion, then that makes it worse.  Do I assume insertive anal with risky partner as my risk?

6.     Is this something that you would have taken PEP for had you been in my position?  I am seriously considering stopping PEP and testing with RNA at 2 weeks.

 

The one time I actually try to avoid risky sex and this happens.

Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago

Welcome to the Forum and thanks for your question.  I'll do my best to help.  From the sounds of things, this encounter did not involve penetration.  Further , I would point out that a rash appearing within 24 hours of exposure is too soon to be an STI and is more likely to be due to the friction of the rubbing you describe than infection.  It is not unusual for such discomfort to get worse for a few hours after being noticed initially.  In answer to your specific questions:

1.  See above.  The timing of the rash you describe would be more typical of friction rash from rubbing than an STI. Its presence does not mean that penetration occurred. 

2.  See above. I would suspect friction and that over the next few days assuming that there is no more trauma (rubbing, masturbation, etc.) that it would improve.

3.  I suspect that if penetration of any sort had occurred, you would have known it.  You are correct that there is less lubrication naturally present with anal than with vaginal penetration.

4.  Sex while unconscious would be most unlikely and improbable.

5.  You are correct that insertion is more risk than not.  for the insertive partner, the HIV risk of anal insertive is about the same as the risk for vaginal insertive (slightly but not too much higher)

6.  It is not clear how long ago this occurred.  Are you taking PEP at present?  PEP is always a personal choice but from the sound of things, I suspect your risk is quite low.  If there are no barriers, the information from an RNA test may be helpful if you are not taking PEP.  If you are taking PEP, I would wait at least two weeks after the last dose before testing even with an RNA test.

I hope this perspective is helpful.  I probably would not have taken PEP in this situation but as I said above, this is a personal choice.  EWH

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14 months ago
Dear Dr. Hook,

Thank you for your reply.  The rash seems to be a little better today.  While cleaning in the shower I noticed like a layer of skin on the glans that peeled off into stringy white clumps which I am assuming are skin.  The only thing is that I don't think there was enough rubbing against genitals to cause friction like this.  If at all, more rubbing happened the first time when she gave me a hand job while my penis was in a condom and it was vigorous for a short while.

Just a clarification - if there was no insertion, then does that mean no risk, and no need to test (RNA or otherwise)?  Would the only reason to do the RNA (or Duo) be in case there was insertion or more for peace of mind?

This exposure happened 3 days ago and I started PEP 19 hours after the exposure.  I have 2 options and its a tough choice to make:

Option 1 is that I continue the PEP even though this may be a low risk incident and the downside is PEP medication for 4 weeks as well as additional time to know HIV status, but the upside is that in case there was insertion, the PEP will lower risk. 

Option 2 is that I stop PEP now, and the downside is that if there was insertion, I have a higher chance of being infected (especially as there was friction which caused skin irritation and I am not circumcised).  But the upside is that in 2 weeks I can take the RNA test and determine my HIV status.

I know its difficult, but which of these two options would you choose if you were in my place?

Thanks.

Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago

Thanks for your follow-up.  To deal with your first question- yes, if there was no insertion, there is no risk for HIV, no medical need for testing, and no need for PEP.

On the other hand, PEP is always a personal choice and now that you have started it, it is also up to you regarding whether or not to continue. From your description, I would not have started it.  EWH

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13 months ago
Hi Dr. Hook,

I decided to continue the PEP since I had started it. 

On the 19th day after starting it, I was lying down and watching TV in the evening and suddenly developed severe pain in both my calf muscles - like nothing I have experienced before.  It lasted for an hour and then remained more of a dull pain. The next day the pain was on and off throughout day. I took a Tylenol at night and the following morning pain was gone during day but returned again at night. 

1.  Could this be atypical ARS presentation due to PEP failure?

2.  Could the PEP medication cause side effects after 19 days or would side effects have happened much earlier?

3. The symptoms started 2 days ago. If I took the duo now would it be of any value to determine if symptoms are due to hiv? Even though I’m still on pep?

4. I have been reading that viral infections cause muscle pains and am worried that the PEP has not worked. How effective is PEP really? 
Edward W. Hook M.D.
Edward W. Hook M.D.
13 months ago
Thank you for the follow-up. Once PEP has been started it is logical to complete it, even if it may not have been warranted on the basis fo your exposure except when persons may be experiencing side effects.  In your. Case, please remember that you did not need PEP to begin with. In answer to your specific questions:

1.  While muscle aches may occur as part of the ARS, when they occur they do so in combination with high fever and severe sore throat.  What you describe is not a sign of PEP failure.

2. Yes, this could be a medication side effect.  If it continues to worsen, you may wish to stop the medicine which, as we have discussed previously was not needed.

3.  A DUO type test at this time would prove that this is not the ARS although I really do not see the need.  There is nothing you have described to suggest that this is HIV due to the exposure you described.

4.  In persons at risk (which there is no reason to think that you were) PEP reduces the risk of HIV about 80%.  Again, in your situation there is no reason to think this is HIV.

As you know, we provide up to three responses to each question.  This is my third response.  Therefore this thread will be closed shortly without further responses.  Please don’t worry.  EWH 
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