[Question #6805] Sex with a high risk CSW

13 months ago
Hi Dr’s
I’ll try to be straight to point 
I went to a trip at the 8th of this month to morroco,
Met a csw for the first time of my life(I was a virgin) 
And had sex with her for 2 hours.
Ejaculated 4 times and changed condoms every time
No kissing - oral 
After we have finished I asked her how often she does this and she replied “every day”! 
I’m currently  having one of the worst headaches I’ve ever had, started since two days ago 
With muscles pain especially in neck and extreme
Fatigue 
Should I worry about HIV?! 
I didnt have any symptoms such as the ones for herpes or syphilis.
No pus or itching 
What is your advice? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Welcome to the forum. Thanks for your confidence in our services.

Congratulations for your wisdom in having safe sex, i.e. using a condom -- and changing condoms as you did. This was a nearly zero risk event for HIV. First, HIV is reported to be uncommon in Morocco, including female sex workers, in whom it's estimated to be present in about 1%. When a woman has HIV, the average risk for her male partner is around once for every 2,500 vaginal sex events. Condoms are at least 99% protective, so with a condom, the risk becomes once for every 250,000 exposures. If we multiply that by 0.01 (i.e. a 1% chance your partner had HIV), the risk becomes 1 chance in 25 million. Since you had 4 vaginal sex events, your risk calculates to be 1 in 6 million. I hope you'll agree that's zero for all practical purposes! The risk of other STDs is somewhat higher, but still quite low given your condom use.

Headache is not a typical symptom of new HIV infection. And if it started just recently, it's too late:  symptoms of acute retroviral syndrome (ARS, i.e. initial HIV infection) generally start after 8-10 and almost always within 2 weeks. Absence of urethral discharge or penile blisters or open sores is reassuring, but not proof against other STDs. 

Should you be tested for HIV and/or other STDs? From a strictly medical or risk perspective, there's really no need in view of the overall low risk and absence of symptoms. The vast majority of these infections occur in people with multiple high risk exposures, not just one. That said, many people who are worried, as you obviously are, find more reassurance fom negative testing than from professional opinion, no matter how expert. From that standpoint, you can consider waiting until 6 weeks after the event and having blood tests for HIV and syphilis, and a urine test for gonorrhea and chlamydia. (The urine test can be done at any time, but if you wait, you'll need only one visit to a doctor or clinic.) I suggest you not have a "panel" of multiple STD tests offered by many labs:  based on this one exposure, you definitely do not need any tests other than these.

Bottom line:  Exceedingly low chance you have any STD, but consider testing for additional reassurance. In the meantime, do your best to stop worrying. All is well. I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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13 months ago
Thank you for your reply,
I’d rather say it’s guilt, as this was my first sexual encounter.. ever!
What type of tests do you suggest? 
Ex: syphilis (VDRL or CIA/EIA) 
HIV(4th gen or just a rapid test)?
Don’t really know if these are the correct tests but did my research days ago.
I have read in many sites that if the condom was fully intact there is no way HIV could enter. Do you agree? 
Finally: I have oral sex ( never vaginal or anal) with my girlfriend (religious matter) can I continue it safely with her? 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Syphils:  These tests are equally accurate and valid at 6+ weeks after exposure. Whatever the lab, doctor or clinic routinely provides is fine.

HIV: For sure not the oral fluids test. Rapid blood tests are almost but not quite as senstive as the lab-based AgAb (4th generation) test.

I agree about intact condoms.

Oral sex is very safe even if HIV is present. If I were in your situation, I would continue any and all sexual practices with my wife without worry. But nobody can guarantee you aren't infected until you have been tested. (I would happily bet my life savings against you being infected, however.)
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13 months ago
Thanks again,
I’ll follow your advice and go for these tests after 6 weeks 
I think this is the final reply so I have some questions:
1 - Do you think taking  doxycycline for 4 weeks-every 12 hours-  would stop syphilis even if I have it? Although no sore or chancre is present.( I have a couple of boxes a doctor gave me to treat acne)
2 - If there is no way HIV could enter through condom is the testing just for reassurance?
3 - You've never mentioned Herpes, should I test for it or just be aware of symptoms?
4- I was thinking of talking OraQuick- Saliva test- as it’s in every pharmacy near me. Should I skip it and just go for the AB AG test? 

Thank you for all your responses
I do actually believe that you’re the best STD expert not only @ the USA but worldwide
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
1. Doxycycline is highly effective in both treating and preventing syphilis. (In fact, research is underway on the benefit of giving doxycline routinely to people at ongoing risk of syphilis, such as men who have sex with men.) I definitely would not reccomend it for syphilis prevention for you, given the near zero risk. But if you have been taking doxy anyway, or will start taking it soon, it will prevent any possiblity of active syphilis. So much so that I would recommend you not be tested for syphilis. Even if you were exposed and infected, the treatment will prevent the test from ever becoming positive.

2. Correct, HIV cannot pass through intact latex. The only hypothetical risk would be infected secretions entering at the condom rim then working their way to the tip of the penis. This probably is rare, and properly used condoms that don't break should be considered virtually 100% protective against HIV.

3. Herpes is very unlikely after any single exposure. Even regular partners of people with known genital herpes often stay uninfected for years. And the blood tests have problems, often with confusing or unreliable results. It isn't worth the hassle and potential risk of a misleading result.

4. Oraquick is not appropriate in this situation. It takes the longest of all HIV tests to turn positive (up to 3 months); and even then, misses some cases. You don't want a test that detects only 96-98% of infections, do you?

Thanks for your kind words. It's an exaggeration, but I appreciate it.

As you understand, each question includes two follow-up exchanges and we're there, so that concludes this thread. I hope the discussion has been helpful. My final advice is that if and when you have non-monogamous sex, if you go about it with the safety you did this time, there really is no need for STD/HIV testing after every encounter. Should such events happen from time to time, just plan on yearly testing -- unless of course you develop symptoms suggesting an infection.

Best wishes.
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