[Question #6991] Unprotected sexual encounter and risk assessment

8 months ago
Hi Drs.,

Thanks in advance for your input. I had asked a question several months back about an unprotected encounter and you were very helpful. 

My husband and I separated a few months ago and this past Saturday I met up with a guy I had met online and had been chatting with for several weeks. We hit it off and ended up getting a hotel room for the night.  Unfortunately he did not bring condoms and in the heat of the moment I agreed to forgo them (stupidly). During previous conversations we discussed our STD risk and he did not “appear” high risk. 

We had both unprotected oral, vaginal, and anal sex that night.  I freaked out the next day over my colassal bad judgement....again. He sent me a copy of his most recent testing which was in 2/2019 where he had a fully negative STD screen (G &C, HSV, HIV, syphillis)  and he had a long term girlfriend after that until a few months ago. He says I’m his only partner since her.  No hx sex with men or IV drug use that he says. 

On my side I had 2 risky encounters over the winter and was tested completely negative for all the same tests in January and again in March. 

My question is:

Although I don’t believe my partner to be high risk our encounter certainly was. I will get screening done again in a few weeks and plan to use condoms going forward (bringing my own from now on).  However I’m not sure if based on this encounter I should take PEP and wondered your thoughts? 

Thanks again in advance! 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
8 months ago
Welcome back to the forum. Thanks for your continuing confidence in our services.

I hope you don't mind my saying so, but you are overreacting to a pretty safe situation. It seems that as you enter (or re-enter) the dating world, you may have some mistaken understandings about STD/HIV risks and sexual safety. STDs and HIV are not nearly as rampant as you may have come to believe. True it would have been smarter to use a condom. On the other hand, you describe a partner at low risk, especially in view of his relatively recent negative test results and his sexual history. In addition (now assuming your partner's age is probably somewhere around your own), most STDs are quite uncommon beyond age 30; the vast majority of chlamydial infections, gonorrhea, and other STDs occur in people under 30-35. And syphilis and HIV remain very rare in even the most sexually active heterosexual men and women, especially outside such obvious risk groups as commercial sex workers, injection drug users (who may need to exchange sex for drugs or the money to buy them), gay men with multiple partners, and a handful of other groups.

Even in younger persons in the typical urban, heterosexual dating scene, it is not the norm for people to seek STD/HIV testing after every new sexual encounter or partnership -- and it certainly isn't necessary for the large majority of people in your situation. The way your sexual life seems to be evolving, based on your previous threads and this one, testing once a year might make sense, without concern about every encounter unless other information emerges -- symptoms in either partner, new information that a partner is infected, and so on. But absent such factors, my advice would be the same if you were my own patient, my daughter, or anyone else close to me:  no need to test now; choose your partners with common sense; do use condoms (but don't freak out if it doesn't happen or the condom fails); and in absence of symptoms like new vaginal discharge, genital sores, strong vaginal odor, or pelvic pain, don't get tested after every new exposure. Once a year would be fine!

And as for HIV, I absolutely recommend against PEP or even HIV testing at this time. (If you came to my clinic, we would refuse to prescribe PEP for you.) I also do not recommend pre-exposure prophylaxis (PrEP) unless and until you have partners at particularly high risk for HIV, such as bi men, possible IV drug users, etc. However, I certainly endorse your plan to start carrying your own condoms -- as much for the reassurance value after the deed is done as for actual risk reduction.

Having said all that, I do understand that anxious persons often are more reassured by test results than professional opinion (no matter how expert) based on probability and statistics. But if you decide to be tested, don't overdo it. A vaginal swab or urine test for gonorrhea and chlamydia at any time, and after a few weeks blood tests for syphilis and HIV are the only ones you consider. And if it were me (or my daughter), I would reemphasize that there's really no need at all.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD
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8 months ago
Thank you Dr. Handsfield for your candid response.  As as health care provider myself I completely understand the difference between following recommendations rooted in possible worst case scenarios and making decisions based on knowledge gained after many years of patient care and real world experiences. It’s not always the “zebra” is what you’re saying I think. 

It would be hard for me to follow this advice coming from someone with less knowledge and experience re sexual health so I truly appreciate your expertise and the opportunity to have access to it. 

I will really take your advice to heart and try to relax as best as I can. The last 6 mos have been an emotionally tumultuous time causing me to make some less than ideal sexual decisions. As I said before this is an opportunity I have to be better with in the future. 

Again a sincere thanks for you taking the time to respond in a way that feels both professional and personal as well. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
8 months ago
Thanks for the thanks. We're always especially happy to aid other heath professionals. I wasn't aware until now.

Based on the tenor of both your questions, it was pretty clear you're going through a rough patch. My only other advice -- undoubtedly something you're telling yourself -- is to try not to conflate your anxieties and uncertainties about sex and romance with STD/HIV risk. It's easy to focus on the latter as an aspect that has potential easy solutions like diagnostic tests, treatment if needed, etc. But you surely know that the core issues are psychological, deeper, and won't go away by addressing only the infection risks.

Best wishes.
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8 months ago
Sorry one follow up question. If I do decide to get tested even in the absence of symptoms is there any difference in accuracy of a urine vs. vaginal swab test for G&C? And if urine is performed should it be the first morning urine that’s collected? 

Thank you again for your availability, expertise, and education. I’m most grateful. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
8 months ago
Urine misses a few GC or CT infections; vaginal swab testing almost never does. It makes sense, if you think of the likely concentrations of gonococcal or chlamydial DNA/RNA closer or farther from the anatomic site of infection, the cervix.  Urine testin should be reserved for screening in settings where collecting vaginal swabs may be inconvenient or less well accepted by women at risk, e.g. at schools or places of work. Vaginal swab should be the norma in all medical/clinical settings.

Time of day probably makes little difference in women. If for some reason you have urine testing, maybe best to wait at least a couple hours since last voiding, but probably makes little difference. And I'm sure no difference for vaginal swab testing.

That completes the two follow-up exchanges included with each question, but I'll leave the thread open for a couple of day in case something else comes to mind. I hope the discussion has been helpful.
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