[Question #7033] HIV Transmission and should I take PEP?

9 months ago

Today I made the regretful mistake of going to see an escort. I know it was a bad idea and I’m having a hard time getting over it but I need to know the odds of getting HIV and if I should call a doctor for PEP. 

I received protected vaginal sex from an escort however 5 minutes into it she got up to adjust herself and while doing so was touching my penis. During this time I notice the condom broke and had a tear at the tip. 

There was a language barrier but she essentially told me that the condom broke when she got up and was touching it with her hand not while I was inside of her. She was adamant that she had no STD’s as well. 

My question is what are my chances of contracting HIV and should I talk to my doctor about taking PEP.  To make matters worse and more complicated I had a kidney transplant years ago and I’m worried PEP might not be an option for me since I take immunosuppressive medications. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
9 months ago
Welcome. Thank you for your confidence in our services.

Nobody on this forum ever needs to explain or apologize for a sexual decision, as long as nobody is harmed or participating in sex without consent. Whether or not having sex with an escort was a "bad idea" is strictly your issue and not anything we would ever care about or comment on.

You don't say where you are. If in the US or other industrialized country, it is very unlikely your escort partner has HIV -- probably under 1 chance in a thousand. And likely lower than that, given her assurance she isn't infected. Most escorts (expesnvie female sex workers by appointment, i.e. not brothel workers, bar pick-ups, and so on) know the score, have mostly low risk clients (men like you), care about their health, use condoms regularly, and are tested quite frequently. Second, even if she had HIV and you had entirely unprotected sex, your risk of HIV would be in the range of 1 in 2,500. Third, you had protected sex -- and if she says the condom tore during her hand-penis contact, that's probably what happened. Remember how experienced she is in such matters; you can trust that expertise.

So based on all known so far, I really don't think you need to worry. I recommend against PEP; even testing for HIV and other STDs is optional. The only factor that might change this would be if you're in a place or setting where HIV is a lot more common than in the US; or perhaps if your partner wasn't truly an escort but a higher risk sex worker. 

Being immunosuppressed because of your kidney transplant does not increase the risk of catching HIV if exposed. Such drugs may increase the risk of complciation in infected persons, but not risk of being infected. So that medical history really has no bearing on any of this.

In summary, I really wouldn't be worried about this event in terms of HIV or STD risk. But of course you are free to be tested if you feel you would like the additional reassurance of negative results. If so, you can have a urine gonorrhea/chlamydia test any time 4-5 days or more after the event, and HIV and syphilis testing after 6 weeks. But I stress these are optional. Your risk really was very low.

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

9 months ago
Hi Doctor Handsfield,

Thank you for the quick reply and assurance. 

I’m located in the US in Miami. I apologize if I come across as vulgar in the following statement but I’m not sure if she was just a regular sex worker or high end escort. I paid $100 and it took place in a hotel in a rough part of town. 

If the condom actually broke during penetration while I was inside of her would that warrant PEP? 

I ask about PEP because to make things complicated I have a long term partner and would hate to put them at risk for HIV. 

When would PEP be needed in your expertise and is PEP safe if you have CKD (chronic kidney disease)?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
9 months ago
Thanks for the clarifications. Nothing you wrote is at all inappropriate or vulgar! However, I'm not sure your partner meets my definition of "escort", and she might therefore have a higher risk of having HIV and other STDs. Still, note the low risk of catching HIV from a single unprotected exposure, even if she is infected (probably she is not). And it seems unlikely the condom broke during penetration: when that happens, usualy the condom breaks wide open and is very obvious. And the small defect you describe may not have allowed for very much exposure to vaginal fluids.

Having said all that, PEP decisions are best made by providers who understand the epidemiology of HIV in the local area. For example, if such a doctor or clinic has information about the likelihood of HIV in sex workers in that particular neighborhood or even in the hotel where this took place, that could affect the risk assessment. So my advice is to find a Miami provider with excellent HIV knowledge. Your best route to expert care may be through the health department, i.e. the Miami-Dade Co. offices of the FL state health department. Or contact the doctor or clinic where your CKD is managed:  they may be very knowledgeable themselves, or migh recommend a particular infectious diseases or HIV/AIDS specialist.

To my knowledge, PEP is safe and effective in pesons with renal impairment, but that might depend in part on how advanced it is. Here too your CKD provider would know more than I do.

Before you make a final decision about PEP, be aware of an important and common downside. PEP is highly effective -- but if it doesn't work (maybe 10% of cases?), the time to conclusvie testing to diagnose HIV is prolonged. So instead of having a conclusive test in 6 weeks, it might require waiting 3 months to know for sure you weren't infected. That's a pretty long time to go through the anxiety of not knowing.

Don't over-read all this. Your risk for HIV is very low; if somehow i were your situation, I would not personally want PEP. But you need to know the options and make your own choice. Good luck.