[Question #7119] Vaginal fingering with a cut on finger, cunnilingus and condomless fellatio

8 months ago
Hello Doctor, Am a 46 years old male. Approx 20 hours before, I had sex with a woman whom I had met online. I received condomless fellatio, blow job from her. The blowjob was rough because the skin of my penis was stretched and very sore. I also formed cunnilingus on the woman with no oral protection and deeply fingered her for a very long time. The act went of for a long time. In the heat of the moment I had forgotten that just a couple of hours before the sexual act I had torn the skin right next to my finger nail and it had bled and was painful. That skin area, near the finger nail is still painful and reddish. That very finger which was used to do the  fingering on the woman.

 I did have protected, using condom, sex in the vagina for a very short duration.

My question is, what is the risk of HIV infection from the above mentioned activities. The status of the woman is not known and she on asking has refused to undergo a test. That worried me. Should I start of PEP immediately? Please advice.

Thanks
Edward W. Hook M.D.
Edward W. Hook M.D.
8 months ago
Welcome to our forum. Thanks for your question. The encounter you describe was very, very low risk. If you came to me in my clinic seeking help, I would not be willing to prescribe it because the risk is so very low. Despite your partner’s refusal to be tested, it is quite unlikely that she had untreated HIV. To my knowledge, and based on continuing careful review of the medical literature there are no cases of HIV which have been proven to have been acquired as a result of receiving Oral sex or performing cunnilingus from an infected sex partner. You will not be the first.

Similarly the recent tear of the skin on your finger does not represent a meaningful risk for HIV.

While I understand that your concerns may lead you to seek testing, I am confident that, if you choose to test, the result will show that you were not infected.  Testing with standard combination HIV antigen- antibody tests will be more than 99% conclusive at 4 weeks and entirely conclusive at 6 weeks.

I hope that this information is helpful.  EWH
---
8 months ago
Hello Doctor, Thank you. you response has eased up my stress level. Before I read your response,  I had gone ahead and got a prescription for Truvada as PEP. The pharmacy based on the prescription gave me "APO-EMTRICITABINE/TENOFOVIR 200-300 mg" to be taken once a day for 30 days. I started off with the first dose yesterday itself.

To elaborate on the skin tear:  The hangnail, next to my finger nail, which I pulled out had left a deep tear which was painful and had bled. This was just some hours, approx 8 hours, before the deep fingering incident.

Questions:
1 - My understanding now based on your response is that, even if the wound had come in contact with vaginal fluids it is a no risk for hiv infection. Please confirm.

2 - Since I have started off on the medication, I intend to complete the course of 30 days. My understanding is, taking this medication will in no way interfere in any STI / hiv testing that I would take anytime be it within the 30 days or post 30 days of starting the medication. Please confirm

3 - Would it better to wait for the 30 days does to completed before going in for a testing? Please confirm.

4 - I do occasionally take febuxostat in case my uric acid pain goes up. And as long as I continue to abstain from any further sexual activity and alcohol for the next 6 weeks, consuming the afore medication is a safe activity.   Please confirm

Thanks

Edward W. Hook M.D.
Edward W. Hook M.D.
8 months ago
Your elaboration on the nature of your skin tear in no way changes my opinion or recommendations. Masturbation of an infected sexual partner with a skin tear of the sort you describe is a no risk event for HIV acquisition. 

As I said before, the nature of the exposure that you described is not amongst those for which HIV PEP is recommended. If you have chosen to take PEP, of course that is up to you. I hope that the side effects won’t trouble you. More importantly however simply taking Truvada alone as PEP is not a recommended regimen. Recommended PEP regimens should involve taking three different anti-HIV medications from at least two different medication classes.  You should at least be taking a recommended HIV PEP regimen.  In answer to your specific questions:

1.  Your understanding is correct. The exposure you describe is considered a no risk exposure, even in the unlikely circumstance that your partner had HIV.

2.  Taking HIV PEP will in no way interfere with the accuracy or results of testing for other STI’s. On the other hand conclusive testing for HIV will be delayed by 30 days so that accurate conclusive HIV testing would not occur until six weeks following completion of your HIV PEP.

3.  Please see my comments above. You can certainly test for the most common STI’s such as gonorrhea and chlamydia at this time although as for HIV the event you describe put you at no risk for those infections. Testing for hepatitis or Syphilis will not be helpful until at least 30 days following the exposure.

4.  Febexostat will have no effect on either the medications you are taking for HIV PEP nor your test results for HIV or other infections when those tests are taking at appropriate times. Similarly there is no need to abstain from alcohol while taking HIV PEP.

EWH
---
8 months ago
Hello Doctor, Thank you for your valuable advice. 

Timelines of activities:
Monday 27th July  00:30 AM sexual encounter
Monday 27th July 14:00 started 1st pill of Truvada
Tuesday 28th July 16:00 had started 1st pill of Reltagravir in addition to Truvada

Questions:
1 - I have decided "not" to proceed on PEP considering the advice provided that oral sex, fellatio and cunnilingus and fingering of vagina represents no risk. Also taking into consideration the side effects of raltegravir.  If I had approached your clinic, if you had been my family doctor, would you agree to my decision on to stop PEP? Please advice.  

2 - If I continue with PEP, it is my understanding that to have a reliable HIV test result, testing should be done after 9th October.  considering PEP therapy ends on 27th August therapy and 6 weeks after that would be after 9th October. Is my understanding correct?

3 - Considering I am going to discontinue PEP, after taking just the 1st does, I intend to go for my hiv testing after 9th September. My understanding being test done after 9th September will not provide a false results. Please advise.

Thanks,

Edward W. Hook M.D.
Edward W. Hook M.D.
8 months ago
Thank you for your follow up. I know how worrisome encounters of the sort you describe can be but I also entirely agree with your decision to stop taking HIV PEP.  As I indicated earlier the exposures that you described are not exposures in anyway associated with increased risk for acquisition of HIV. Please find my responses to your follow-up questions below:

1. If you had come to my clinic with a question about discontinuing HIV pep in your situation I would endorse your decision to stop taking the medication. The reasons for this is that the medication is unnecessary and all medications have potential side effects. Further, taking PEP would delay the time interval until you were able to obtain conclusive HIV test results.

2.  Yes your time calculation is correct. You would get conclusive test results if you continue to take Pepke after October 9.

3.  This calculation is also correct. If you stop taking PEP at this time, you will be able to obtain conclusive and accurate test results for HIV on September 9. 

I hope that the information I have provided is helpful. As you know, we provide up to three responses to each set of questions. This is my third response. Therefore, as per forum guidelines, this thread will be closed shortly without further responses. Take care. Please don’t worry. EWH


---