[Question #7187] This is a Mess !!!

6 months ago

Hi Doctors,

In a right pickle here! Had unprotected vaginal/anal sex with multiple prostitutes in a red light area in Mumbai. This was under the influence of substances so this carried on over a 24 hour period.

By the end of the 24 hour period, my penis (am not circumcised) was swollen and the foreskin would not retract. I also noticed a pain in the pubic region above the penis towards the right side and attributed it to just hair being pulled or something like that. Its been 3 days since then and the swelling has gone down considerably, but there is a lot of white skin (I think chaffed skin) peeling off the penis glans and foreskin. I also noticed a rash on the groin area above the penis (where the pubic hair is) and more to the right side which is bumps that are red and some have puss in them.

My questions:

1. I had all the girls undergo HIV Duo and HIV RNA PCR which thankfully was negative. Does this mean that there is no chance for HIV transmission and I have been extremely fortunate despite my stupidity? I stopped the PEP based on this.

2. What is the correct blood test to take to see what type of Herpes this is? I dont think I can find a doctor during covid here to try to take a sample from the blisters. Many years ago, I did get a herpes rash on my penis after oral sex, so thought I already had it and could not get it again. Guess I was wrong.

3. The prodorme started in 24 hours - is that normal of herpes? The herpes rash is in the pubic hair region and slightly above as well. But not on penis. Does this mean the rash will come in this specific place each time?

4. I took prophylaxis of 2.5 grams zithro and 800 mg cefixme and 2 grams tinidazole for STDs Is there any other STD I should be worried about due to unprotected anal/vaginal after this medication?

Edward W. Hook M.D.

6 months ago

Welcome to the Forum. Thanks for your questions. I'll be glad to comment.

This was a high risk exposure. As I suspect you know, HIV is relatively common among CSWs in Mumbai. The fact that each of them did have negative HIV Duo and PCR tests provides a high degree of assurance that they were not infected and that you were not exposed to HIV. Based on these data, it is reasonable to not take PEP.

The immediate swelling and irritation may have been due to the friction of your encounters or possibly a local reaction to a lubricant or other chemical formulation used by you or one of your partners. The location of the lesions in the pubic region you describe is an unusual one for herpes. Genital HSV would certainly not appear in the day or two after exposure and even an onset at day 3 is on the early side although not impossible. At this early time, blood tests will be of no meaningful use for determining what is causing your current symptoms, you need a swab taken from the lesions, preferably for PCR testing or, in PCR is not available, for culture. There should be no COVID risk from taking a swab or your genital lesions.

A possible HSV rash occurring following receipt of oral sex is most likely to be HSV-1. Thus you would be still vulnerable to HSV-2 although from your description, this may not be HSV but a bacterial folliculitis or other irritative process. I would suggest you work to see a trained clinician with testing capability for evaluation.

See my comments above. What you describe is not all that suggestive of HSV. I think you need evaluation

4. I took prophylaxis of 2.5 grams zithro and 800 mg cefixme and 2 grams tinidazole for STDs Is there any other STD I should be worried about due to unprotected anal/vaginal after this medication?

These medications should eliminate your risk for bacterial and protozoan STIs including gonorrhea, chlamydia, syphilis and trichomoniasis, I would not worry aobut other STIs.

Hope these comments are helpful. If anything is unclear or their are further questions, please feel free to use your up to to two follow-up questions for clarification. EWH

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6 months ago

Hi Dr. Hook,

Thank you for you replies. Would appreciate a few clarifications:

1. When you say the partners having negative Duo and PCR test results provides a high degree of assurance, does this mean I do not need to test as I was not exposed to HIV?

2. If I did want to test with PCR, would a 10 day PCR result be meaningful for HIV status or too early (what's the earliest a PCR test is reliable)?

3. Regarding the rash, I did show pics to another dermatologist who concurs with you in that this looks more like folliculitis. Although this is a sense of relief, what is the incubation period for HSV earliest to latest so I can continue to monitor in case I develop symptoms?

4. Its been 3 days since the antibiotic prophylaxis, and there is still discomfort in the urethra. How long does it take for medication to work (or to know the medication is not working and need to change)? Is a one week course of doxycycline recommended for hard to treat urethritis in case the zithro doesn't get rid of symptoms?

5. Forgot to ask about risks of Hep B and C? Am I at risk for either? And if so, when is the earliest I can test for each? I do understand that there may be a PCR test for Hep C - is this advisable to take and what is the window period for this PCR test?

Thanks!

Edward W. Hook M.D.

6 months ago

Clarifications:

1. Testing is a personal choice. Available research however has led to the conclusion that persons with undetectable HIV by PCR do not transmit the virus to others. Negative Duo and PCR tests are assurance that a person (in this case, your sexual partners) were not infected with HIV.

2. Most experts state that a negative PCR at day 10 or 11 is very strong evidence that you are not infected but still recommend follow-up Duo testing at 6 weeks. I have never seen nor heard of a patient with a negative PCR at day 11 or beyond who went on to later become positive.

3. If HSV lesions are going to appear, the almost always appear by day 10 after exposure.

4. The medications work virtually immediately when take as prophylaxis. You do not need more antibiotics. If you test, I anticipate that the tests will be negative. You need to stop focusing on possible symptoms. It may very well be that your concerns are leading you to be more aware of normal sensations.

5. Hepatitis C is virtually never sexually transmitted and should not concern you. If you have not been vaccinated against hepatitis B, there is a small risk for infection. A negative hepatitis be blood test (both antigen and antibody tests at 30 days would prove that you were not infected).

Hope this helps. Clearly you remain concerned about your exposures and while I understand this, I really think that nothing you have suggested raises concerns. EWH

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5 months ago

Hi Dr. Hook,

Thanks for your advice. I have one final follow up post and would sincerely appreciate your advice:

This concerns the antibiotic prophylaxis that was taken earlier (2.5 grams azithromycin, 800 mg Cefixime, and 2 grams Tinidazole)

1. Since Azithromycin has such a long half life (68 hours), online half life calculators show that there would still be the equivalent of a 250 mg dose of Azithromycin in my system at the Day 11 mark. Is this correct?

2. Unfortunately, I had another exposure at Day 11. Would the small amount (250 mg) of azithromycin already in my system actually help stop any potential bacterial STD? Or would the opposite be the case - i.e. because I already had such a low level of azithromycin (250 mg) in my system, could this actually cause drug resistance had I been infected with an STD during the second exposure?

3. I did take another prophylaxis (2.5 grams azithromycin, 800 mg Cefixime, and 2 grams Tinidazole) 3 days after the second exposure. That means any potential STD from the second exposure was exposed to a low level of azithromycin in my system for 3 days before being exposed to the large dose in the second prophylaxis. Would this be sufficient in strength and timing to make irrelevant any potential drug resistance and would this ensure all bacterial STD's would be prevented?

4. I am assuming cefixime and tinidazole have short half lives and hence not a cause for concern at the day 11 mark as it would no longer be in my system. Is this correct?

5. Do I need to test for any STD's or can I finally move on?

Thanks

Edward W. Hook M.D.

5 months ago

I appreciate your concerns regarding development of antimicrobial resistance due to lingering amounts of azithromycin 11 days after your last dose. Low levels of antibiotics however do not cause development of resistance as much as they select for it, meaning that if your partner had an antibiotic resistance variation of bacteria you would be more likely to be infected than if you had been exposed to a more sensitive strain and still had small amounts of azithromycin in your system. In addition, as you point out, on day 11 after taking antibiotics, the cefixime and tinidazole you took would have been long gone. In answer to your specific questions:

1. Some small amount of azithromycin may have been in your system and had some effect in making infection by chlamydia and perhaps Gonorrhea less likely. Precisely what level would be hard to estimate.

2. See above. Any azithromycin remaining in your system however would not cause resistance.

3. It is likely that the medications you took for prevention would have cured any existing gonorrhea, chlamydia, or trichomonas infections which you acquired during your exposure.

4: correct

5. I see little benefit to testing at this time unless you develop symptoms.

I hope that this information has been helpful. As you know, with this third reply this thread is complete and will be closed shortly. Take care. EWH

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