[Question #7965] CSW HIV risk from condom failure + HPV
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50 months ago
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Dear Doctors
I met a Brazilian CSW who works from a flat in London and has lived in the UK for several years. We had vaginal sex twice. The condom broke the second time (without ejaculation). I could have been unprotected for seconds or a few minutes. She seemed to notice that the condom had broken during the intercourse, rushed to the bathroom with a towel and returned a minute later to give me a new condom. Her main concern seemed to be the risk of pregnancy. She said she gets tested for STDs once every two months but isn't taking birth control.
The next day, I visited a walk-in PEP clinic in London. The health professional asked me a series of questions and determined that I don't need PEP or HIV testing for this event. He said that HIV prevalence in UK sex workers is less than 1% and that my overall risk is at 'hit by lighting' levels. The fact that I am circumcised further reduces my risk, he said. I left the consultation feeling sufficiently reassured.
However, two things have since come to mind which I did not mention at the clinic:
1. At the top of the penis (the area covered by pubic hair but barely by a condom) I have what look like genital warts. I had noticed these a couple of months earlier upon trimming, but thought that they were likely skin tags, which I get in the armpit and neck regions. Having now googled HPV, it looks like they could indeed be genital warts - they're brown, raised and in a cluster of about 1 cm wide. There is also a tiny brown spot on the head of penis, although this is a lot fainter in colour, not really raised and could just be a normal blemish.
2. The CSW said that she's had both covid vaccinations, despite being in her 30s, which, currently in the UK, could indicate that she has an underlying health condition (diabetes, asthma, HIV...).
Would these two additional factors have called for PEP and HIV testing? Not having had an STD before, I'm especially concerned about the additional HIV risk represented by HPV infection.
Thanks.
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Edward W. Hook M.D.
50 months ago
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Welcome for thanks for your confidence in our service. I agree with the advice you received at the PEP clinic that the exposure you described was low risk. Not only most commercial sex workers not have HIV or STI’s but your partner seems particularly aware and cautious. I would’ve provided you with the same advice. With regard to your specific questions:
1. The lesions that you have noticed at the top of your penis are in a place which is relatively unusual for genital warts to occur. Related to the possibility that they may have increased your risk for acquisition of HIV, if exposed, this is unlikely. There are no scientific data which suggest that general warts meaningfully increase the risk for acquisition of HIV.
2. That your partner had been vaccinated against COVID-19 would not change my assessment regarding your need for PEP. If anything, or vaccination makes your exposure to her safer. I cannot think of a biological reason that COVID-19 vaccination would influence recommendations regarding provision of PEP.
I hope this information is helpful. If there are additional questions or if any part of my response is unclear please don’t hesitate to use your ability to follow up questions for clarification. EWH
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50 months ago
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Dr Hook - Many thanks for the reply. Could I just clarify that, if the lesions are HPV, the added risk in my case would still not require PEP and HIV testing? I've read that HPV can double or triple the risk of HIV infection (https://www.aidsmap.com/news/dec-2013/men-penile-hpv-infection-have-increased-risk-acquiring-hiv). Would the following statistical risk seem fairly accurate for my case (apologies for any errors - maths isn't my strong point):
2,500 (risk per episode of vaginal sex with HIV positive partner) x 100 (risk of partner being HIV positive) / 2 (doubling the risk of contracting HIV due to HPV) = 1 in 125,000 risk?
The reason for raising the covid vaccine concern is that it could suggest she has an underlying health condition - e.g. HIV - which has meant that she has been able to receive both vaccines before adults in her age group who don't have underlying health conditions. However, I'm assuming that this would probably also imply that she is on HIV treatment and therefore non-infectious (according to UK health authorities, 97% of those receiving HIV treatment in the UK in 2018 had an undetectable viral load, which I believe is now accepted to mean that they can't transmit the virus sexually).
Thanks again for all your help.
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Edward W. Hook M.D.
50 months ago
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I really think you are overthinking this. Estimates of increased risk of HIV acquisition related to the presence of general warts is biased by the fact that persons with more sexual partners have both diseases. There is little biological reason to believe that genital warts actually work to increase risk for HIV acquisition. Furthermore, your Calculation fails to consider the brevity of your exposure ( but your math is correct).
Quite frankly, using your figures, IF warts double the risk if HIV acquisition ( And I maintain that they do not), With or without genital warts the fact is that there is 99.999% chance you were not infected. This is simply too unlikely to consider PEP with it’s risks of side effects, prolonged period until a worried person such as yourself can prove he was not infected, inconvenience, and cost.
---Cool, in my opinion, you are assumption that because your partner has managed to be vaccinated against COVID-19 she must be HIV-infected is over the top.
Again, I do not believe you need PEP for the exposure you describe and I have no meaningful concern that you will acquire HIV from the exposure you’ve described. I hope my explanations are helpful to you. EWH
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50 months ago
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Ok, thanks, Doctor. 1 in 100,000 could, I suppose, be called a negligible risk, which is reassuring.
Thanks again.
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Edward W. Hook M.D.
50 months ago
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Glad I could help. This will complete this thread. EWH ---