[Question #817] Risk Assessment Please

99 months ago

Hello experts,

I am a woman who had an unpleasant experience with a man, and I am hoping you can assess the situation and provide a numerical estimation of the risk I exposed myself to. I live in North America.

The interaction started as protected vaginal intercourse entailing very vigorous sex at which point I asked him to exit. Upon exiting, I noticed his penis was without a condom - which was now inside of me. I asked him about it and he said that I pulled the condom in with my muscles when he was existing and that, supposedly, we didn't have unprotected sex. Coming from someone who was repeatedly trying to persuade me to take the condom off, I have doubts about his words.

I pulled the condom out from my vagina, checked that it's intact and he put it on again. The sex continued in a rough way until I noticed I was bleeding vaginally. Since my period was two weeks away and the blood didn't look like menstrual blood, what came to mind is that he tore a tissue which led to the bleeding. The sex continued with a condom on until I asked him to exit again, which he did, then gave him oral sex until he ejaculated outside my mouth. I then checked the condom and seemingly there were no tears, it appeared intact to me.

My two points of concerns relating to HIV risk are the fact that when he exited the first time he was condom-less and the condom was inside of me (I guess that qualifies as unprotected) and the presence of blood which would suggest an internal tear and hence a potential point of entry for an STI. Briefly about the guy: He lives in NA, not a stranger to substances (not IV though), frequently travels the world, and when asked, said that he was tested recently and is clean (I must say I completely distrust him). Please assess and provide a numerical risk estimation as it relates specifically to this situation. Should I be reasonably worried in light of condom staying in me and all the blood?

Thank you very much in advance!!

H. Hunter Handsfield, MD

99 months ago

Welcome to the forum. Thanks for your question.

Statistically, it is unlikely a partner like yours has HIV. Despite your lack of trust, people rarely lie about HIV status when asked directly; and without being an injection drug user and without frequent sex with other men, it is especially unlkely he is infected. The risk isn't zero, and may be a bit higher than for heterosexual men without some of his personality characteristics and non-IV drug use. But there's probably under one chance in a thousand he has HIV. And for unprotected vaginal sex with an infected male partner, the average transmission risk is around once for ever 1,000 exposures. And your vaginal exposures were (mostly) condon protected and oral sex carriesl ilittle or no risk. So the odds you caught HIV from these encounters probably is no higher than one in a million.

It's pretty common for condoms to remain in the vagina when the penis is withdrawn. When it happens, protection is considered complete or very close to it -- although not if withdrawal was not immediate. It would have been best to use a new condom at that point, but I don't see this as a major risk factor.

All things considered, I am more concerned about your risk for other STDs than HIV, and so would recommend testing for gonorrhea and chlamydia in a few days. (Any time more than 3-4 days after exposures is sufficient time for testing to be valid.) Syphilis testing makes sense as well -- the risk is almost as low as for HIV, but testing is easy and cheap. That means a blood test at 6 weeks or later. Other STDs are too infrequent or testing insufficiently reliable that I would not recommend any other testing unless you devlop symptoms that suggest STD.

Back to HIV: from a purely risk standpoint, testing is optional. But if you would like the additional reassurance of testing, I suggest having an HIV antibody-antigen combination test at 4 weeks. If you'd like earlier reassurance, you could also be tested at 10-12 days; while not conclusive at that time, around 90% of newly infected persons would have positive Ag/Ab tests at that time, so the negative result would be reassuring while you wait until the 4 week mark for a truly conclusive test.

I hope this has been helpful. Let me know if anything isn't clear.

Best regards-- HHH, MD

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99 months ago

Thank you very much for your comprehensive reply, Dr. Handsfield. It has been helpful.

Since you didn't address the likely vaginal tear and presence of blood as a reason for added concern, I am assuming you believe it doesn't markedly increase the risk calculation.

With respect to HIV testing, where I reside the options are a)rapid finger prick testing b) blood sample withdrawn and results provided in about a week

I am not sure whether the tests are Ag/Ab combo or something more outdated. The clinic I go to adheres to CDC's recommendation re: results being conclusive at 90 days, but they do say that at around 6 weeks it's roughly 95% assurance in validity. I will wait and get tested in a few weeks.

My last point of inquiry is more of a nudging curiosity: I know that ARS symptoms are not a basis for diagnosis and surely cannot replace testing; however, out of experience, what is the relative percentage of people who get them out of those infected and what is the actual time-frame for the body to mount this type of response against the HIV virus after infection?

I don't have any further questions. Many thanks again for your assistance.

H. Hunter Handsfield, MD

99 months ago

I'm not necessarily confident the bleeding was from a vaginal tear, although I suppose it is possible. But also maybe from the cervix. In any case, I don't think it materially raised the risk of HIV or other STDs.

The rapid HIV test probably is a standalone antibody test; the lab based test could be either that or Ag/Ab. Whatever test it is, 3 months is outdated; CDC knowingly sticks with that conservative advice and many labs go along. But the expert consensus is that it doesn't take that long for 100% conclusive results.

Interesting question about HIV symptoms. The consensus has been that 60-80% of people with new HIV develop at least mild symptoms. However, a brand new research study appears in the current issue of the New England Journal of Medicine, and found that only only a few percent of newly infected persons had symptoms, mostly mild. I've only been able to see the abstract, not the full article -- I'll know more details and be able to judge why the difference compared with past work when my issue arrives in the mail. However, it remains clear that many (most?) people develop no symptoms at all, and also that when symptoms occur, they are nonspecific -- i.e. no different than for innumerable minor conditions, and therefore rarely helpful in judging the likelihood someone has HIV. Blood testing will always be far more reliable than either symptoms or exposure history.

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