[Question #8897] New exposure. Probably higher risk

38 months ago

Hello doctors, here I am again. After a fight with my gf, a few drinks and no conscience I went 2 days ago to a bathhouse, where I had two “exposures” that, according to what I have learned from previous exposures weren’t really exposures.

1. Protected Anal sex (Topping) with another male. The condom didn’t break (or at least no noticeable, I removed it intact) and I didn’t ejaculate. Regarding this exposure I'm not really concerned. I asked the guy about his status and he told me that he was free of std, and that he "plays safe". I should trust him, so I’m that case it is a no risk exposure.

2. After the first exposure, Unprotected oral sex. I gave and received from another guy (no related to the first one). He mostly did all the oral sex and I gave him Oral sex for a few seconds, since I don’t like giving oral sex. There wasn't ejaculation on any mouth. I know from previous posts and other resources it is a extremely low and even could be considered a no risk exposure but after I finished I noticed that had blood in my mouth, and I would say that it wasn’t a huge amount but it wasn’t also minimum, I had to spit like 2/3 times until I stopped seeing it. I don't have any cut, sore or wound in my mouth, I checked right there and the , after cleaning my mouth, I think it was my blood, probably he bit my lips or something like that. Also he was the one who gave me the oral sex in most of the time, so I didn't come in contact with many fluids, probably only precum of the brief giving, but as far as I remember, I don't recall blood in that moment,so it had to be after the blowjob, because after the oral we did french/deep kissing with handjobs. Of course I started panicking, also because I started wondering if the blood was from the guy, which could be a lot worse, or if it came from the throat. I also asked his status before starting and he told me that he was clear, but we didn't go deep in the conversation. I'm hoping he wasn't lying. And regarding sexual intercourse, he told me that he was a top only, no bottom. That I believe decrease a little bit more the risk. But I’m extremely scared.

So my only question is regarding my risk from a doctor’s perspective. I have asked in MedHelp.org (where I was told that there is absolutely no risk), poz.com forum where I also was told something similar (minute risk, no need of testing) and HealthTap (where doctor H. is actively helping, where I was told it was also a low to null risk). Of course I am still extremely worried because of the blood, since it could come from my throat or gums, or worse, it could come from the guy. About testing, I already know that I should test at week 4-6 with a 4th gen, and a RNA Qualitative HIV 1/2 at 14 days is highly accurate (95%). Im planning on taking a RNA at 14 days and a 4th gen at day 21 (probably too early but I want to finish this asap, dr HHH told me it was virtually 100% accurate the mix of both).

H. Hunter Handsfield, MD

38 months ago

Welcome back, but sorry you found it necessary.

Yes, these recent exposures (condom protected insertive anal sex and unprotected oral both ways) are higher risk than in your recent discussions with Dr. Hook, but still very low risk. That said, your emphasis on the oral sex is maybe a bit misplaced: I would say the condom protected anal exposure was higher risk than the oral events. But in any case, people rarely lie about HIV/STI status when asked directly, so it is unlikely your partner has HIV. Even if he does, and even if the blood in your mouth was his, that event still was nearly zero risk; the amount of HIV in blood is no higher than in genital fluids, and oral exposure always is very low risk. The kissing and hand-jobs were risk free.

So I would advise against testing for HIV at this time. You really are not at high enough risk for testing. People who are sexually safe from a procedural standpoint, as you are (condoms for anal sex and asking confirming negative HIV status or taking effective treatment), generally should not be tested after every encounter, but instead should just plan on periodic testing, e.g. every 6 or 12 months. But if you're going to be tested anyway, I suggest you skip the RNA test and have an AgAb (4th generation) blood test at 4 weeks. Although not quite 100% conclusive by that time, a 4 week test picks up at least 98-99% of infections. Since you're starting out with under one chance in a million you caught HIV, a negative 4 week test would lower that risk to 1 in a hundred million. I hope you would agree that's conclusive for all practical purposes. And as I said, if somehow I were in your situation, I wouldn't be tested at all at this time.

Let's plan on your not posting a new forum question each time you have a new exposure that concerns you. This your two other recent threads contain all the information you are likely to need in event of new sexual contacts going forward. Detailed differences between one exposure to the next are not likely to make any difference.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD

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38 months ago

Hello doctor, I handled my anxiety levels as good as I could during this week, but today I started worrying a lot.

I have a few questions:

1. When you say my risk of the protected anal was higher, it is still a low risk, right? I've read in other posts where you say the small holes in a condom are more of a myth, and if a condom breaks, it will be noticeable. Is that right? I mean as far as I remember it the condom was in a whole piece when I remove it (I did it normally, if broken I would have noticed but well, I was pretty drunk that day). In that case it is almost impossible that the condom failed. Also, I have been reading about the effectiveness of the condoms, where USAID says in >95% but the CDC estimates it on 70%. I am probably overthinking the situation, but I felt the need of asking.

2. When you say my chances are 1 in a million, how do you estimate that? I am also really concerned that, even when the partners told me that they were clear, I still don't trust in their statements since the situation where it happened. I don't know if you have some stats about the chances of them being HIV+ in a case where I don't know their status.

3. I'm really sorry, but for my own mental health, and with the opinion from a doctor, I took the RNA test today (Day 10 and 1/2). I know you told me not to worry but I couldn't. I'm expecting my results by tomorrow, and if negative, would it be a good indicator? Even if it isn't conclusive, can I somehow trust the results? I will test after 4/6 weeks to confirm but that would give me some reassurance. Once Dr Hook told me that after day 11 (and ideally day 12-14), but I want to know if one day (or well, 1/2) could make any difference? My doctor told me that day 10 was reliable enough.

4. I also tested for Chlamydia/Gonorrhea today (day 10), in urine only. Can I consider that test conclusive? Should I test for other std's (Shyphilis, HSV). It's over day 10 and I haven't noticed any blisters or chancre, so I don't know if I was at risk enough. I should also test for oral Chlamydia/Gonorrhea but I couldn't find any at home test, I guess I need to go to a specialist for that, or can I find it online?

Sorry again for so many dumb and repetitive questions. I am pretty sure you have answered them many times, I tried to read most of the similar questions, but probably I couldn't find the best answers (that I'm sure are there). Now I know this will be the last time for me in this forum. It was enough with the exploration phase. I'm still young (23) but I think I want now to leave all this behind.

Thank you for all your help!

H. Hunter Handsfield, MD

38 months ago

1. Correct, still low risk. Correct about condom leaks and breakage; microscopic pores or leaks are rare and probably do not significantly increase the risk of HIV.

Good questions about understand the effectiveness of condoms. Typically 90-100% efficacy usually represents biological effectiveness (whether or not bacteria and viruses can pass through) or single use effectiveness for one exposure. 50-80% figures typically are what is called "use effectiveness", which takes into account human failures: not using them correctly, etc. The lower figure usually applies to usage over time -- for example, people who SAY they used condoms to prevent HIV have a 70% lower infection rate than non-users, not 100%. Again, the difference between single exposures with careful use versus typical success over the long run in people who rely only on condoms for prevention.

2. One in a million was just a guess, but intended to mean extremely low risk. But a mathematical calculation more or less confirmed it. Most people do not lie when asked directly about HIV status, so local stats are less predictive than what people say. Even with no condom with an infected partner, insertive anal has around 1 chance in 1,000 of catching the virus. If properly used condom reduces that by 99%, the risk becomes 1 in 100,000. If we assume a 10% chance your parter was lying and is infected (and not on treatment), your risk indeed becomes around one in a million.

3. There's no need to apologize.

4. Your gyn/chl results are conclusive. A syphilis blood test is fine, but not valid until 6 weeks. If no syphilitic chancre of the penis in the next 2-3 weeks, you will be able to be nearly 100% certain you don't have it. If you performed oral on your partner(s), feel free to have a throat swab for gonorrhea testing. (Chlamydia is irrelevant, with throat infection very rare -- but is pretty much automatic along with gonorrhea testing.)

Thanks for the thanks! I'm glad this is helping.

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37 months ago

Hello doctor. Sorry for coming back with a last round of questions.

This morning I was fine, but around 11 am I started with some neck pain. I want to believe it is muscular pain, but of course my anxiety started to increase exponentially. I looked on internet how to check the lymph nodes and I don't feel any bump in my neck, armpits or groin. Also I don't have fever or sore throat, only a mild headache but it my regular daily headache. I'm trying to believe it will disappear by tomorrow, but it is difficult not to think about the risk.

I have a few questions to ease my mind:

1. I'm almost at day 25. I didn't have any symptoms before, and I've read here that most of the ARS symptoms should start at 7-14 days and since it is a syndrome, it should be a group of symptoms. Am I correct? Also, a swollen lymph node should be easy to detect (I have never had a swollen lymph node as far as I remember). My temperature has been between 98.2 and 98.6F, so I have no fever.

2. I had a negative HIV RNA Qualitative test taken at day 10 1/2 of the exposure. With a 4th gen taken at day 29 (since 28 is 4th of July), can I rule out HIV? Or there is still a need for a final test at 42 days? I have read a LOT of mixed opinions regarding this.

3. Since it is day 25, Chl/Gnr tests negative at day 10 were conclusive and at day 25 I don't have any blister/chancre or discharge. Is it safe to say no HSV, Syphilis and Chlamydia/Gonorrhea. I didn't test for the throat but I don't have any kind of sore throat, how likely could be that I have oral STI or STI in general?

Since this is my last question, I want to thank you again. This site is a great source of truth for STIs and HIV.

H. Hunter Handsfield, MD

37 months ago

1. Neck pain is not a symptom of HIV or ARS, and indeed this started too late to be due to HIV from the exposure 25 days ago.

2. Your negative RNA test is additional strong evidence you do not have HIV and it is not the cause of your symptoms.

3. There was no need to retested for gonorrhea and chlamydia; the negative results at 10 days were 100% conclusive. Your exposure was very low risk for the other infections mentioned. However, I'm not clear on whether the gon/chl testing included a throat swab. If not, you could consider doing that. For a conclusive syphilis result, you could have a blood test 6 weeks after the exposure. In the meantime, don't be seriously worried: it is exceedingly unlikely you have anything at all.

That concludes this thread. Thanks for the thanks; I'm glad to have helped.

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