[Question #9] HIV Risk Question (For Dr. Handsfield or Dr. Hook)

42 months ago
Dr. Handsfield
I recently went to an Asian massage parlor (one week ago) and had protected oral and vaginal intercourse with a worker there. When changing positions I noticed the condom on the floor. I don't know if I was in her with out the condom. I freaked out and asked her to take an orasure test. She did and it was negative. Do I have to test? Should I be cautious because she could be in a window period?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago

Welcome to ASHA’s Ask the Expert forum. Thanks for your question.


It sounds possible the condom was in place as your penis withdrew, in which case protection against HIV probably was complete. But since you don’t know for sure, better to assume you were at risk.


Even if your partner had HIV, the average transmission risk for the male partner for a single episode of unprotected vaginal sex, if the woman has HIV, has been calculated at somewhere around 1 chance in 2,000. (That’s why many heterosexual spouses of HIV positive persons never catch the virus themselves — which perhaps you didn’t know.) And in this case, you know your partner is uninfected. Could she be in the window period? Sure — but the odds of that are extremely low. Since fewer than 1% of sex workers in the US have HIV (fewer than 1 in a thousand in many parts of the country), there is still far lower chance that any particular sex worker is in the window period. I would add that your partner apparently uses condoms with her clients, unless for some reason you think you were the exception. So the chance she has been exposed recently seems lower still.


As for the oral sex part of it, no worries. HIV is rarely if ever transmitted by oral sex:  there has never been a reported, proved case oral to penis or by cunnlingus (oral-vaginal) in either direction.


All things considered, the chance you were exposed to HIV is extremely low, and the likelihood you were infected virtually zero. You probably should be tested yourself in a few weeks; I imagine the negative result will be more reassuring than anything I can say here. If you have a 4th generation (duo, combo) test — for both HIV antibody and p24 antigen — the result will be conclusive at 4 weeks. Or 6 weeks for a 3rd gen antibody test, even though official advice says 3 months.


Turning to other STDs, your risk is a lot higher than for HIV. Still low, but high enough to warrant testing. I recommend you have a urine test for gonorrhea and chlamydia (it’s been a week, so you can do it now), and a blood test for syphilis 6 weeks after the exposure. The chance of syphilis in this setting is extremely low, due to current rarity of heterosexually transmitted syphilis in most of the US. (Most cases currently are in men having sex with men.) But better safe than sorry!


I hope this has helped. Best wishes—  HHH, MD

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42 months ago
Thanks for the response! She did say that she uses condoms and does not accept money to have sex without them. She also said she is tested regularly.

I know that emotionally a negative will give me peace of mind, but from a strictly risk assessment point of view, do I need to have an HIV test? 

Another thing that has been bothering me is that she supplied the condom. Is it safe to say it was latex or another safe substance as opposed to natural skin? I am inexperienced as I have been monogamous for a long time. The condom was red, if that helps.

I will be tested for other stds. Have you ever seen someone with such a low risk test positive?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
Sounds like your massage partner is aware of the risks and works hard to protect herself. From a strict risk assessment standpoint, you don't need testing. Most STD/HIV experts would say that individual exposures almost always should be ignored, unless especially high risk (e.g. unprotected with known infected partner) -- instead that people with ongoing but lower risks should have routine testing from time to time, like once a year, without worrying about individual events. This is only a guideline; everybody has his or her own risk tolerance.

It's something of an urban myth that natural condoms don't protect. Any difference in effectiveness against HIV and other STDs is theoretical only, and nobody has reported an increased transmission risk in consistent natural versus latex (or polyurethane) condom users. Any intact cover is far better than unprotected sex; beyond that, it probably doesn't make any realistic difference. That said, I don't think natural condoms are dyed, so red color suggests latex.

Hard to say if I have "ever seen" someone with risks like yours who tested positive for an STD. For HIV, I doubt it -- or only because of infections that predated the recent exposure they were concerned about. For STDs, especially gonorrhea and chlamydia, probably yes; as discussed earlier, your STD risk was not trivial. But still, without any symptoms like penile discharge, the odds are very strong in your favor.

Please note ASHA's policy that permits 2 follow-up comments, after which a new question (with fee) is required. If you have any further concerns, consider them carefully before posting so you don't miss anything.
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42 months ago
I have not had any symptoms or discharge, but will certainly get tested and use condoms with my wife till I get results ( I will probably just not have sex). The question about seeing someone become positive with such a low risk was for Hiv (I assumed you would see low risk people with other bacterial std's because of how easily a person can get one)

The reason why I asked the question is because in reading a reply from a number of years ago you stated that you never saw someone with a low risk (similar to mine) test positive and wanted to see if that still stands.  I know it sounds silly but I am trying to find comfort and reassurance where I can find it.

Finally, without symptoms is herpes a consideration?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
The last statement still stands. As a guess, my previous reply referred only to the new exposure. In your case, I gave a more comprehensive reply that covers the possibility that my clinic might have found a positive result, but considered it to have come from some more distant past exposure. Don't get more nervous because I gave you a more thoughtful reply!

You shouldn't wait several weeks to resume sex with your wife. If somehow I were in your shoes, I would confidently resume unprotected sex with my wife once I had the negative gonorrhea and chlamydia results -- which in your case could be within a couple of days (or maybe a bit more over the weekend).

Don't confuse your likely guilt over a sexual decision you may regret with STD/HIV risk from that event. They aren't the same. Deal with the former as you need to, but don't overreact to the latter. The chance of any infection other than gonorrhea or chlamydia is low enough to safely ignore.

That winds up this discussion and the thread will shortly be close to new comments. Take care and stay safe.
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