[Question #9283] HPV Concern After Protected Sex with CSW

34 months ago

Hello,

Thank you for offering this service and answering our questions. I made a huge mistake about three months ago during a visit to Amsterdam when I used the services of a CSW in the Red Light District. I am very concerned I may have received HPV from this encounter and put my partner of five years in danger. Prior to this, we were both each other's first and only sexual partners and her last pap smear/cervical cancer screening was negative, so it's unlikely that either of us had HPV prior to this encounter.

During the encounter, I had protected vaginal sex with a condom for about five minutes. I also performed cunnilingus with a dental dam. I tried to avoid skin to skin contact outside of the condom, but it's hard to say whether I was successful. What are the chances that I acquired HPV from this encounter? My partner has an upcoming pap smear test and I am fearful that she may have gotten something as a result of my mistake.

Thank you for reading my question.

H. Hunter Handsfield, MD

34 months ago

Welcome to the forum. Thank you for your confidence in our services.

There are no data by which to judge the likelihood of acquiring HIV during any single exposure. On one hand, HPV is very frequent in all sexually active people, so it's certainly possible -- even probable -- your CSW partner has HPV. OTOH, a single exposure rarely results in any STD, and you took precautions that probably were quite effective in preventing transmission. The risk from whatever brief skin contact might have occurred undoubtedly was near zero. So all things considered, I believe your risk of acquiring HPV (or any other STD) was near zero.

Despite your and your regular partner's sexual history, you should not be surprised if HPV shows up someday, e.g. in a Pap smear. Genital HPV infections sometimes appear in people at apparently zero risk -- when, how and why such persons were infected usually is unknown and unknowable. But even in that situation, it would not necessarily implicate this particular event as the source.

The bottom line is that you really needn't be at all concerned. There was little risk, and there will be little if any important health consequence (or relationship consequence) in the event either of you turns out to have an HPV problem in the future.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

---

34 months ago

Thanks Dr. Handsfield. I should have also mentioned that I am unfortunately not vaccinated for HPV.

I’ve read online that condoms can prevent the spread of HPV in up to 70 percent of cases, and I believe I’ve seen you and Dr. Hook refer to this statistic as well. If my risk was near zero, why do condoms only prevent spread in 70 percent of cases? What accounts for the failure of condoms in the other 30 percent of cases? Does the HPV virus, particularly high-risk HPV, exist in large quantities in areas outside of the vagina and cervix (such as around the clitoris)?

I was also wondering if the use of lubricant during intercourse, the fact that I am circumcised, and the presence of public hair have any effect on transmission. Thanks again.

H. Hunter Handsfield, MD

34 months ago

Thanks for asking. This gives me an opportunity for one of my occasional blog-like replies that can be referred to by other users or in reply to similar questions.

Condom efficacy calculations typically cite "use effectiveness", i.e. they account for real-world factors like improper use like brief penetration before the condom is applied or even just forgetting them entirely, occasional breakage, and, in the case of HPV in particular (and to some extent with other STDs transmitted skin to skin like herpes and syphilis) that the large majority of condom protected sexual exposures still have substantial contact above the condom range. Also, sexual fluids that may work their way inside the condom during thrusting. (With sexual thrusting, the penis may slide within the condom to some extent, possibly carrying fluids below the condom rim.)

Biological effectiveness is the ideal -- i.e. can HPV or other STD bacteria and viruses penetrate latex? The more carefully condoms are used perfectly and ideally, and with the particular precautions you took to avoid skin contact, the closer use effectiveness may approach the ideal of biological effectiveness.

So people who say they use condoms consistantly for all new or potentially risky sexual exposures have around 30% the frequency of HPV as those who use no condoms, i.e. 70% protection. This is use effectiveness, not biological. The careful way you used the condom during the exposure described surely gave you a lot higher protection than 70% -- probably 100% or close to it.

A final example and some of the best data are for condoms as contraception. Couples that consistently use condoms as their only pregnancy prevention have, on average, 90% effectiveness: that is, their pregnancy rate is 10% of what it would be with no contraception at all, compared with zero for hormonal contraception. Which is why couples who seriously want to avoid conception generally should not use condoms as their only method. However, even these couples can come close to 100% effectiveness if they take special care.

I don't see your circumcision status, lubrication, or that either you or your partner do not shave your pubic hair would make any difference in HPV risk.

---
---
---

34 months ago

Thanks again Dr. Handsfield. I am not as confident that I was as careful as I could have been, and I am fearful about the possibility that the condom might have slipped down. When you say that contact can still happen "above the condom range" are you referring to the top of the penile shaft? In an HPV-positive female, does the HPV virus typically reside around the vulva which might have more contact with the top of the penile shaft, or is the virus more often found inside the vagina? Can transmission of high risk HPV happen without penetration (for example, via bare grinding of the genitals)?

How can I avoid transmitting this to my partner if I ended up contracting it? And do cases of high risk HPV resolve/clear at the same rate, without intervention, as low risk HPV (I've read between 1-2 years typically)? Does this clearance rate still hold even if you contract multiple types of HPV at once?

Thanks so much. I know this is my last reply and I appreciate your time.

H. Hunter Handsfield, MD

34 months ago

Sorry, but I can't say much more. You're really overthinking all this: did you even read and concentrate on my replies? This was a very low risk event that should not be causing nearly as much concern as you apparently are feeling.

"Above condom range" indeed means skin contact above the condom, plus the possibility of fluids working there way slightly under the top of the condom. But all this isn't scientific at all -- just common sense judgment. And yes, when someone has HPV, it is often all over the genital area, not a specific location. But which parts of the genitals it might occur cannot be predicted for any particular infection or person. In theory HPV can be transmitted by genital apposition (if vigorous, e.g. "grinding") without penetration, but probably rarely. In my 40 years in the STD business, to my knowledge I've never had a patient who acquired HPV without penetration.

If you were infected, you cannot avoid exposing your partner, other than avoiding sex entirely. The average duration of HPV indeed is around 1-2 years, which to my knowledge has been studied only for cervical infection in women. On average, the duration tends to be shorter for low risk versus high risk HPV types, but with a very wide range: some probably are gone in a couple of months, others can last well beyond two years. It is impossible to predict for any particular infection.

Please re-read my initial reply and concentrate on every word. It was intended to be highly reassuring, and you should interpret it that way. You probably were not infected with HPV (and would not have acquired it even if no condom at all were used). And I also explained why it won't matter if you were: most infections never show up on Pap smears, even if your wife were infected; and I've also explained why you would not necessarily be the source if that ever happens.

HPV is a trivial issue for most people and should be in this situation as well. Finally, why are you so focused on this one STD? Where are your concerns about the important ones, like gonorrhea, chlamydia, syphilis and HIV? Your risks for these were almost as high as for HPV -- but still pretty much zero. Try to get a realistic perspective on all this.

As you predicted, that concludes this thread. I hope the discussion has been more helpful than it seems at this point. Good luck and best wishes.

---