[Question #9646] Risky behaviour

30 months ago

I recently saw a trans escort in Toronto Canada who only tops (she said she never bottoms). She assured me that she was on Prep and had negative test results a couple months ago. I received receptive anal sex that was unprotected (I didn’t realize at the time). There was no ejaculation or bleeding. I know a condom should have been worn and I am very anxious because of this fact. She seems very smart, is mature(30’s), local (lives in the area) and doesn’t appear to be a drug user.

I’m curious of my overall risk of HIV and if I should take PEP? I have a partner who is unaware of this and am regretful, guilty and nervous. A once fantasy has turned into a nightmare.

Edward W. Hook M.D.

30 months ago

Welcome to our Forum and thanks for your question. I'll be glad to provide some information however the decision as to whether or not to seek PEP will be up to you. Hopefully the information I share will help your decision making process.

Although the majority of trans women do not have HIV, rates are relatively high. Your partner has informed you that she was HIV negative and on PrEP and most people do tell the truth in such situation. Further, while most persons in North America with HIV are on therapy for their HIV and effective therapy renders infected persons non-infectious to sexual partners. If she was infected and untreated, the risk for acquiring HIV from bottoming with an infected partner is, on average, about 1 infection /700 sex acts (i.e. more than 99% do not lead to infection. Thus if you believe your partner, and my sense is that you do, your risk for acquisition of HIV is very low (less than 1 in 1000, probably substantially lower). In such a circumstance, and with the assumptions that I have indicated, I would probably not pursue PEP. That said, it is still a personal decision.

A final piece of advice. For persons on PrEP, rates of other, more traditional STIs such as gonorrhea and chlamydia are relatively high. Whether you pursue PEP of not, my advice is to get tested at all sites of exposure for these STIs.

I hope this information is helpful to you. If there are further questions, please don't hesitate to use your up to two follow-ups for clarification. EWH

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30 months ago

Thanks for the response. I am curious if the fact that she only tops and there was no ejaculate decreases the risk also. I know it doesn’t eliminate the risk but curious if it is less. Based on what you told me I don’t think I will seek out the Pep

30 months ago

I am assuming there was technical difficulty with the site. I just don’t want to get lost in the shuffle.

Edward W. Hook M.D.

30 months ago

thanks for the follow-up.

The fact that she tops only, as well as that she says she in on PrEP both reduce the risk that she is infected (topping is somewhat less likely to lead to HIV acquisition than bottoming). As for the ejaculation issue, we DO know that HIV is present in pre-ejaculate and can lead to infection of partners. There are no good studies to indicate that, in unprotected intercourse, lack of ejaculation changes the risk for infection.

I agree with your decision not to take PEP- that's what I would do. EWH

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30 months ago

Thanks. One last question. If I have no sti symptoms after 2 weeks would you recommend still getting an sti test? This is the only other partner I have had in many years, and the first (outside my long time partner) since my last test. Thanks again for your help

Edward W. Hook M.D.

30 months ago

Final Response:

Yes! As I explained earlier, while persons like your partner who are on PrEP are well protected against HIV, they remain susceptible, and are often exposed, to other STIs which can be asymptomatic. It would be in your, and your future partner's interest to be screen for bacterial STIs at all site of exposure- specifically for gonorrhea and chlamydia. Better to be safe than sorry.

This completes this thread. EWH

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