Dear Doctor, back again unfortunately.  I recently had insertive oral and vaginal intercourse with a Vietnamese csw in Malaysia. The oral was briefly unprotected and then I made her use a condom.  The vaginal sex was with condom throughout. However, much to my horror, after ejaculation when I withdrew my penis, there was no condom visible,. Penis withdrawal was shortly after ejaculation as there was semen oozing from my penis after withdrawal.  I am not sure whether the condom had come off in the last stage of sex prior to ejaculating or when I removed my penis. Due to her position I couldn't see but she shortly pulled out the condom and showed me.  Her English was poor but she told me she didn't have HIV.  Questions. This incident occurred 8 days ago.  So far no penile discharge but just vague penile aches and pains(not sure if psychosomatic) or real.  I will get tested for chlamydia, ngu and gonorrhea in 2 days (waiting a clinic appointment).  Given its 8 days and no discharge, am I unlikely to be free from ngu and gonorrhea? More importantly,  of course, I am concerned I have now been exposed to HIV.  Given the condom removal was either late stage or upon penis removal am I at high risk for getting HIV? Thanks

Welcome back to the Forum. I'll be pleased to comment.  Even without considering the condom problems you mentioned it is a good idea for you to be checked for STIs as you plan.  Unprotected receptive oral sex as you describe, while not a risk factor for HIV, does put you as slight risk for gonorrhea, NGU and very rarely, chlamydia.  

With respect to the condom problem, what typically happens in these situations is that the condom comes off as the man removes his penis from his partner. in such situations, since the penis remains in the condom until it is outside of the vagina (or rectum), the condom has done its job or protecting you from acquisition of infection.  When condoms come off earlier during sex acts they are hard to remove because they are deep within the vagina.  I suspect that your tests will be negative and that you will find that you did not get gonorrhea, chlamydia or NGU from this exposure.

With respect to HIV, your risk for infection is likewise low.  Most commercial sex workers in Malaysia do not have HIV and fewer than 1 in 1000 unprotected sexual exposures lead to infection.  Despite all of this, for your own peace of mind and reassurance, it is probably a good idea to plan to be tested for HIV with a DUO (combination HIV antigen/antibody), 4th generation HIV test at some point more than 28 days after the exposure.  At  that time you test the results will be conclusive.  In the interim, I would not worry that you might have been infected.

I hope these comments are helpful.  EWH

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Thank you Doctor. I will test as you recommend. On a separate note, does HIV cause slightly swollen but not painful tonsils? No fever or other symptoms. I am not concerned related to my current exposure, but 8 months ago I have unprotected oral performed on me and a deep prostrate massage and am slightly paranoid, the slightly enlarged tonsils may be a sign of chronic HIV.  Many thanks

Tonsils are lymph nodes and swollen tonsils are a non-specific finding.  Isolated tonsil swelling is not a sign of HIV- acute or chronic.  Receipt of oral sex, deep prostate massage and condom protected sex are all safe sex with no meaningful risk for HIV.  Your swollen tonsils could be due to any number of other causes including dental or gum disease.  There is nothing you have mentioned which raises a concern about HIV risk.  EWH
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Thank you Dr for your time and patience. 

Doctor, my final question.  Going back to my potential but unlikely exposure 8 months ago, would a persistent dry cough, particularly at night be a symptom of HIV after 8-10 months,? Or would it be related to post nasal drip? And if so, would HIV cause nasal post nasal drip? Or am I just being completely paranoid?  From my limited understanding dry cough is a symtom of very late stage HIV/AIDS,  but some websites say that nasal problems are a common manifestation of HIV. Thank you

I think you are worrying more than you need to.  A dry, non-productive cough can be a sign of a pneumonia which may occur in the late, advanced stages of HIV.  On the other hand, it is not at all characteristic of recently acquired HIV and can be a sign of nay number of other problems, including sinus problems and resulting post-nasal drip.  HIV does not cause post nasal drip.

As you indicate, this is my third reply to your questions and so, as a result, this thread will be closed later today.  I hope you have found my advice and comments helpful. EWH

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