[Question #9713] HIV concern, possibly unprotected sex

30 months ago

Dear Drs Hook and HHS, I am an uncircumcised 49 year old. I met a woman on February 1st through a sugar dating website. We have had 4 intercourse on the 2nd, 9th, 15th and 21st Feb. Everytime it was oral unprotected (always intense, long and more than once during each encounter) and vaginal sex with condoms. After we were done with the first intercourse, I did not find a condom on my penis. Shaken, I bought a HIV RNA and 4th generation test from STDcheck.com on 20th, 17 days after the concerning encounter. Both the reports came back normal. I asked her about testing on the 22nd and she has gone quiet since then. Assuming the worst that she is HIV infected, untreated, what is your opinion, given my test results? Am I in the clear, almost in the clear, or do you think I have a problem? I am planning to get another 4th generation test done at the 28 day mark. Do I need to add RNA to that? I would appreciate your guidance.

H. Hunter Handsfield, MD

30 months ago

Welcome back to the forum. You were one of our earliest customers after moving from our previous online forum to this one over 7 years ago -- question no. 97, as we approach 10,000 (as well as another question 6 months later). Thank you for your continuing confidence in our services, although of course I'm sorry you found it necessary.

The main discussions back then were about the absence of significant risk of HIV from exposures other than unprotected vaginal or anal sex, including the very low chance of HIV from oral sex. There still has never been a scientifically proved case of HIV transmitted oral to penis, and based on how some people believe they were infected (whether or not it's true), CDC calculates the risk at one chance in 20,000 if the oral partner has HIV. That's equivalent to receiving BJs by infected partners once daily for 55 years before infection might be likley. And that's only with known infected parteners and it's great to learn you've apparently been protecting yourself appropriately. So we can dismiss your oral sex exposures as carrying significant HIV risk.

So it is appropriate that your main concern is the missing condom after vaginal sex. Since you obviously were careful about placing the condom before sex, probably the condom remained in your partner's vagina when sex was complete. In that circumstance, protection is believed to still be complete. While of course I cannot say whether that event was in fact not condom protected, probably you would have noticed if the condom had come off before intercourse was completed. And even if not, the average chance of HIV transmission by vaginal sex -- again, this is IF the female partner is infected and not on anti-HIV treatment -- is around once for every 2,500 exposures. And despite your partner's having "gone quiet" in response to your questions about her HIV status, most likely she doesn't have HIV, so your risk would be correspondingly lower.

Your negative results with both RNA and AgAb (4th generation) testing at 17 days are around 90% reliable. Your plan for another AgAb test at 4 weeks is a good one. You definitely can expect it to be negative, which will be conclusive proof you did not acquire HIV. (Since your previous questions all those years ago, we advice conclusive testing with the AgAb tests at 6 rather than 4 weeks. But that's for AgAb testing alone: the combination of negative RNA at 2+ weeks and negative AgAb at 4 weeks is equally conclusive. There is no need for another RNA test.

You don't mention testing for other STDs. I would recommend it if not yet done. Unprotected oral risks gonorrhea, and both chlamydia and gonorrhea are risks from the vaginal sex, if the condom was off during intercourse. And syphilis is always a potentially serious concern. Absence of penile discharge and chancre (syphilitic ulcer) by this time is strong evidence you have none of these, but testing is the only way to know for certain. So if not yet done, I recommend a syphilis blood test and urine gonorrhea/chlamydia test. You can have these when you have the 4 week HIV test.

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

HHH, MD

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29 months ago

Dear Doctor HHH (my apologies sorry for the HHS, don't know how that happened): Yes, I'm very grateful for the continuing guidance from both of you on these issues and am fortunate to count myself an earlier follower of this forum, as you point out. Well, she finally agreed for testing. We both came back negative on a full STD panel. I got the results in a couple of days. She went to Quest labs and gave her HIV blood sample for 4th Gen HIV AG/AB test on 03/09 at 9:00 in the morning and it was received at the processing facility on 03/11 at 7:00 in the evening (like two and a half days later). The results were reported on 03/14 at noon. I wonder if Quest too unusually long to get this done. Is the integrity of her HIV blood sample and the test results an issue here? If Quest is doing it, then I guess I don't think it is a problem. Your opinion? Sorry in advance if this is crazy thinking on my part. Thanks for your continuing guidance; we all are VERY grateful:)

H. Hunter Handsfield, MD

29 months ago

I'm glad to hear of the negative HIV test results. You can rely on them; the time to the result doesn't seem unusually long to me, but in any case it means nothing about the reliability of the test.

Thanks for the thanks. I'm glad to have helped.

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29 months ago

As I write this it feels like I'm making this up. Unfortunately, this is the reality for me. I trusted this woman a little more than I usually do. She's well accomplished professionally and is a graduate of Oxford in the UK. So I went ahead and had an intercourse on the day we received the reports. Later I kept urging her that we go to the urgent care center and get them printed. She refused. I found some discrepancy in our reports and I went to the testing center. To my surprise, they actually disclosed to me that they do not have any reports for her. Obviously, she had made up those reports through digital manipulation. Of course she has stopped communicating and I too have given up. What does all this mean for me? I think this heightens the probability and I would request you to assume the worst, which is she has untreated HIV. My testing conclusively cleared me of the first incidence of missing condom. After that we have had sex five times, all protected vaginal, condom intact, and mutual, long, intense, unprotected oral. Based on my understanding of the collection of advice from both of you, I think I am in the clear and do not need any testing? My ex is visiting me next week and she likes to indulge with me without any protection. Would it be unwise to do so this time? Would you recommend any testing? If yes, if I take an RNA after 2 weeks of the last exposure, given the inherently low risk, would those results be considered conclusive? Or do I also need to take the 4th generation test at 4 weeks?

29 months ago

BTW, we had exchanged report document electronically. Seemed legit to me. But now I know there does not exist any such report for the at the testing center. They say it's all fake. She had to get it from them and they don't have anything for her and no evidence that she actually went ahead with the tests. We went together to this center and were provided with lab orders We then had to take these orders to Quest lab to get the actual tests done. We went to the labs separately. Well, we now know she never went to the lab.

29 months ago

What she did is clearly illegal and I have all the evidence. I do not believe in retribution but this kind of dangerous behavior, I wonder if there is anything under the law that can and should be done to stop her from this.

Respected Dr. HHH, thanks again for your valuable guidance1

H. Hunter Handsfield, MD

29 months ago

Interesting situation. I don't think you're expecting any comment about potential legal issues, but in any case I have no opinions or advice about them; that's definitely not the purview or expertise of this forum.

From an HIV/STD standpoint, you obviously cannot rely on her claims. That said, statistically it is very unlikely she has HIV, which is quite rare in UK sex workers and likely to be especially uncommon in upscale, educated ones. The chance she has other STDs is higher, but as discussed in my main reply above, condoms are highly protective and oral sex is inherently low risk. Further, the main STDs from oral sex usually cause obvious symptoms; absence of urethral discharge, painful urination, and penile ulcers or other sores is good evidence (although not perfect) that you don't have anything. Also, I assume your latest urine tests at Quest did not show gonorrhea or chlamydia.

For those reasons, if I were in your situation, I would be OK having unprotected sex with my wife. The likelihood you acquired HIV, syphilis, herpes, or any other significant infection is very low, if not quite zero. It would be reasonable to continue with plans to have final/conclusive blood tests for HIV and syphilis 6 weeks after your last sex with your escort partner, but you definitely can expect negative results.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes and stay safe.

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