[Question #9714] SEX WITH ESCORT

29 months ago

I am an uncircumcised 27year old. I paid for sex with an Brazilian escort in Boston on February 17st through a eros website and she was highly well reviewed on the exotic review with a $400 hourly rate. She does not french kiss or anal sex, only Condom Blow Job and Condom sex(TWICE).Both times CBJ AND Condom sex. After the sex I tested the condom by putting water in it and no water came out(do not think it broke or slipped but not sure about if micro-tears are a real thing) This was my first experience with an escort and I became very nervous about STI, specifically HIV/HTLV. I asked her if she would get tested, which she said yes to because she said she is very safe and clean. She's been escorting for over a year and a half and follows alot of safety precautious. The tests were performed Thursday Feb 23rd and are 11 STD Panel was done through quest including HIV PCR +HEP C PCR+HTLV. Hiv 4th gen, herpes 2, syphilis, clamydia, ghonnorea, etc have all come back negative. The only test I am still waiting for are HIV PCR+HEP C PCR+HTLV(since she is from south america). The two pcr test have taken longer than I expected since everything else has come back- could it be because she is positive? Because of window periods I'm nervous she could be positive between the delay of the the PCR and 4th gen test?If she had a high viral load would that mean she would have high antigens, which would make window period on the 4th gen shorter in her case?Do you think she will test negative for the PCR RNA. If she test negative for the PCR RNA am I in the clear? What are your thoughts of me getting HTLV from her through protected since if she test positive? Started (TRUVADA+TRIVCAY) before 24 hours- will that work if she has a high viral load/HIV2

H. Hunter Handsfield, MD

29 months ago

Welcome. Thanks for your question. I'm happy to help.

You've posed several "what if" questions. Honestly, they aren't very useful. I'll bet not one person in the last 20 years has acquired HIV from a situation of the sort you describe. Regardless of her national origin, it sounds like your partner is typical for female escorts (high-end, expensive, by appointment -- as opposed to street walkers, bar pickups, brothel workers, etc). Such women tend to be health conscious, require condom use, and get tested frequently; and their clients tend to be low risk for HIV (men like you!). And you used a condom that remained intact. (We recommend against condom "water tests". There really is no such thing as microscopic leaks that allow HIV/STD transmission; if a condom doesn't break wide open, protection is complete. Even if a drop of water had leaked with your test, it would not have raised your risk of infection.) All things copnsidered, the chance your partner has HIV is exceedingly low; and if she had it, the risk of transmission to you (without a condom) was somewhere around one chance in 2,500. With an intact condom (assuming 99% effectivness), one chance in 250,000. And if we guess there's even one chance in a hundred your partner had HIV, we're now at a likelihood of one chance in 25 million you were infected. Which, I hope you will agree, is zero for all practical purposes.

As implied above, I'm not going to address your handful of "what if" scenarios. All of them a) are unlikely and b) wouldn't materially increase your risk of HIV even if they came to pass.

As for HTLV, it is true that the prevalence of infection is higher in parts of South American than in most geographic areas, but still the large majority of sexually active women are not infected. In any case, there are no data on the efficiency of transmission of HTLV. If she is infected, you're still at low risk. (Since she isn't currently living or working in Brazil, there is no realistic chance she has been exposed to HTLV recently and thus it is unlikely she is in an HTLV window.) Regarding HIV2, it is virtually absent in the US and not a serious consideration; and in any case, your anticipated negative HIV test results will include HIV2 as well as HIV1.

Your negative tests on 2/23 (6 days after the sexual event) are meaningless: they show you were not infected but all were too soon for positive results from less than a week earlier. (Except for urine gonorrhea and chlamydia: those results show you were not infected.)

Finally, in my view it was a mistake to take post-exposure prophylaxis against HIV. Your risk was too low. The main effect, if you contoinue PEP, will be to prolong your period of uncertainty until you have conclusive HIV test results. With PEP, the window period clock starts with the last dose, not with the time of exposure. And although 6 weeks is probably conclusive for an AgAb (4th generation) HIV blood test after PEP, some experts recommend 3 months. So instead of a conclusively negative test 6 weeks after the exposure (about March 31), after 4 weeks PEP, a conclusive negative result will be delayed until the end of April -- or, acording to some experts, until mid to late May.

We do not give specific treatment advice, so I am not telling you to stop PEP. But it would be reasonable for you to discuss it with the doctor or clinic where it was decribed, to consider whether to continue PEp or not. If somehow I were in your situation, I certainly would not have started it.

Having said all that, there is almost no chance you have HIV, and almost as low a chance of any other STD. Whatever you do about PEP, stay relaxed over the next few weeks as you await your negative follow-up test results.

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

HHH, MD

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29 months ago

Hi Dr Hunter, I appreciate your prompt reply. One thing I wanted to emphasis was that I did not get tested the 23rd, the escort did. She tested negative for HIV 1 on the 23rd and our encounter was the 17th. We are still waiting back for her PCR exam. Hypothetically if she tested negative 4th gen on the 23rd do you think the PCR will come back negative as well as its been 5 days without the result and im worried its delayed because its positive? If she did have a high viral load would the 4th gen pick it up since high viral load= higher antigen production?

H. Hunter Handsfield, MD

29 months ago

That's even better! Sorry I misunderstood, but glad to hear it. There is no realistic possibility her PCR will be positive; people naturally get nervous when test results take longer than expected, but I've never heard of a case in which a delayed HIV test result was because if was positive. You can stop your PEP -- but as I said above, that's something for you to discuss with the prescribing doctor or clinic, not on account of my advice.---

29 months ago

If she did have a high viral load would the 4th gen pick it up since high viral load= higher antigen production? Just worried the couple of days the 4th gen and me visiting her did not detect the infection. I know possibilites are small but my anxiety and delayed test results has made it very difficult to function without these results being sent back. We booked the test through STDCHECK which has partnered with quest for the test. I got tested on 23rd(wed) and my results came 25(sat). She tested 24th(thursday) but still hasn't gotten results. What do you think could have delayed her test but not mine if its not thats she's positive?

H. Hunter Handsfield, MD

29 months ago

You keep asking questions that imply an incomplete understanding about HIV. The AgAb (4th gen) blood tests detect even minute quantities of HIV; a positive result does not imply either high or low amount of virus; anyone with a positive antigen test component is considered highly infectious.

I cannot say why it sometimes takes longer for test results. I imagine the most common reason might be that not all tests are done in-house: that is, the Quest lab where the blood was drawn might send it's HIV PCR samples to a central lab, adding specimen transport time. And in general, more complex tests (like HIV PCR compared with serological tests) may not be performed until a minimum number of specimens accumulates so they can be tested at the same time, generally a more efficient process. (Unless urgent and ordered "stat"). But I speculate.

Threads are closed after two follow-up exchanges, and we're there. I'll leave it open for one more cycle so you can let me know her PCR result when you have it -- although if it's negative, I'll have no more advice. Either way, this thread will be closed after one more brief question/comment or after a week, whichever comes first. In the meantime, do your best to mellow out. You are way overreacting to a nearly zero risk situation. Please re-read my original reply above, including my back-of-the-envelope risk calculation and believe it! (Perhaps it will also help to know that in the nearly 20 years of this and our previous forum, with thousands of questions from people worried about HIV, not one has yet reported they eventually tested positive. If and when that finally happens, almost certainly it will be from a genuinely high risk exposure, not a trivial risk event of the sort you have had.)

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29 months ago

Good afternoon Dr

Wanted to let you know the HIV 1 PCR test came back as HIV undetected! Quick questions because the 4th gen test also came back negative one week after the exposure- the odds of her contacting HIV 2 in the 3 weeks that the 4th gen doesn't detect antibodies for HIV 2 would be very rare I presume? I know HIV 2 is specific to Natives of West African countries- just not sure of her previous sexual encounters and what kind of risk exposure I have to HIV 2 since she did not test for the HIV 2 Viral Load PCR

Thanks

H. Hunter Handsfield, MD

29 months ago

Congratulations on the result (of course I'm not surprised and neither should you be). In the US, HIV2 accounts for under one case for every 10,000 HIV1, and as you state, those are mostly in people infected in West Africa and their regular (not one-time) sex partners. Nobody recommends and most labs do not due HIV2 PCR testing.

So all is well. You don't need PEP (and from a strictly medical/risk perspective, you don't even need HIV testing).

That concludes this thread. I hope the discussion has been helpful.

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