Hi doctors

I'm a 42yo male from Sydney (Aus). Mid-jan I had vaginal protected intercourses and oral sex both ways. The first night there was a foul odor (not strong but unusual) while we had sex but it had me worried as I gave her oral a minute before. I read it could be due to menstruation or the weather (it is very hot in Sydney). 10 days after we also had condom-protected sex (vaginal only) and only oral sex on me. No smell. But it was rougher and she bled a little bit. I had blood on the tip of the condom and a bit on the shaft of my penis. I got worried as I did trim my pubic area a few hours before and had a small cut. But the cut bled for one drop and didn't bleed after I showered.

I left for France then 18/19 days after I had congested/runny nose and very mild sore throat (no fever or unusual symptoms). Thought it was a cold and didn't think too much about it. No symptoms for 6-7 days but then had nausea for 2 days an unexpected nose bleed (5 min and occurred once). A week after I believed I felt a lymph node in my neck but can't be sure.  I discussed with her our status and she stated she has nothing and she shared a STD results she did over a year ago (December 2021).

1 - Should I get tested now or wait for my next check-up (it is approx 6 and 4 weeks after these encounters?). I already had a full STD checkup in January 2023

2 - Does the cut I had increase my chance of catching HIV?

3 - Do my symptoms suggest ARS?

4 - According to the official Australian data (https://data.kirby.unsw.edu.au/hiv), 3700 women live with HIV and 3000 are undetectable. Does it mean the chance she is HIV+ and infectious is about 1/12000 (assuming a female adult population of 9M)?

The exposures you describe were low risk for HIV and other STDs, primarily because they were condom protected. Oral sex, even unprotected, is low risk, both giving and receiving. There has never been a clearly documented case of HIV being transmitted by cunnilingus (oral-vaginal) or from oral to penis. That's not to say it can't happen, but the chance is as close to zero as it can get.  Other STDs are higher risk from oral sex, but still a lot lower chance than for unprotected vaginal or anal sex.

The main cause of strong vaginal odor is bacterial vaginosis, an overgrowth of mostly normal bacteria; and as you may have experienced, the odor is often most prominent after sex. (Neither hot weather nor menstruation cause vaginal odor.) BV itself is harmless, with no comparable problem in males, but BV sometimes is triggered by STDs like gonorrhea and chlamydia. But both of these are low risk from oral exposure. You needn't worry about having recently shaved your pubic area:  this has never been known to elevate risk of HIV or other STDs; and superficial skin cuts also do not elevate HIV transmission risk. In any case, your follow-up conversation with one of your your partners is reassuring:  people usually are honest in this situation.

To your specific questions:

4) This first, as it directly influences the other three. The Kirby Insitute is internationally respected as a highly authoritative source. It is closely linked with Sydney's sexual health centres; collectively Australia's federally supported SHCs are the world's very best network of STD/HIV clinics, and Sydney's (and Melbourne's) are the best of the best. However, I'm sure you misinterpreted part of the data you quote; there is no way 3,000 of 3,700 women with HIV are undetectable by blood test. Almost certainly that's the number estimated to be infected but not yet tested (or if tested, escaped reporting in the national database). And although I am not intimately familiar with the details of HIV epidemiology in your country, I'm quite confident the large majority of undetected HIV infected women are in especially disadvantaged populations, starting with some Aboriginal communities. In any case, your partner's testing last December undoubtedly included HIV, and there is no such thing as blood tests being unable to detect the infection. So you can be sure that partner doesn't have HIV, or at least did not have it as of December.

1) I'm not sure I understand the timing of the AgAb (4th generation) HIV test(s) you already have had. If negative 6 weeks or more after the second exposure, the result is conclusive. If before six weeks, have another test now. Since the chance of HIV frome the exposures described was no higher than one in several million, you definitely can expect any future test results to remain negative.

2) No, the cut makes no difference -- both because of the low chance your partners had HIV, and because it wouldn't significantly raise the risk if they did.

3) As for your symptoms:  First, no they are not typical for ARS, which does not cause nasal congestion. As you surmised yourself, you had a cold (or maybe covid?). Second, your negative blood test so far proves HIV wasn't the cause. It isn't HIV itself that causes ARS or other symptoms, but the immune response to the virus -- as reflected in HIV antibody. It is not possible to have symptoms from HIV in the absence of a positive antibody test result.

I hope these comments are helpful. Let me know if anything isn't clear. Or if you remain uncertain or otherwise concerned, visit your local SHC for the very best evaluation and care available worldwide.

HHH, MD

My apology I should have been clearer in my initial message.

When I said "3000 women out of 3700 living with HIV, are undetectable" - I meant that 3000 women have a suppressed viral load and are not infectious. The rest (700 individuals in the country) can potentially transmit the virus.

You said "last December" for my partner's test, it was December 2021 (not 2022) so over a year ago. I know it was done a long time ago but I just wanted to clarify in case it changed your assessment.

I haven't had any tests yet following these events. I had a full STD check-up prior to that the first week of January. So if I take the test today it will be 6 weeks (first event) and 4 weeks (second event) post events

As a matter of fact, because I'm quite worried I just called the clinic and a specialist will see me today. Bitting the bullet and hoping for the best.

I would have advised not testing now, but waiting another two weeks, i.e. 6 weeks after the second encounter -- until I read your closing comment. Glad to hear you're getting expert personal care. (At a Sydney SHC? Or private sector? In addition to the SHCs, there are superior private HIV/STD clinicians in Sydney; I've had the privilege of visitng a couple of them in addition to the SHCs.) "Today" would seem to mean Monday afternoon:  I'll be interested to learn what advice you receive and how it accords with my own.

Regarding the foul odor, he said the same thing as you. It's most likely BV and he mentioned it could come from excessive washing if I understood properly and I should not be worried at all about it. Same for the cut and blood, he said it's irrelevant.

In the meantime, I had a conversation with the partner and she has an appointment with her GP this week and will get tested too.

Thanks again for the service provided.

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