Hi

28 days ago, I received oral sex from a sex worker. I wore a condom, but we also fondled and kissed. She brushed her teeth first, which increases the risk of gum bleeding. Here are the symptoms since.

T+16: Fever and diarrhea. Fever only lasted two days but diarrhea has been on and off.

T+17: 4th Gen Duo test -ve, but within window period

T+26: Slightly itchy red dots. Five dots from my leg to my thigh, and two dots on my lower arm. Not clustered and are mostly distinct single bumps. 

I notice slight hoarseness but I wouldn’t call it a sore throat. I do not notice other symptoms. 

My questions:

1. What's the risk of me catching HIV specifically, and other STIs?

2. Does genital grinding with / without protection change the risk?

3. If my penis were to have touched the outside of my used condom, or unclean towels and sheets, does this change the HIV risk? 

4. If I had protected vaginal sex 4 and 11 days after above, could I have spread anything to my partner?

Thanks

The encounter you describe was a no risk event for acquisition of HIV. Most commercial sex workers do not have HIV and you wore a condom.  Further, there has never been a case of HIV proven to have been acquired through receipt of unprotected oral sex, through frottage (grinding), or through the other activities you described.  In addition, your testing proves that your symptoms are not due to HIV.  When symptoms are due to recently acquired HIV, combination HIV antigen/antibody tests are always positive.  Thus, while fever and diarrhea have been described as part of the symptoms of recently acquired HIV, your testing proves that the symptoms were not due to HIV.  In response to your additional questions:

1.  As described above, between the low likelihood of infection in your partner and your condom use, there was no real risk for acquisition of HIV or any other STI. I would not be concerned and see no scientific or medical reason for testing of any sort.

1. Are there any additional risk factors you can think of in my setting that would make my risk of HIV non-negligible? i.e Stress, poor hygiene, open wounds on body but not on penis?

2. Would you have any advice on how to deal with STI/HIV hypochondria?

3. Given what I have shared with you, would you say I should skip a second test on day 45 entirely?

4. In the case of future encounters of receiving oral sex as the sole risk event, is it fair to conclude that HIV testing is unnecessary, regardless of protection use?

5. Would you mind defining which events merit an HIV test when done with a sex worker? Would you recommend a test for any protected activity?

1. Are there any additional risk factors you can think of in my setting that would make my risk of HIV non-negligible? i.e Stress, poor hygiene, open wounds on body but not on penis?

No, none.  as I said, there has NEVER been a case of HIV proven to have been transmitted through receipt of oral sex.   This is true for fondling, and kissing as well.  

2. Would you have any advice on how to deal with STI/HIV hypochondria?

That is beyond the scope of this Forum.  Exaggerated concerns about HIV and other STIs sometimes comes from a belief that a person is doing something "bad" and is a manifestation of guilt.  You have done things right to minimize your risk for infection.  If these concerns continue to be problematic for you I would suggest discussing them with a trained cousnelor.  To be clear, I am not saying you are crazy but suggesting that such a discussion might provide you with helpful insights. 

3. Given what I have shared with you, would you say I should skip a second test on day 45 entirely?

I see no medical or scientific reason for further testing.  

4. In the case of future encounters of receiving oral sex as the sole risk event, is it fair to conclude that HIV testing is unnecessary, regardless of protection use?

Yes

5. Would you mind defining which events merit an HIV test when done with a sex worker? Would you recommend a test for any protected activity?

Since most people (even CSWs) do not have HIV or other STIs and even most unprotected single exposures to infected partners do not result in acquisition of infection testing for HIV and other STIs following sex with a new partner (CSW or otherwise) is reasonable, as is periodic testing for persons with multiple partners.  How often varies depending on the type of partner and the level of concern but testing more often than every 6 months is probably not necessary in most instances.  Condoms dramatically reduce risk for acquisition of STIs, including HIV as long as they are worn throughout the encounter and do not break.  Condoms break about 1% of the time they are used.  

EWH

1. I think you have mentioned that the acquisition of HIV in my case is zero, but I understand there are other STIs that can be transmitted by skin. Given I have not had any specific symptoms around my genital area for almost 30 days, is it OK to rule out other more transmissive infections, such as herpes (or HSV-2 specifically), gonorrhea, chlaymdia, so I can skip those tests as well?

2. Just for my future knowledge, can you help us better understand what HIV rashes look like? There's conflicting information on whether they are itchy, whether they have to be clustered, whether its usually an outburst of tens of dozens of small nodules, etc. Put differently, are there any telltale signs that would make it easy to determine that a skin problem is NOT an HIV rash?

3. Also as future knowledge, is it true that a) HIV ARS symptoms are very obvious (i.e. a very sore throat / skin itchiness, and not just the usual soreness and occasional itch), and that b) HIV ARS usually take 10s of days to recede and not three or four days?

4. Given our discussion, should I conclude that any further common but non-specific symptoms within the 45 day window period (intermittent spots on legs / thighs, occasionally itchiness in genitals) are irrelevant and that I need not change my view / actions? 

5. Would PREP + protection essentially remove all risks for HIV contraction from ALL sexual activity (oral, vaginal, anal) regardless of the number of partners / sexual events, regardless of serostatus? Are there any major / permanent side effects to taking PREP long-term if I foresee that I will have many sexual encounters in the future?

PrEP is more than 99% effective for prevention of HIV from sexual exposures in persons who take the medications as prescribed.  Side effects of the medications are few although one of the medications typically used in PrEP can cause kidney problems from time to time.  

I hope the information I have provided has been helpful.  EWH