[Question #998] HIV Risk Assessment

62 months ago
Dear Drs.,

Thank you in advance for your time. At the end of June, about 4 weeks ago now, I had an encounter that has gotten me quite worried. A female friend of mine, who is a dentist, informed me that about 5-7 days prior, she had a patient who was HIV+, but who had an undetectable viral load (less than 50 copies, I believe from the data they had at her clinic). She accidentally got struck by the needle she used for local anesthesia in the patient's mouth, not deep inside her skin (she was wearing 2 pairs of gloves also), on the upper side of her thumb, close to her thumb nail. She then followed the procedures, went to a MD at the hospital her clinic is affiliated to, and the doctor reassured her about the incident as the risks were small it seems of her getting infected, but she still opted to do PEP, approx 1 hour after that exposure. That night (thus about 5-7 days after her exposure), we kissed (for about 30 seconds max), she then performed fellatio on me (for also about 30 seconds), and there was no visible blood mixed with her saliva; she does have good hygiene. We also had brief (less than 2 minutes) protected vaginal intercourse. I had a latex condom on and it did not break. I am uncircumcised.  
I've been very worried ever since that encounter and wanted to know if I should get tested for medical reasons now that it's been 4 weeks. Also, worst case scenario, if she did get infected, usually how long does it take for the person to be able to infect others? I know that at the beginning, viral load tends to be quite high, wouldn't that be the case with saliva as well, as saliva also includes traces of HIV? What if (can't really remember, but most likely that wasn't the case) some vaginal fluids got on my penis foreskin (the little area at the end not covered by the condom)? 
Would really appreciate your help. Thanks again. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
62 months ago
Welcome to the forum. Thanks for your question. 

My first reaction is to congratulate you on the wise decision to have only safe, protected sex. More to the point, the bottom line is that you are at no risk at all of HIV, for several reasons. First, HIV infected people with undetectable viral load are not infectious sexually. While there is no proof they are non-infectious through blood or injury-related exposure, for sure they are minimally infections and perhaps not at all. Even in the pre-treatment era of HIV, probably nobody ever caught HIV from an exposure your dentist friend had. Almost all medical-injury infections are from deep wounds with visibly bloody instruments or large-bore needles. (Had she been my patient, I would have advised her against PEP, although I recognize it is a legitimate option if the exposed person wants it.)

Second, if your friend caught HIV, probably she was not yet infectious for other persons. It takes a while for the viral load to build up.

Third, she was on PEP, which even further reduces the probabilities.

Fourth, HIV has never been known to be transmitted by oral contact, i.e. by oral to genital or oral to oral (kissing). That's not to say it hasn't occured, but there are no scientifically proved cases, world wide, of anyone who acquired HIV whose only possible exposure was kissing from oral to penile exposure. Among other reasons, saliva kills HIV. And all these observations apply even if the infected person is untreated and/or has a high viral load. Finally, for intercourse, condoms work. Even with condoms, sexual secretions almost always contact the penile skin above the condom, yet still condoms are virtually 100% protective.

So in brief summary, your risk is zero for all practical purposes: little chance your partner was infected by the needle injury, no chance she was infectious (too early, PEP), and you had entirely safe exposures.

So I really wouldn't worry about it. In personal terms, if somehow I had been in your situation, I would not feel a need for testing and would continue unprotected sex with my wife, without any worry about my health or hers. Of course you are always free to get tested anyway, if the negative result would give you additional confidence about it. CDC recommends that all adults be tested for HIV at least once, regardless of risk; and assuming you have otherwise been sexually active and not always monogamous, you should be tested from time to time regardless of particular exposures. So if you haven't been tested in a while (or ever), this might be a good time, when it's on your mind. But definitely not because of this particular event.

I hope this has been helpful. Let me know if anything isn't clear. Best wishes and stay safe--

HHH, MD


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62 months ago
Dr. Handsfield,

Thank you very much for your very clear and detailed response. I feel much better, and relieved now. 
The last time I got tested for STDs/HIV was about a year and a half ago, so I will do so again very soon, being sexually active.
I do have the below final, follow-up questions, for my own understanding:

1. With regards to PEP - wouldn't the individual need to have taken it for a month to suppress potentially the risk of infection? Or taking it so quickly after exposure as my friend did and after a few days of taking it can already help?

2. With regards to the needle used for local anesthesia in the patient's mouth - there was probably some blood on it that potentially then entered, through the thumb, inside the skin, even if it was superficial. I guess even if that was the case, that amount of blood from that needle and taking into account where it struck, would not be enough for infection to occur?

3. Any gum inflammation in my mouth would not really have increased any risk (with regards to the french kissing), correct?

4. Being circumcised or uncircumcised would also not make a difference with regards to HIV risk by receipt of oral sex, correct?
 

Thank you! I, again, really appreciate your help and you taking the time to read and respond to my questions. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
62 months ago
Thanks for the thanks. I'm glad to have helped.

These additional factors do not change my opinions or advice. 

1) Once PEP is started, it is suppressing the virus, if the exposure resulted in transmission. There are no data on length of PEP required to be effective; 4 weeks is arbitrary and shorter regimens haven't been studied. It is possible that even a day or two would be sufficient.

2) The amount of blood likely to be carried in the small guage needles used for anesthesia is very small. Nobody can say the risk was zero, but given the patient's low viral load, the risk is still very low.

3) Oral exposures don't result in HIV, or so rarely it can almost be ignored. And of course at any point in time, a few percent of people have gum inflammation, oral sores, etc. So these factors appear to make little if any difference.

4) Being uncircumcised roughly doubles the risk of HIV infection by sexual exposure. If we posit a risk of 1 in a million of catching HIV through vaginal sex in your case (which probably is way too high), doubling the risk means one chance in 500,000, which you will agree is trivial.

All things considered, you really have nothing to worry about here.


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61 months ago
Hi Dr. Handsfield,

I understand that this is my final follow-up. 
With regards to the situation I had described - my dentist friend got tested at the 6 week mark and the result was negative. As we had discussed, her risk was low already. I'm not sure for how long she ended up taking PEP after that exposure, but I guess that even if she did get infected, she would not have been infectious to others throughout as the PeP would have been effective and suppressing the virus. 

I was thinking about another issue however. I happened to be reading online about how placing latex condoms in the wallet for a long time (not sure how long that is) is not a good idea. I have done that already, but the condom was probably never in there for a long time. Last time that happened it was there for about a week I believe. Worst case scenario, let's say there's been a time where I've experienced a micro tear in a condom that I wasn't able to notice (tear not in the front of it as I've always checked and made sure the sperm is still inside the condom at the end), but on the sides. Would that substantially increase a risk of infection, if vaginal sex took place with a girl of unknown status? That would mean that vaginal fluid, probably a very small amount, could have went through the very small tear and into my penis foreskin. 
I do think the fact that my dentist friend's result is reassuring for her and me as well, however, vaginal was always protected with her and it was just the kissing and oral sex that wasn't.

Thanks again for all your help. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
61 months ago
Improperly used condoms -- old, used with oil, subjected to high heat e.g. in a car glove compartment -- can break more readily. But these factors do not raise the chance of leaking or of microscopic defects that can result in infection. if a condom doesn't break wide open during sex, protection was complete, regardless of factors like this.

As for kissing and oral sex, we already discussed that aspect:  no risk at all.

And anyway, you now know your partner didn't have HIV:  no way, no chance.

Time to move on. Thanks for the thanks. I'm happy to have helped. Best wishes and stay safe.

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