Bangkok Prostitute HIV, Please Help?

[MadWithWorry]

Dear Doctor,

Thank you for your help, I am worried sick, having reoccurring nightmares and losing weight with worry. I am 20 year old male from Great Britain. 31 days ago whilst backpacking in Bangkok I engaged in sex with two freelance street prostitutes. (I put their HIV prevalence at 20%, is this correct?)

-One performed unprotected fellatio on me for aprox. 10 seconds.
-I had protected sex with them both one after the other. (I was very drunk and can't say for certain it was protected for the entire time, but almost certain. they provided the condom.)
-I performed unprotected cunnilingus on one of them in the '69' position for about 30 seconds. (this is my biggest worry. Am I correct for it to be so? I am having trouble reconciling the "zero risk" advised on the MedHelp forum and the CDC advice which says it is a sizeable risk. I fear I was so drunk that I wouldn't have noticed even if she was menstruating, would this "increased risk" increase the risk to bring it up to highly risky? When articles say "good oral health" is important, what constitutes good oral health? I have several childhood fillings, and brush my teeth twice a day when at home and pass dentist checkups. My gums occasionally bleed a little when I brush them too hard, but nothing the dentist has ever brought up in bianual checkups.

Also from a few days ago, really day 28 or so, I have started to feel fatigued despite spending much time in bed. Is this a clear indicator of Acute infection? Or could it be due to the fact that i'm not really eating/ I am depressed/worried?

Additionally as a side note I did a gonorrhoea and chlamydia test at day 12  and tested negative.

Please help me, I am so worried at the moment.
Thank you.

[Edward W Hook, MD]

Why did you not mention receiving PEP.  I cannot provide good information if you do not describe the scircumstnaced of your exposure accurately.  Your exposure was virtually no risk and use of PEP reduces any risk for infection still further.  

These will be your last answers
You are correct- having taken PEP does  change when you can test accurately.  It is recommended that you wait at least 3 months after completion of PEP before answers will be definitive. These recommendations are probably conservative but those are the recommendations.  

Your symptoms in no way suggest acute infection.

I repeat, there is no meanigful risk of infection from cunnilingus. Use of mouthwash is not know to change this.

Your condom question is silly.  It was almost certainly latex.  

There are no data to suggest that persons of one body habitus or another are particualrly susceptible to infection.

This thread is now over.  EWH

[MadWithWorry]

Thank you very much for your quick and detailed response, I hugely appreciate it and it has calmed me slightly knowing that you are such an authorative figure on the matter.

I am just concerned they have hiv as they were on the street at 6am when the district bars and clubs were otherwise closed and few other workers were about. ie the polar opposite of the 'high end' escorts.

I don't think I can have a conclusive test for another 3 months, as I was given a 28 day course of PEP (Truvada & Kaletra) in Bangkok, at around 40 hours post exposure, and finished that 6 days ago. I know the success rate of the course is really unknown/proven in non-occupational exposures, but what is your view on it?

And re the fatigue that I have felt since around day 28 until now (day 32), I feel unenergised after even 11 hours sleep, knackered after mowing the lawn for 5 minutes, and just a general sense of having no energy. Isn't this a decent indicator of acute infection?

Also one or two more doubts are I have read using mouthwash just before the cunnilingus disables the hiv-inhibitor enzyme in one's saliva. I used mouthwash before, in your opinion was this a fatal error or is this a too simplistic view?

Furthermore, as the prostitute supplied the condom, presumably it was a latex one that would work and be in date, and not one of these lambskin ones that are useless?..Are they useless?

Also are some people more suceptible to infection due to their biological/physical make up. Ie is the fact that I'm smaller & lighter than most males, participate in a British University type unhealthy (ish) lifestyle, and not one of these gym obsessed healthy eating types, mean that my body will pick up the virus more likely?

Sorry to bother you again, I really appreciate you replying so fast, It's just that I'm beside myself with worry that I feel if I can't get around this worry for 3 months I simply just will not wake up one morning out of stress. So your review of my situation is greatly appreciated.

[Edward W Hook, MD]

Welcome to the Forum.  I will try to help but you are going to need to decide who you wish to believe.  As you have already found out, you can find estimates of your risk for HIV that are highly variable.  Naturally, we believe the estimates we provide which reflect our combined over 70 years of practice caring for persons with and at risk for STDs, including HIV, as well as information learned by regular reading of the scientific literature and attendance and meetings and scientific advisory boards which we are asked to take part in.  We believe that estimates of governmental agencies such as the CDC tend to be overly conservative, both because they cannot be individualized and because of the belief that, as governmental agencies, they cannot “afford” to be incorrect.

Your estimate of the likelihood that your partners are HIV infected are probably a bit high - Thailand has had one of the most successful HIV prevention campaigns in the world and while rates were high, they then declined as the HIV prevention/condom promotion campaigns took place.

Even more importantly however, your risk for infection is low or perhaps even zero.  Condom protected sex is safe sex and there has never been a case of HIV documented to be transmitted through receipt of oral sex (fellatio) or performance of cunnilingus (there are a very few cases reported which MAY have been transmitted through performance of fellatio.  Neither of us has ever seen one however.  At most, the estimated risk of getting HIV, IF your sex partner had HIV is estimated to be, at most, 1 infection per 10,000 exposures and is probably lower.  The increased risk associated with "poor dental" hygiene is theoretical And from what you describe yours is fine (although you should probably floss more).

My advice is not to worry.,  Given your degree of worry however, it appears that would benefit from a test.  If you have access to one of the combined HIV p24 antigen/HIV antibody tests available you can get a definitive answer as to whether or not you were infected at this time since these tests provide definitive results at any time more than 4 weeks (28 days) after an exposure.  

I hope my comments are helpful- please do not worry. EWH