Exposure with CSW in Bangkok

[larry152]

Dear Doctors,

I had unprotected insertive oral and protected vaginal sex twice with the same CSW in Bangkok on July 15 and 16. To be honest, I didn't give it too much thought as the vaginal part was protected ( and the condoms intact (to the best of my knowledge and I know what a breakage looks like!). In addition, the CSW assured me she has regular blood tests (incl. HIV) in connection with her job in the bar where she works and the last one (which took place a few days before our encounter) was all good.

However, I started developing a rash in my groin a few days post-exposure (maybe 7-10 days or so) with no fever, sore throat or any other symptom. It was subsequently diagnosed as a fungal infection which reacted well to Nizoral treatment (it lasted for a month or so). I also developed an itchy scalp after that (maybe 2 weeks post-exposure) which is almost gone now after applying a medicated shampoo for the past few weeks.

However, on day 24-25 post-exposure (which I understand is too late to be ARS based on Dr Handsfield responses to multiple posts), I had a viral tonsillitis with fever (lasting for 4-5 days between 38c and 39c at its peak), sore throat and swollen lymph nodes in the neck (but no related rash except for the one on the groin and scalp itch which had appeared way earlier). By the way, my son also had a tonsillitis that same week so I guess it was just a virus we exchanged. Plus, I also had a flu and another tonsillitis earlier this year (in March and April, respectively) so I think it is just a coincidence.

I just want to confirm with you that this does not sound suspicious for HIV and that a rash cannot possibly occur so early before the rest of the symptoms during ARS (my understanding of the sequence is that a sudden fever onset is followed by the rash, not the opposite). Your feedback / re-assurance is highly appreciated.

[Edward W Hook, MD]

Good question.   There is no information to suggest that antibiotic resistant gonorrhea are more easily transmitted than other gonorrhea, nor that they remain at the site of infection longer than others.  EWH

[larry152]

Thanks Doctor. Just a last one if you will. I know that, based on research and your own experience, oral sex is safe with respect to HIV but I understand that gonorrhea becomes more and more of an issue due to antibiotic-resistant strains, particularly in Asia. Is the transmission risk through oral sex significantly higher with these "superbugs" able to survive longer in the throat of infected females?

[Edward W Hook, MD]

Correct. Condom protected sex is essentially no risk for HIV.  I would not worry.  EWH

[larry152]

Thanks Doctor. Your comments are extremely helpful. Last question for you. To the extent the condoms always remain intact, can I safely assume that I do not have to worry about HIV after each episode of protected vaginal sex / unprotected oral sex with a CSW in Asia no matter what symptoms may appear later on?

[Edward W Hook, MD]

Welcome back to the Forum.  I'll be pleased to confirm your sense that these symptoms are not suggestive of recently acquired HIV.  Before I do however, I should point out that HIV rates among Thai CSWs is lower than in most parts as the result of a successful nation-wide condom promotion campaign.  Thus I suspect that your partner was being truthful when she stated that she was tested regularly and was negative.

The symptoms you suggest are not suggestive of recently acquired HIV.  When persons experience the so-called ARS, the symptoms come on at about the same time, not successively. further, the rash of the ARS is generalized, not localized to one part of the body or another.  Thus I agree with your assessment that the symptoms you experience are almost certainly coincidental to your recent exposure and not a manifestation of HIV.  Based on the reported exposures you describe, I see no medical reason for even testing for HIV at this time.

I hope my comments are helpful. EWH