HIV risk analysis

[Concerned_frightened]

Firstly, since this text-box is allowing a very limited amount of characters, due to the complex nature of my concern I will have to break down my case with as many words as I can fit here, proceeded by the remainder in the comment section.

Background:

Dear Dr. Hook,
I am a student who was raised in a well-off, loving upbringing, who foolishly experimented with the services of a sex worker for the first and only time exactly one month ago. The day before the booking I was shaving my genital region but in doing so, accidently cut my testicles (to the point of bleeding). Irrespective of this, the next day I arrived to a much more run-down apartment than I envisioned only to be greeted by a more elderly and rough looking woman than what was advertised in the pictures online. At that point I should’ve had the common sense to turn around and leave, but thoughtlessly I handed her the money and continued. I requested condom protected fellatio in order to mitigate HIV/STI/HCV risk and she obliged. As soon as this started I visibly observed lots of her saliva quickly drip down the condom and onto the area of the cut suffered the day before, but to my horror the saliva was completely opaque, creamy and white. Adding to this, she was strangely and noticeably grimacing while avoiding using her lips and with a wide-open mouth motion she was using solely her throat to gag up and down. I can only rationalize that she must have been doing this to avoid painful oral lesions on her mucous membrane. This was very unnerving and after I ejaculated, I felt disturbed and anxious to leave.

[H. Hunter Handsfield, M.D.]

I'm well aware of Dr. Montaner and his group's research studies.  Pockets of CSWs with very high rates of HIV are easy to find in many cities, and he is very aware that his study population is not representative of all CSW's in Vancouver.  If your CSW partner resides in Downtown Eastside, then she may indeed have a much higher likelihood of being HIV positive, but there is no way theat 26% of the entire population of all CSWs in Vancouver have HIV.  If you'll read and understand my replies above, you will understand that even she had HIV, you were not at significant risk.

You came here for reassurance, presumably.  I have tried to give it.  Accept it or not, and trust my expertise or not, I don't care.  But this isn't a debate.  This thread is over.

[Concerned_frightened]

I live in Vancouver

I'm staring at a study published by the "harm reduction journal" which reports HIV prevalence per capita. In 2009 it estimated 26% of Vancouver's sex workers to be HIV positive. This is not < 1% this is 26%. Don't know what else to tell ya....

Here's the link:

http://www.thebody.com/content/art50751.html

[H. Hunter Handsfield, M.D.]

There has been plenty of research showing that among most female sex workers in most parts of the United States, under 1% are infected -- even among those with additional risk factors, such as injection drug use.

You seem to be prone to over-analysis of HIV transmission and its risk.  Like many anxious people who research their concerns on line, I suspect you are being drawn to information that inflames your anxieties and missing the reassuring bits.  This is expressed nicely by Nate Silver (the recently famous statistician who writes the NY Times' FiveThirtyEight political blog) in his new book. He writes of a hypothetical hypochondriac with an Internet connection:  "The more time that you give him, the more information he has at his disposal, the more ridiculous the self-diagnosis he'll come up with; before long he'll be mistaking a common cold for the bubonic plague."  We see this phenomenon all the time among anxious forum users, mostly fearing they have HIV based on common symptoms of everyday minor illnesses -- but the concept undoubtedly applies to risk assessment as well.

Anyway, I stand by my comments and advice in my original reply.  I'm glad it has helped; thanks for the thanks.

That will wind up this thread, unless and until you decide to get tested for HIV and would like to let me know the result.

[Concerned_frightened]

Thanks for the reply, although I do have some questions and discrepancies with your statement. Is it possible for you to respond to them? I will compensate you more money if required.

Areas of confusion:
Not sure how you can arrive at a statement like, “the overall chance she had HIV probably is well under 1%", when the woman in question is a self-identified crack user and dozens of case studies surveying crack smokers have reported sex workers in particular to be the highest risk group for HIV. Trust me, I've read A LOT of reports over the course of this nervous breakdown, and never once found findings documented where chronic crack users we’re HIV negative more than 90% of the time, let alone 99%! We've got some pretty conflicting data here Hunter...

A lot of these studies were published in the Lancet, and conducted in the US but to address your concern over extrapolation, one study I read was actually performed in Vancouver, Canada, the exact location I live.

After chronicling this entire event to my family doctor, as much as he tried to comfort/console me, I recall his final words of caution being, "the woman could very well have HIV, as sex workers, and especially one who smokes crack, falls under the high risk group category." By no means trying to disparage your inferences, but I’m getting a pretty polarizing assessment between the two of you here, you know what I mean?

As for you not worrying about sleeping bareback with your wife prior to being tested following direct sexual contact with a crack addicted prostitute, I guess you and I just have a different appetite for risk, fair enough.  

I understand the pitfalls of extrapolation, but still completely at a loss of how you estimate her probability of HIV to be below the 1% range. Most research conducted on HIV prevalence among crack/cocaine users typically report a statistical risk of over 20 times your estimate.
Regardless, I don't remember having this amount of pent-up stress since cramming for my finance finals during the same time I was having major issues with my boss at work and you have definitely assuaged/decompressed my anxiety considerably.

It must feel rewarding to have the gift of being able to calm and soothe people's nerves with your knowledge and expertise. Thanks Buddy!

[H. Hunter Handsfield, M.D.]

Good work.  This version still contains some extraneous information not really necessary to assess your risk (the entire first paragraph, for example, which would have taken it under the 2,000 character limit) but it's manageable.  Thanks!

Your partner's crack cocainse use may or may not significantly eleveate her risk; injection drugs, with shared injection equipment, is the main drug-related risk factor.  You are over-interpreting selective research studies in a way that cannot be safely extrapolated to any individual sex worker.  In fact, the overall chance she had HIV probably is well under 1%.

You don't say exactly what sexual exposures occurred, but I gather there was (unprotected?) oral sex and perhaps condom protected vaginal sex (?), and you are also concerned that shaving nicks on your scrotum might have elevated the risk of infection.  All in all, these exposures can be entirely ignored.  Oral sex is virtually no risk at all; some experts believe it never occurs from an oral to penile partner, and another calculation by CDC suggests an average risk -- if the oral partner has HIV -- around once for every 20,000 events.  That's equivalent to receiving unprotected oral sex by infected partners once daily for 55 years before transmission might be likely.  Biologically, this is at least in part because saliva kills HIV.

The shaving nicks on your scrotum also can be ignored.  The only wounds known to have resulted in HIV transmission were actual injuries with HIV-contaminated sharp instruments in health workers.  Deep, fresh, actively bleeding wounds might carry some risk if exposed, but superficial scratches etc carry little or no risk and have not been documented to ever result in actual transmission.

For those reasons, I do not agree that there is "...a strong argument for a myriad of high HIV risk factors that speaks volumes to my risk exposure analysis being one of a considerably high magnitude with a high risk of contracting HIV."  There are only 60,000 new HIV infections per year in the entire United States, and almost all of those occur in people with the traditional obvious risks, like injection drug use with shared equipment, unprotected anal sex among men, or prolonged, repeated unprotected vaginal sex among heterosexual couples in which one partner unknowingly has HIV.  One-off heterosexual exposures, even with unprotected vaginal sex, account for very few infections.

As for your symptoms (which you could easily of included -- I had to glance at your original comments), they are not at all typical of a new HIV infection.  Not even close.

In summary, there is no realistic chance you have HIV from the exposure described.  If I were in your situation, I would feel no need for testing and would happily continue unprotected sex with my wife without fear of infecting her.  However, my guess is that these words will not convince you, in which case I would recommend testing in a few weeks for its reassurance value.  If you decide to be tested, feel free to post the result.

Best wishes and happy new year--  HHH, MD

[Concerned_frightened]

Okay my friend, I will certainly try and do this for you. I wasn't lying when I said I was in tears, this ordeal is really eating away at me. To this end, please find it in your heart to have some sympathy for the trauma that I have most recently undergone. I understand that you are a busy man sir, so here is the condensed version. I realize beggars can’t be choosers and am so grateful for the counsel you are providing as you are literally my only branch of support at this time. To say that dealing with this stressful experience alone has been challenging would be an understatement, so please know you are being appreciated and thanked in spades for your assessment. During this dark period, this means the world to me, and I genuinely mean that Mr. Hansfield.

BACKGROUND:
The night before the scheduled morning appointment less than 10 hours prior to exposure, I accidently cut myself while shaving my scrotum/testicles. There was visible blood and while impossible to say how large, it was a noticeably open wound.

The following day, upon conclusion of exposure and subsequent follow up phone calls the succeeding week, it was established and proven by her own admission that the sex worker was a chronic crack smoker of the survival sex variety.

In the box above, the research quoted from peer-reviewed medical journals is enclosed by “quotation marks.”

Here is a summary of that information:

The research indicates that crack smokers are at high risk of blood rupturing mouth trauma i.e. cuts, wounds, burns, lesions, ulcers etc.  The studies assert that in light of these findings as a function of the delayed healing, the risk of transmission of HIV through oral sex exposure dramatically increases. Additionally the research demonstrates terrifying findings and reports that claim that oral receptive sex (which I experienced) is a higher risk activity for HIV than vaginal sex when performed by crack smokers due to the aforementioned reasons. EXTREMELY WORRISOME!

There is much more scholarly research to support the above findings but I've run out of room to even include all my horrible symptoms! As mentioned earlier, if you would like full citations and references I’d be more than happy to provide them. The academic findings through the research I presented provides a strong argument for a myriad of high HIV risk factors that speaks volumes to my risk exposure analysis being one of a considerably high magnitude with a high risk of contracting HIV.
Do you agree with this assessment? If not please explain how this is not a reasonable conclusion based on what has been examined and substantiated.

Thanks Hunter, and sorry for breaching 400. I tried as best I could to convey the message as clearly and succinctly as possible. Look forward to hearing from you.

[H. Hunter Handsfield, M.D.]

Dr. Hook and I take questions randomly, without regard to requests for one of us or the other.  Our opinions and advice never are significantly different from one another, even if our styles are variable.  I'll be handling your question.  

The reason for the 2,000 character limit (about 400 words) is to require that the entire question be limited to the initial text box.  The moderators have neither the time nor inclination to read such long essays, and I have never seen a question that could not easily be condensed to the required limit.  Please condense your question accordingly, post it in a new follow-up comment below, and then I will respond.

Thanks--  HHH, MD