Dr. I would like to thank you in advance for your advice. I am extremely concerned about an exposure that I had on Friday night. I had insertive anal intercourse with a man I met on the internet. I always have protected sex. On this occassion the condom broke at the beginning of intercourse. I realized that the condom broke within 30-45 seconds of occurence and I withdrew and washed myself. The partner that I was having intercourse with assured me that he is disease free. I am concerned about my risk since I do not know this person. Also would you recommend post exposure prophylaxis for an exposure such as this? I am married and extremely concerned about the potential of contracting HIV and spreading it to my wife.
All things considered, the chance you caught HIV is very low. If you figure maybe a 1% chance your partner has HIV, plus 1 in 100 to 1 in 500 chance of HIV transmission if he were infected, your odds of having caught HIV come to somewhere from 1 in 10,000 to 1 in 50,000. Pretty good odds -- but sufficiently high that you definitely need HIV testing, and also the direct advice of a health care provider who understands local HIV epidemiology and PEP recommendation.
There are no standard guidelines by CDC or other health agencies about exact criteria for PEP (except for health workers exposed on the job), and local health officials and experts set recommendations based in part on risks that vary from one place to another. In other words, criteria for PEP vary from one setting to another; there are no rigid rules. Most HIV infected persons don't lie when asked directly, so the odds are strong your partner isn't infected. On the other hand, if by bad luck he had been infected very recently, the transmission risk could be quite high, since viral load and transmissibility are maximum in the window period. Because the odds of these things vary from one city or population group to another, exposures that would warrant PEP in one city or town might not do so somewhere else. In my clinic (in Seattle), we probably would not administer PEP -- but if you insisted, we might go along with it.
In other words, the PEP question is a judgment call without a clear answer that I can giv eyou. For sure this exposure warrants HIV testing, preferably with a duo test (antibody + p24 antigen). You should find a health care provider who understands local HIV epidemiology and PEP recommendations in your area, then follow his or her advice. Whatever you do, don't panic, and be assured that the risk you were infected is very low.
We avoid moralizing on this forum, and you should not interpret this last comment as doing so. We hear all the time from people in committed relationships who have other sex partners. But by having sex with men, even with all attempts to be sexually safe, you are putting your wife at far higher risk for HIV and other STDs if your outside pleasures were with women. You need to think very carefully about whether it is fair and ethical for you to do that without her knowledge. Again, my concern is strictly with disease prevention, not to give relationship advice.
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