To Dr. Hunter: in desperate need of your assessment of my risk with HIV

Dear Dr. Hunter,
I am a 35 year-old Caucasian female in London, UK. I have tried very hard to resist posting about my HIV worries after scouring this forum for information and the doctors’ analysis of similar types of exposures. I apologise in advance for a long message.

8 days ago I had a sexual encounter with a 40-something Caucasian man (vague acquaintance). We had vaginal intercourse that started unprotected (no longer than 20 seconds) & continued with a condom on my insistence. We repeated the act 2 more times, with a condom, but the 2nd time I noticed that the condom had slipped a bit but not completely. No ejaculation (he was very drunk –I wasn’t). We also had unprotected mutual oral sex.

What concerns me is:
1) obviously the brief unprotected sex (even in the possible absence of precum) + the condom slip
2) I don’t think my casual partner injects drugs (or has done in the past) but he does take cocaine + the high prevalence of HIV in London
4) the unprotected oral sex (which I know is very low risk)
5) the fact I have HPV/abnormal cells
6) the fact that he had a very runny nose (which I believe not to be a symptom of ARS)
7) I know the odds are in my favour but everywhere you read that women have been infected after a single vaginal exposure (I have read your responses about the rarity of such infections).

I had a negative HIV test over a year ago and this is my first risky episode since then. I have no symptoms (I know they can be meaningless, but would you say that the absence of symptoms at 3 or 4 weeks is certainly encouraging?).
I have an appointment for the Duo test at 29 days but I’m not sure how I will cope with the mounting anxiety for another 3.5 weeks! A rapid (antibody only) test would be too early at 4 weeks, wouldn’t it? I have spent literally days online and I find it hard to function normally. I would be so grateful for your opinion. Time is not passing quickly enough & I need to keep myself together somehow.

[Edward W Hook, MD]

Welcome back to our Forum.  As you know, Dr. Handsfield and I share the forum.  Today you got me.  We share the forum is because we have worked together for over 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

I hope that I can provide you with information that will help to ease your anxieties.  First, this was a low risk exposure with your chances of being infected being very low- your oral sex was virtually no risk for HIV and your brief unprotected vaginal exposure would have a no greater than 1 in 1000 chance of HIV infection if he had HIV. Your 2nd exposure was condom protected and as long as the condom covered the tip of his penis, there should be no risk of infection.  It also sounds as though the likelihood of him having HIV is also low- few heterosexual men have HIV and that he has used cocaine in the past does not change this.  

I would not put much stock in the presence or absence of symptoms but instead, to give you peace of mind, would suggest that you see if he would be willing to get tested.  If he has a negative HIV test at this time, there is almost no chance that he could have infected you through the brief encounter that you describe.  Since you do know him, it seems like a reasonable thing to do- you could offer to do the same for him and get tested, not only for HIV but for other STDs as well. That way you could both move forward with the assurance that there was no risk related to the exposure you have described.  

continued below EWH

[Edward W Hook, MD]

Answer, continued

Finally, if you cannot get him tested, testing at 2 weeks will provide some useful information which, while not definitive, might be somewhat helpful to you. At 2 weeks a standard antibody test would be expected to detect over 50% off recent infection and a DUO test would probably detect 60-70%.  thus negative tests at two weeks, combined with the low risk nature of your exposure should be helpful.

I hope these comments are helpful to you.  EWH

[Nenuphar]

Thank you for taking the time to reply. I cannot ask him to get tested -I don't know him well at all and I am too embarrassed by the whole thing so this not an option.
I have read some similar postings where Dr. Handsfield didn't particularly recommend testing for HIV, only to clear the worry. Not that I wouldn't want to be tested (I fully intend to) but I am sorry to say your reply has made me even more anxious. I know my exposure was low risk but now the risk seems even more real. I wish I hadn't written this post. Please forgive me -I appreciate your honesty but I'm being honest. I don't know how I'm going to be able to cope until I get the results. I admit it's not quite what I expected to hear. My fault.

[Nenuphar]

Sorry, just to clarify... It's the fact the vaginal penetration was only for a few seconds -this doesn't reduce the risks even more then? The fact also that you suggest I ask him to get tested... -this worries me a lot. So my risk is high enough to warrant this? I appreciate this is subjective.
Doctor, do you know of a woman becoming infected after one single exposure of a few seconds? If so then of course I should be worried, and also regardless. Again I'm sorry -very, very scared and confused.

[Edward W Hook, MD]

You are not approaching this rationally.   You had sex with the man!  That makes it legitimate for you to contact him and ask him to be tested, particularly if you do not know him well.  Don't you think that you owe it to yourself, and he to you, for the two of you to be sure that you did not accidentally acquire an STD of some sort (and HIV is, statistically, about the least likely STD you could get).  this not a matter related to embarrassment, it is a matter of sexual health for each of you.  You need to approach this as an adult.

As for the risk for HIV, as I said, it is low.  I provided you with numbers which demonstrate this.  I also pointed out that the brief duration of your exposure makes infection more unlikely (IF he was infected- something that its already unlikely) than if the unprotected portion of the encounter had been longer.  

I have had patients who became infected following a single exposure but not on an exposure that lasted just a few seconds.  

Just to reiterate- your risk was low.  Your fears are far, far out of proportion to your risk.  You however are acting to amplify them by your failure to act logically about this.  EWH

[Nenuphar]

I would really appreciate Dr. Handsfield's view on this as well. I thought testing wasn't warranted after one single episode, only within regular sexual health screening?? Unless my exposure is considered high risk. Is it because I am in London, UK?

[Nenuphar]

I don't have his phone number to start with, although I do know where to find him. It was a one-night stand and I want to put it all behind me amongst other reasons. I'll wait and suffer in silence. In an ideal world it would be great but...

Comments like this one really confuse me (amongst a few others I've seen):
http://www.medhelp.org/posts/HIV---Prevention/Unique-Question-About-my-Risks/show/256477
I mean the guy had sex with a CSW! It doesn't make sense.

It would be great if you or Dr. HHH could shed light on these conflicting pieces of information. I don't expect anyone to say my risk was zero, but why give reassurance to people who had full sexual intercourse and mitigate the "lowness" of my risk?

[Edward W Hook, MD]

Dr. Handsfield and I do not comment on each others' responses and I am confident that he would agree with all that I said, i.e. that your risk was quite low.   You seen to want to have it both ways, asking me to assure you there there is no risk (since I have already repeatedly told you your risk was low) and then providing great detail about the anxiety you have about this exposure and your need to know your status.  You are the one who raised her concerns, stated that you  could not " cope with the mounting anxiety for another 3.5 weeks "  and then told me that you had already scheduled an appointment to be tested at day 29- do you think either is going to try to talk you out of testing or tell you there is no risk at all.  That's unrealistic.  Instead I provided you with several alternative ways to demonstrate to yourself that you are not infected as an alternative to allowing your anxiety to consume you.  

Please note that link that you point to is 5 years old.  I agree with the statement for persons who are not cocerned- you are not in that group, as you have already pointed out.  My recommendations were based on the information you provided.  If it makes you feel any better, your numerical risk of infection is probably less than 1 in 100,000 - that's low.  I would not worry aobut it but I am not you.  EWH

[Nenuphar]

So you disagree with the following comment from Dr. HHH (quoting from a posting that's quite old so perhaps things have changed, but there are more recent replies in the same vein):
"I never recommend HIV testing after a single potential exposure unless the risk is quite high (...).  The risk of heterosexual transmission after a single exposure to a CSW doesn't make the cut.  (If every man who had sex with a CSW got tested every time, the HIV testing services in most cities couldn't handle the load!)  Such people should just have an HIV test (and testing for other common STDs) from time to time, such as once a year, but not worry so much about individual exposures."

Please can you try to see where I'm coming from? I am not after certainty. I simply hoped your assessment would reflect other assessments of similar, even high risks.

1 in 100,000?? Where do you get this figure from? A population prevalence of ONE PERCENT?? (1000 x 100 = 100,000). Wow, is this the HIV prevalence in London then?

[Nenuphar]

Another thing, when you write: "I agree with the statement for persons who are not concerned- you are not in that group" (referring to the link I provided), what do you mean? The guy had brief unprotected sex with a prostitute and yet he's only advised to have a routine test. Or did I misunderstand you?

[Edward W Hook, MD]

I'll have nothing more to say.  You are not reading or understanding what I have written - suggest you re-read my earlier answers.  This thread is over.  EWH

[Nenuphar]

Or you do you mean concerned as in worried? -in which case, my apologies. Perhaps being too reassuring is not the best way. A lot of people in my situation wouldn't worry I suppose, even if they planned to get tested as a routine measure.