Vaginal Fluids Penis - Condom Break

[Veryconcernedjohn101]

Dear Doctors,

I have been stupid again. After too many drinks i engaged with a street walker transsexual csw in Hong Kong - she was from the Philippines.  She gave me oral with a condom and then I rubbed my penis against her vagina for 30 seconds to a minute.  I then noticed that the top of the condom was completely broken and the head of my penis was exposed and covered in vaginal fluid.  She was standing up at the time I was rubbing against her vagina so I do not think that there was any penetration. It may have been that the condom was broken during the oral sex and I would have then been exposed to her vaginal fluids for the full duration of the rubbing. 9 hrs 30 mins after the exposure I visited my doctor and started PEP.  Can you please advise my risk given this exposure?  Would the risk have increased considerably if I had penetrated her slightly? I did not know that she was a transsexual until after the event - I am not sure what level of contagious fluids would be present in a transsexual (man to women).  Thanks for your help.

[Veryconcernedjohn101]

Hello Dr Hook,

Thanks again for your previous advice.  I wanted to provide you with an update of my situation and ask for some further feedback.

I completed 28 days of PEP (combivir twice daily, kaletra four tablets daily) and then undertook a series of testing as follows:

- HIV Duo/Combo at 2 days 12 hours following PEP - Negative
- HIV RNA PCR at 2 days 12 hours following PEP - Not Detected, No Amplification Detected
- HIV Duo/Combo at 10 days 12 hours following PEP - Negative
- HIV RNA PCR at 10 days 12 hours following PEP - Not Detected, No Amplification Detected
- HIV Duo/Combo at 16 days following PEP - Negative
- HIV RNA PCR at 16 days following PEP - Not Detected, No Amplification Detected
- HIV Duo/Combo at 21 days following PEP - Negative
- HIV RNA PCR at 21 days following PEP - Result is "<29 copies / mL", Amplification Detected

The RNA PCR test is a Roche Cobas Taqman Version 2 with sensitivity of 29 copies / mL.  My concern regarding the last result is that it is different that the earlier results and the test appears to have picked up something?

My understanding is that if I had been infected with HIV then my RNA level would be very high at least in the thousands.

Could you please advise your opinion regarding the latest RNA result.  Do you think that it means that I am negative?  Am I just being irrational here?

Thanks,

[Edward W Hook, MD]

Correct.

this is my final comment.  There will be no further responses. EWH

[Veryconcernedjohn101]

Dear Dr, sorry to keep hassling you - I am trying to rationalize your comments which I really appreciate.  Setting aside that I have started PEP, in your opinion is the risk of this exposure sufficiently low to not consider testing and to move on, continue unprotected sex with my wife? Thanks for your patience

[Veryconcernedjohn101]

Thanks.  I will aim to complete the PEP and then test at the appropriate time.  I will try to remain calm in the interim.

[Edward W Hook, MD]

"What If" questions are rarely helpful.  Had you penetrated your partner, you would have known it.  Even if you had however, I woud not have recommended PEP.  EWH

[Veryconcernedjohn101]

Thank you.  One part of my earlier question was a "what if" as I had a lot to drink at the time.  If there had been brief penetration would you have prescribed PEP in this intstance?  Thank you

[Veryconcernedjohn101]

Thank you.  One part of my earlier question was a "what if" as I had a lot to drink at the time.  If there had been brief penetration would you have prescribed PEP in this intstance?  Thank you

[Edward W Hook, MD]

Welcome to the Forum.  I'll be pleased to comment.  This was a virtually no risk event.  HIV is not transmitted through receipt of unprotected oral sex or as a result of non-penetrative sexual activity. Thus, even when a partner's genital secretions get on a person, whether in the course of mutual masturbation or frottage (genital rubbing), there is no known risk for HIV.  Further, you do not know that your partner had HIV (most transsexual CSWs do not).  In this situation, I would not have recommended PEP as there are no instances in which this sort of sexual activity is known to have led to HIV transmission.

I hope this comment is helpful  Now that you are on PEP, I would urge you to hold the prescribing physician accountable for follow-up and questions.  Sadly, there are all too many health care providers willing to provide it, thinking that their jobs are done when the prescriptions are written.  This is not the case.  In my opinion, it is essential that anyone who provides PEP also provide follow-up and a commitment to answer their patient's questions about risk, side effects, etc.  EWH