HIV - Prevention Expert Forum
small cut on penis
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This forum is limited to prevention of HIV and to safe sex in general. All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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small cut on penis

Hi,

I am concerned -- I believe I've had a fairly risky exposure.  I'm going to try to be specific and unemotional in this question, but suffice it to say that I am freaking out.

Last Saturday (5 days ago), I had sex with a transsexual escort.  We both gave each other oral (w/out condoms), and then, for about 5 minutes, I penetrated her anally with a condom that she had applied to my penis.  My penis was only semi-hard during the anal penetration.

After this event, I masturbated later that evening for a considerable amount of time -- until it hurt.

What scares me most is what I noticed on Monday morning: a small cut on the top of my penis shaft, around 1/3 the way up from the base to the head.

I do not know if the cut occurred during the sex or afterward.

If we assume that the cut happened prior to or during the anal sex, I don't know whether the condom stayed well-enough placed during the anal sex to have prevented skin-to-skin contact.  If it did not, the cut most likely only came into contact with her anus and the immediate area of the sphincter behind the anus.

Question: If we assume that the cut was present and the condom didn't keep it covered, and that this portion of my penis contacted her anus and the sphincter area near the anus, how much risk do I face of transmission, assuming she was HIV+?

Question: Are there any statistics on the percentage of transsexual escorts in the U.S. who are HIV+?

Question: Is there any chance that PEP could help at this point?

Question: Any other advice on how to look at this potential exposure in a way that will comfort me vis-a-vis the risk of having contracted HIV?

TIA,
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I will try to help calm your fears.  But I'm going to start with a mini-lecture, aimed not just at you but all forum users, especially those who are fearful of HIV after particular exposure events.

Most people do not understand how difficult it is to transmit HIV through sex, compared to most infections, including all other STDs.  Mainlining HIV -- that is, direct exposure of infected blood into another person's bloodstream (or an infected organ transplant) -- is the only highly efficient transmission mechanism.  Even childbirth is less risky; most babies born to infected mothers don't catch the virus.  Even though it seems to the nonprofesional that other potential blood exposures might also be efficient transmission mechanisms, they are not.  It is rare that someone is infected because a cut, an inflamed skin lesion, or an oral sore is exposed during sex.

By far the highest risk sexual exposure is anal sex.  If the insertive partner (the "top" in gay parlance) has HIV, the risk for the receptive partner ("bottom") averages 1%, i.e. one transmission per 100 events.  The risk has been estimated at 1 in 200 in the opposite direction, i.e. the risk for the anal top if bottom has HIV.  Transmission by vaginal intercourse is estimated as being 10 times lower, i.e. 1 in 1,000 to 2,000 events.

Therefore, even in the highest risk encounters -- when one partner is known to have HIV (and is not on treatment for it) -- most exposed people dodge the bullet.

Can other things increase those risks? Absolutely yes.  Those risks are higher when a partner is uncircumsized, when either partner has another STD (especially herpes), or when there are cuts or other skin defects in either partner.  But those factors typically only double the risk.  "Double" sounds big, but it is not:  doubling a risk of, say, 1 in 1,000 still means that for every 500 events, only one transmission will occur.

Finally, one more point.  Some questioners on this forum assume that if an escort or other apparent high risk partner insists that clients use condoms, it means s/he is infected.  The opposite probably is true most of the time:  insisting on condoms more often means s/he is uninfected and is trying to stay that way.  Statistically, commercial sex workers are at higher risk of HIV from their clients than their customers are from them.

OK, lecture over.  As you should now understand, your risk was zero for all practical purposes.  First, most likely your partner didn't have HIV. (Of course you asked, didn't you?  Yes, people can lie, but most don't.)  Second, your anal sex was condom protected; there is no reason to suppose that not being fully erect increases the risk; and if it does, the effect is minor.  Third, even if you had a penile cut at the time, and if it came into direct contact with infected secretions, the chance of transmission would have been very low.

Now, finally, to your specific questions:

1) Even "assuming she was HIV positive", the chance of transmission due to the cut probably was on the order of 1 in 1,000.  But she probably didn't have it, so your risk was a lot lower than that.

2) I am not aware of HIV data for transsexual escorts.  About 5-10% of gay men are infected; that might be the closest estimate available.

3) PEP is recommended only for much higher risk exposure than you describe.  If you had had unprotected anal sex, yes; or if you had shared injection equipment; and so on. But with an exposure like yours, the chance of a serious side effect of the HIV drugs is higher than the chance you caught HIV.  (Anyway, 5 days is much too late.  PEP has no benefit unless started within 72 hours of exposure, preferably 24 hours.)

4) See above.  In effect, the "lecture" was intended to provide the reassurance you seek.

Bottom line (no pun intended):  The risk wasn't even high enough for you to have an HIV test, but you certainly could do that if you want still more reassurance. All persons who are sexually active outside mutually monogamous relationships ought to have routine HIV testing from time to time, like once a year.  If you haven't been tested recently, this is a good time, since it's on your mind. But not because of this particular event.

Best wishes--  HHH, MD
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Just one question, if the risk of catching HIV is about 1 in 1000 and the risk of catching Herpes (HSV2) is about the same (if i have read correctly in past questions/answers), then why is HIV not affecting 25%  of the population here like genital Herpes does?
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