Bite...

Dear Doctor

Yesterday a Sex Worker performed me unprotected Oral Sex (No vaginal sex). I performed her unprotected oral sex (cunnilingus). But she bite my penis and it was bleeding. She didn´t notice it, until she performed oral sex newly and saw the blood. She performed me three more times oral sex with my bleeding penis (because she thought that the blood was not present anymore)

Am I in a high risk level for HIV?? And should I be tested?

Thanks.

[H. Hunter Handsfield, M.D.]

The fresh bite wound probalby increased the risk of HIV transmission, if your partner was infected.  However, the risk still was very low.  Even when someone has HIV, typically there is little or no infectious virus in saliva, and oral exposure in general is very low risk for HIV.  You don't say where you are, but in the US and most industrialized countries, typically under 1% of commercial sex workers (usually under 0.1%, i.e. 1 in 1,000) have HIV, although it is much higher in some settings, such as sub-Saharan Africa.  However, the frequency of HIV in such women can vary widely.

You certainly should be tested for HIV after this sort of exposure.  Also, depending on local HIV epidemiology (i.e., the local likelihood your partner has HV), it is possible that even with the relatively low risk you describe, local experts would recommend post-exposure prophylaxis (PEP), i.e. anti-retroviral therapy to further reduce the chance of transmission.  For PEP to be effective, it needs to be started as soon as possible, preferably within 24 hours of exposure and definitely within 72 hours.  Therefore, I recommend that you immediately contact your local health department or a hospital emergency department, to get direct advice about PEP.

Most likely they will reassure you and simply suggest you have an HIV test in a few weeks.  In most areas of the US, you would not qualify for PEP.  But that could vary from place to place, depending on what is known about the frequency of HIV in CSWs in that area.

Best wishes--  HHH, MD

[tsukuyomi]

Hi, I am living in Colombia. The percentage of HIV are aprox. 1% for non-street sexworkers. If I decide don't take PEP, how much increase the odds for acquiring HIV?? Is it very high??

[tsukuyomi]

And is my risk very high?

Thank you very much.

[H. Hunter Handsfield, M.D.]

There are no data on which to calculate a precise risk.  As a guess, no higher than 1 chance in 1,000, if your partner had HIV.  If the 1% risk that you cite for CSWs in Colombia is correct, the chance you were infected would be somewhere around 0.01 x 0.001 = 0.00001, or 1 in 100,000.  PEP probably reduces the risk of infection by 80-90%, but that number declines rapidly from a few hours to 72 hours after exposure, i.e. probably no benefit after 3 days.

Don't try to decide yourself.  I repeat my advice that you see a local health care provider and follow that person's advice.  A clinic or emergency department in your area of Columbia probably will have a more accurate assessment than me.

[tsukuyomi]

Yesterday, I went to Doctor. He said me, "your risk is very low because the HIV virus don't survive in saliva, and the prostitute could be negative, because the majority are negative. PEP in Colombia is only available for occupational exposures". "And said me got tested 3 months and 6 months". Is my doctor wrong?? Should I be tested only at 6 months or should I be tested 3 and 6 months??

[tsukuyomi]

And today I spoke with the Sex Worker and she will be tested the next week.

[H. Hunter Handsfield, M.D.]

I'm glad you sought health care directly. The Colombian doctor and I obviously agree with each other about PEP, but he is being super conservative to recommend a 6 month HIV test; most experts would stop testing after a negative result at 3 months.  It's also a good move to ask the sex worker to be tested.  If her test is negative, you won't need further HIV testing at all.  But even if she does, your risk of infection remains very low.

[tsukuyomi]

Thanks doctor. Your advice was very good!!!! I am more quiet and less anxious ...

[inthecorneralone]

Hi I am a bit confused over here , if the exposure was low to begin with why all that PEP story at the beginning , and if the person giving oral is infected odds of getting infected is 1 chance in 1000, that is lower even for  unprotected vaginal intercourse. Why sudden change in your opinion about this type of oral exposure. Thank you  in advance

[H. Hunter Handsfield, M.D.]

I knew somebody would interpret this thread that way.  But nothing has changed.  A wound/injury during sex is different than a preexisting minor cut etc, and to my memory there has never been a previous question on this forum about an injury during sex with a potentially infected partner.  And with I was very careful not to recommend PEP, only raise it as a possibility, based on local epidemiology of HIV.  As you saw in the follow-up comments, the doctor there agreed with me that PEP wasn't necessary in this circumstance.  I just didn't know enough about HIV in Colombian sex workers to be certain about it.