Concern of potential HIV transmission + risk evaluation

[Worried307]

Hi, i'm a male and i recently had intercourse with a female sex worker which i deeply regret. This happenned in the beginning of May (2009). I am very concerned about STD transmission, in particular HIV. Here is what i know from what SHE told me:

- She is "clean", as in desease free and gets tested for all diseases apparently every 3 months, including hiv. Last time 1 month ago = no diseases.
- Been doing this job for the last 5 months, and she is very clean, if she sees "anything wierd", she refuses any sort of intercourse.
- She's a smoker (cigarettes) and she smoked at the time we were together. Acted normally, dont think she's doing any drugs.
- Told me she doesnt have any bruises or cuts in her mouth, and her gums as fine. I personally didnt see any blood anywhere or puss dripping.
- She used another form of protection for herself which she inserted before i came, im not sure if it was a diaphragm, or a cervical cap, with spermicide she said.

Info about me: no drugs or medication, no other risky contacts of any sort ever before this, no health problems.

Ok, now, there was 2 types of contact:

1) Vaginal = WITH a condom + lubricant (Lifestyles brand, not expired, package opened with fingers, not teeth) for approximately 1 minute. the condom did not rip, i looked at it after. ( Are micro-rips possible? )

2) Oral ("*******", so oral "her to me" ONLY) two times for about 1 minute each time = NO condom.

I'm very concerned and i scheduled for a RAPID test in 8 weeks. Some websites say that after 8 weeks post possible exposure the test is only 97% accurate VS 99% of accuracy after 12 weeks. Should i take the test again if its negative from your professinal opinion? if so, when?

Its been about a week already: no weird symptoms, but anxiety +++ (a bit of liquid bowels but im sure that its caused by that)

In your professional opinion, what is my risk? Should i be really really concerned?  

Thank you so much for your help and your time doctor.

[Edward W Hook, MD]

My sense is that your concern is far greater than your risk.  Let's talk about factors which determine your risk of infection.  For starters, the chances that you partner has HIV is very small.  While CSWs are more likely than the average woman to have HIV, the risk remain low, particularly if she does not use drugs.  Second you used a condom for the higher risk exposure (genital sex).  Condoms work and if they fail, the break wide open, not just leak a little.  If your condom looked intact after use, it was.  As a result, with a condom, if your partner was infected your risk of infection goes from 1 in 1000 exposures to less than 1 in a million.  As for the oral sex, the quoted figure for HIV risk, if one has oral sex with an infected partner is less than 1 in 10,000 and, in my estimation that is too high. Some experts state there is no risk at all from oral sex.  Neither of us on this site have ever seen or reading the medical literature of a convincing instance in which HIV was passed by oral sex.  Bottom line, your risk from this exposure was very, very low.

No reason not to get tested however, particularly if it will give you peace of mind.  The sensitivity of rapid tests for HIV detection, when you consider multiple studies is in the same range as other tests and has at least a 99% sensitivity at 8 weeks.  But remember, that is a 99% chance of detected an event which has only a 1 in 10,000 chance of occurring, at most. Further testing will add virtually nothing to your 8 week result.  Thus, my advice is to not worry and one you have your negative test at 8 weeks, forget about your concerns and move on. I am confident that you did not get HIV at this time and anticipate that your testing will only confirm this.

Hope this helps.  EWH

[Worried307]

Thank you for your comments, Doctor. They were very helpful to me. To complete my previous post, I just had a few other questions:

1) As the status of the person i was with is unknown to me ( i cannot verify from simply what she told me ), should i ask to be tested for other STD's as well? (i'm particularly thinking of herpes + syphillis). I'm asymptomatic 7 days after the event but i heard that herpes is 30% unsymptomatic and syphillis can appear within 90 days of possible exposure to it. A family doctor i saw asked me " was any puss leaking from her mouth when she was performing the oral on you?" . I said not that i saw (i was watching her), and then he said, then nothing to worry about. I was wondering if you can verify that, how much visible puss are we really talking about medically speaking?  

2) Also, I heard of HIV-1 and HIV-2 detection...im not sure what all this means and i was wondering if this rapid test at the STD clinic is enough (as a one and only test) to detect everything that encompasses the HIV infection?

3) My appointment is actually in 7 weeks currently, i made a mistake in my previous post, sorry. Should i re-schedule to 8 weeks exactly?

4) Basically based on your reply to me, once i test negative in 8 weeks from now, then, i can have safe sex with another partner of known STD free status (or even uprotected genital sex) without worry of transmitting anything to them. Am i right?

Thank you again for your time.

[Worried307]

Oh, and one final clarification that i forgot to add to my last comment (last one promise).

If she were a drug user, this does not change my risk of contracting potential HIV as i used a condom, right? (In other words, the risk of getting HIV from a drug user CSW while using a condom in vaginal intercourse = risk of getting HIV from a NON drug user while using a condom in vaginal intercourse - both of the females being HIV positive).

So, if she would be a drug user, this would only increase the risk of her actually being HIV positive. correct?

Thank you again.

[Edward W Hook, MD]

Sigh

1.  Condoms protect against STDs too. You are not at risk from condom protected genital sex.  Similarly, oral sex is an inefficient way to transmit STDs.  Of the bacterial STDs only gonorrhea and nongonococcal urethritis (NGU) are transmitted through oral sex; chlamydia is not and without an obvious sore or lesion on your partner’s mouth, the chances of syphilis and herpes is likewise tiny.   If you do not develop herpes symptoms in 4-10 days after your exposure, you do not have herpes.  If you had gotten gonorrhea or NGU you would have most likely developed symptoms of urethritis (penile infection).  Even if your partner had an STD (any STD and it is likely she did not), most exposures do not lead to infection.  If you wish, you could go to your local STD clinic or health care provider to be tested at this time.  I do not feel strongly about this and predict that the tests will be negative.
2.  The Rapid test will be sufficient.
3.  You are splitting hairs.  Seven weeks will be fine.
4.  I feel as though you could probably have sex with other partners today.  Certainly you can do this after 7 weeks.
5.  Read my original answer.  The risk figures I gave were if you were for the situation in which your partner had HIV.  Thus "what if" questions about being a drug user have nothing to do with them.

No further questions.  EWH

[Worried307]

I respected the rules of the forum and i waited to re-post until after i had my test done. this is follow-up. Its been exactly 8 weeks since my last exposure. Its negative. thank you for everything doctor and the reassurance you provided. I have to say though, that my meeting with the nurse practitioner at the std clinic left me with a couple of questions that i hope you can shed light on:

1) The test done was MEDMIRA (he said it was 4th generation...but i googled it and cant seem to find an answer to this). He told me its 99.6% accurate unlike older tests and i certainly dont need further testing. Are you familiar with this MEDMIRA test and do you agree with him?

2) He took blood samples to test me for chlamydia, gonorrhea, herpes + syphilis. Isnt it too early to test for syphilis and herpes at 8 weeks? Should i re-test at 12 weeks for these? (In other words, would a 12 week negative herpes test assure me 100%  i dont have it either? I read in archives that herpes blood tests arent too reliable before 3 to 4 months)

3) I know you said the risk of catching herpes and syphilis is tiny from my exposure. He told me the same thing, but he said that i can easily transmit syphilis (IF i have it) through kissing someone. I'm concerned for my current partner now...as i've been kissing her quite a bit lately. Is there any truth to that? Could i transmit herpes 1 or 2 this if i had it?

Thank you again for your time.

[Edward W Hook, MD]

Brief answers:

1.  i am not familiar with the test you mention.  there are many tests available however, too many to track. If the test is FDA approved, you can have complete confidence in the result.

2.  I'm surprised to hear that you had blood tests for gonorrhea and chlamydia.  they are not typically reliable.  Are you sure it wasn't a urine test?  8 week tests for syphilis ( a very rare disease) should be reliable at this time.  For the herpes blood tests, the 12 week test will detect 15-20% more infections than an 8 week test.

3.  Syphilis and herpes are both transmitted by direct contact with an infected area. If you had genital tract infection, there is no risk to you of transmitting infection to a partner by kissing.  EWH

[Worried307]

Indeed, you are right, it was a urine test for chlamydia and gonorrhea (my mistake). I decided i'll redo the tests at 12 weeks to get a more certain result for herpes. considering i didnt have symptoms up to now and if i end up with a negative result at 12 weeks (i hope), then i guess i dont need to do any more tests. Please correct me if i'm wrong (i just dont want to infect my partner with anything...). thank you.

[Edward W Hook, MD]

You are correct. I'm confident you did not get STD from the exposure you describe.  EWH

[Worried307]

Doctor, my last concern is HPV infection as it is known to be the most commonly transmitted STD. I scanned through numerous threads in the forum, and i read that often in men its asymptomatic...and months may go by up to years before getting any symptoms (i.e warts). What do you think are my chances of having HPV after this 1 time exposure - protected vaginal/unprotected oral? And if somehow i transmit it to my partner, what are the risks of oncologic complications for her?

Do you believe its absolutely necessary to tell her that i may have it and tell her to get vaccinated with Gardasil before any further sexual contact?

I will not post again until my final test results in august.

[Edward W Hook, MD]

Your questions were about HIV risk.  I answered them.  Further questions should start as new threads, realizing that you should not post more than 2 questions to our Forums over any 6 motnh periods.  

Your risk of HPV is low.  All women can potentially benefit from receipt of the HPV vaccine.  This thread is no over.  There will be no more answers.  EWH