High ore moderate risk?

Dear Doctor,
could you please evaluate whether the following situation was risky: I had one vaginal intercourse with a woman whose HIV status was unknown to me and was very likely to be positive. She insisted on a condom, which was good, but she had a fresh cut on her finger and she also insisted on her putting the condom on my penis, so there was a contact between her fingers and my penis for some time. The day before the contact I had small sores on the head of my penis that remained throughout that day and became nearly invisible at the day of the contact, the sores about which I am certain of being non STD nature as all my STD tests, including HIV test, have been negative right before the contact (I also abstained from sexual contacts for more than 3 months before that one). The intercourse itself lasted for about ten minutes and I suspect that most of the time it was without the condom that must have slipped off the penis at the beginning. Once I have discovered this, we have finished the intercourse. Do you believe this was a high risk for an HIV transmission and what is the shorthest period of time after which it makes sense to get tested?  May be I should add that I am not circumcised. All this happened three days ago. Best wishes, Al.

[H. Hunter Handsfield, M.D.]

Welcome to the HIV forum.  I'll try to help.

First, I do not necessarily accept your judgment that your partmer was "very likely to be positive".  Maybe so, but probably not if you are in the US or other industrialized country, where heterosexual HIV transmission remains rare in most population groups.

Second, when a woman such as a commercial sex worker insists on condom use, it does not indicate a high likelihood she has HIV.  Just the opposite.  More likely your partner knows she is not infected and intends to stay that way.

Those factors all are in your favor.  As for factors that increase the risk, of course having unprotected sex -- assuming the condom slipped off early during exposure -- is the most important.  Being uncircumcised would have raised the risk if your partner had HIV.  Similarly, penile sores could do the same thing.  However, for both the lack of circumcision and the penile sores, the influence on HIV risk is rather small compared with the favorable factors discussed above.

I'm concerned about your penile lesions.  Herpes comes to mind.  Or maybe you just had a yeast infection or minor inflammation under the foresckin (balanitis).  If such sores have appeared in the past, you should get them checked out next time they appear, mostly to check out the herpes possibility.

As suggested above, you omitted the most important information in assessing HIV risk; I would need to know more about your partner, where the exposure took place, etc.  But even if you assume the worst -- that your partner had HIV and that your penile lesions are due to herpes -- the chance you caught HIV is in the range of 1 in several hundred.  Your risk of other STDs (chlamydia, gonorrhea, etc) is a lot higher than for HIV.

Even if your partner was at low risk for HIV, you probably should be tested for it.  Anyone nervous enough to seek advice on a forum like this generally should be tested for peace of mind.  A single HIV antibody test at 6-8 weeks is all you need.  When you do it, get tested for standard STDs as well, i.e. gonorrhea, chlamydia, and syphilis.

Good luck--  HHH, MD

[Al99]

Dear Dr. Handsfield,

thank you very much for your reply. You are absolutely right, my lack of trust about my partner had to have some reasons. This particular episode has happened in Russia that is reported to have a high growth of HIV infection. The partner was definitely not a professional sexworker. As she insisted on a condom she added that we were both likely to have STDs that we were unaware of, so this fact would be a good reason to have a condom. I don't deny some logic in these words, but there was an ambiguity about this too. This, and many scars on her arm (an attempt of suicide, I presume) created these suspicions of her being infected. Of course, I will be glad and relieved if these suspicions turn out to be groundless, but I don't count on hearing from my partner again.

What I was really worried about is the presence of blood and my penile problems.
What we could exclude is that my penile lesions are due to herpes -- more than 3 months ago I have tested negatively for Herpes Simplex virus of both types and have not had any sexual intercourses since then. Do you think herpes could manifest itself meanwhile? The tests were taken after two and a half months after the previous possible exposure and, like I said, there were no exposures afterwards (except that one that we are discussing). These lesions, however, occurred a few times over last three months and vanished within several days without any help from my part (once again, there was no sex whatsoever during this period) and the last time they appeared was a couple of days before the contact but they nearly disappeared the day I had the intercourse. Do you think having a yeast infection or balnitis instead of herpes reduces one's chances to get infected under the circumstances as above?

As for tests, as you may well see I am nervous enough to be tested, but I was also wondering whether it makes sense to get tested after some two weeks or even less after the exposure (having in mind a PCR test).

Thank you for your time. Best wishes, Al.

[H. Hunter Handsfield, M.D.]

I don't know the statistics about HIV frequency in non-CSW Russian women, but I'm sure well under 1% have HIV.  A woman who is a consistent condom user should have lower than average risk.  The blood exposure doesn't materially increase risk over that associated with genital secretions per se.  I agree that the blood test timing etc makes herpes unlikely.  Probably any genital inflammatory lesion enhances HIV risk, but not by much.

Let's estimate a 1% chance your partner had HIV.  Chance of transmission female-to-male per episode of unprotected vaginal sex averages around 1 in 2,000.  We might double that risk for your penile lesions and double it again for your being uncircumcised, making the per-exposure transmission risk around 1 in 500.  Thus, the chance you caught HIV probably is somewhere around 0.01 x 0.002 = 0.00002, or 1 chance in 50,000.  This is equivalent to an exposure of this sort once a day for 137 years and maybe never catching HIV.  It's also 3 times higher than your lifetime chance of being killed by lightning, if you live in the US (about 1 in 17,000).  And the 1 in 50K is on the high side, since 1% probably is an unrealistically high likelihood of HIV in your partner.

All thing considered, from a strict risk assessment/medical perspective, you don't need HIV testing at all.  You certainly don't need to spend the money on a PCR test.  But it's your money. If you can find a provider who will do it, feel free.

Do see a health care provider if/when your penile lesions reappear.

That will end this thread.  Really, don't lose a lot of sleep over this.  Whenever you are tested with whatever tests, you can expect negative results.

[Al99]

Thanks a lot for your reply. It really helped.
Best wishes, Al.