POSSIBLE HIV/STD Exposure Bali

[moto77755]

I've seen many answers to this TYPE of question. One (physician) said, "if you changed the condom immediately there is very little risk of ANY STD, let alone HIV." Many other posts around the net said, "same as unprotected sex." However the physician (and your previous answers) were directed toward sex with low risk prostitutes.

A few days ago, I got too intoxicated and had sex with a prostitute in Bali, Indonesia. The condom broke; I felt it. I stopped INSTANTLY (maybe 1 second) changed condoms and finished in about 10 minutes. (I was scared to death, but I finished mainly because I once heard that ejaculation or passing urine lowers risk.) In actuality I should have stopped and cleaned up immediately, but as I said, I had too much to drink.

I read today that the HIV infection rate in Bali is very high, especially in prostitutes. I think last year's data says  15%, if I recall accurately.

This is only the third time in my life I've had sex with someone whom I didn't know their HIV status, (literally the THIRD time, not just the third person) and I used a condom in each of the three instances. But I've heard that health workers have gotten HIV from a single needle stick.

Things in my favor:
- She asked for a condom, so she must use them at least typically.
- I'm circumcised.
- I stopped within about a second and changed the condom which took maybe 10-15 seconds.
- I examined my genitalia and found no visible breaks in the skin.
- Cleaned up 10 mins later with alcohol.
- She didn't have much in the way of vaginal secretions that I could notice. Just some kind of lubricant I think.

Things against:
-HIGH HIV rate in sex workers here

What is my risk? Would the virus stay alive under the new condom?

This is very important to me because I had a rift with my long time girlfriend last month, but we talked today (NOT about this issue) and want to work things out. (She uses oral contraceptives, so if I wanted to use a condom, I would have to explain why...)

[H. Hunter Handsfield, M.D.]

What you were told by other doctors, and the responses on the HIV community forum, were correct.  You had condom-protected sex, which means no risk for HIV for all practical purposes, even if your commercial partner was infected.  I can't comment on your statement about 15% of sex workers in Bali having HIV, but my guess is that's an exaggeration -- but even at 15%, the odds obviously are in your favor.

Looking down at your comments below, seeking and taking anti-HIV drugs in this situation is a gross overreaction.  You do not meet any rational criteria for post-exposure prophylaxis (PEP) and I suggest you not take the drugs, especially if you are doing so without medical supervision, which apparently is the case.  Among other things, if you take PEP, it might delay the time until you can have definitive HIV testing, so you'll just prolong your anxiety about it unnecessarily.

At this point, my only advice is that you see a competent health professional and follow his or her advice about all this.  But you really have no serious HIV worries here.

Regards--  HHH, MD

[moto77755]

I wasn't clear, sorry... I am obviously most worried about HIV, but need to know about other STDs as well. Antiboiotics are OTC here and I was considering ciprofloxacin (Cipro)  to prevent /cure Gonorrhea as well. It seems to be a single dose drug.

[moto77755]

Well as a follow up, I was able to obtain lamivudine/zidovudine 150/300mg here--after great effort and expense.

I was told that there are no interaction problems with ciprofloxacin (or any other antibiotics). Was also told that overall reduction in patients with KNOWN HIV exposure is nearly 80% that they have had 100% success locally in about a dozen cases.

How rigid is the 12 hour dosing schedule? I was told that it was too late in the day to begin a course because 12 hours from now would be 3AM and I would not be able to continue with that schedule.

[H. Hunter Handsfield, M.D.]

I meant to say above that I will not comment on proper use of treatment that I do not recommend and believe to be wrong.

[moto77755]

I understand your unwillingness to comment on medication and I withdraw that question.

Thank you very much for your other comments. I do have some followup:

1. Yes, I used a condom, but it broke... (though I changed it immediately) which is the reason for my concern. In case you didn't notice the breakage, does that change your answer at all?

2. Do you believe that I even need to be tested in this case? (Actually, after multiplying all of the odds, I'm not as worried now as I once was and believe my odds are much better than I originally anticipated.)

3. When you say "treatment that I do not recommend", do you mean in this case, or do you mean that you never recommend PEP in any case? I won't ask for a comment on my specific situation, but if you mean that you *never* recommend PEP, could you comment briefly on why not?

Further research on Bali seems to indicate that the 15% figure includes the locals' brothels, in which condom use is--apparently--rare, and the women see 5-10+ clients per night. I'm fairly sure tourists don't even know where these are and wouldn't use them if they did. No comment is requested here. I'm posting this info in case someone else runs across this thread.  I don't want to spread misleading information.

[H. Hunter Handsfield, M.D.]

To be honest, in my reply above I missed the fact that the condom broke.  Certainly testing is reasonable in this circumstance.  Recommendations for PEP vary from one location to another.  If the HIV prevalence in CSWs in that area really is as high as 15%, local guidelines might call for PEP.  In any and all places, PEP should be administered and supervised by a knowledgeable health care provider; the proper use of the drugs, monitoring for side effects, and a recommended testing schedule are too complex for self-determination, or for management by a distant online forum like this one or any other.

[moto77755]

I got the PEP from the local international hospital in order to get started right away.

Wow... your comment has me frightened again. I've noticed that most of your comments are not this conservative. Can you comment on the 1 second exposure during the breakage? I'm sure it was no longer than that. Like I said, I stopped IMMEDIATELY.

What kind of odds do I have?

Could I transmit it to someone else at this point?

[moto77755]

This is what scares me the most and why I wonder about those 1:1000 type numbers. The North American studies are likely from people with controlled HIV. The other studies are not. There seems to be a big difference between the two. It looks like much depends on whether the HIV+ person KNOWS that they are HIV+ and whether they are being treated or not.

"Studies in Thailand and Africa7,9 report high estimated rates of transmission per act of intercourse among men exposed to infected prostitutes. Mastro et al.9 estimated a probability of 0.03 to 0.05, arguing that this was an order of magnitude higher than estimated rates per sexual act in European and American studies of partners. The authors suggested that the purported differences were due to biologic differences between countries. The flaw in this argument is that the two types of study use different methods, and therefore their results cannot be directly compared. The Thai study examined men who had multiple acts of intercourse with many HIV-infected women. Studies that examine multiple acts of intercourse with different HIV-infected women cannot be compared with studies examining multiple acts of intercourse with the same infected woman, such as partner studies. In the first type of study, individual acts of sexual intercourse can be considered independent of one another, since each carries a similar average probability of HIV infection. In the second, this assumption cannot be made, because of evidence that the level of infectivity varies among people, so that, for example, multiple acts of intercourse with a person who has a low level of infectivity are unlikely to result in infection."

http://content.nejm.org/cgi/content/full/331/6/391

[H. Hunter Handsfield, M.D.]

The odds remain strongly in your favor, despite your fears and even if you didn't take PEP.  Otherwise, I have no further opinion or advice.  You are in a realm where you need professional advice in person, not from a distant online source.  Therefore, I will not have any further comments.