Risk from single contact

[robespierre]

Dear Doctor,
first I make exsuses myself if my english is no good, I’m italian.
I admire a lot the answers you give in this forum, that I have read with great interest, because of I had a “low risk exposure”: broken condom (in a very strange way, because after a brief insertive vaginal, less then 1 minute, with an escort, I have noticed that condom was non very adherent, and sperm was not in the upper part of it, even the penis was enterely covered; then, I filled it up with water, and appeared a little hole, about 5 cm from the upper size; now, I don’t know what has really happened, but I worry that the upper part of penis has worked out of condom, even if there wasn’t a obvious and noisy breach, like I often hear about condom breaking).
Okay, I know that you are against HIV test in these cases: “you apparently have seen my comments about 1 in 2000 being the average risk for female to male transmission through vaginal sex. And you also have seen my comments about the low overall HIV risk in non-drug using heterosexual men and women. But those are average figures. I have no way of knowing how well they apply to any particular case. But I would not have recommended HIV testing at all, if you don't have other risks” (9.11.2006).
But I have also read some affirmations that make me doubtful.
In fact, you always  talk of 1/2000 average, but you also said: “In my STD clinic, which has tested thousands of persons for HIV every year, we have never diagnosed HIV in a heterosexual male after a single episode of high risk vaginal sex. Not once” (9.4.2006)
This is an affirmation that would remove every doubt!
But you even say: “In my STD clinic, testing thousands of persons per year for 20 years, we have seen only 1 or 2 heterosexual men who acquired HIV by vaginal sex” (8.30.2006) (this second affirmation is lightly different by first: can you explain that? Maybe here you are talking about more than a single episode?).
Now, don’t you think that your personal experience imposes to modify those averages?
Where is the truth?
What must I think?
What does it means 1/2000 averages, and why you remember always that, if your personal experience for hetero acquiring HIV is very, very different and seems to conclude for a very less probability than 1/2000 (in certain cases, near to 0% probability)?
If we talk about averages, it means that, sooner or later, one person will take the virus, maybe the first time he have a contact, even low risk!
Is very different to say “non risk at those conditions (only one too brief contact, etc)”, or “one about 2.000” (that “one” could be me, and soon!).
At last, what do you think about may personal experience?
Here in Italy, all doctors in forums about HIV say: “you have a low risk, but the only way to know exactly is making test in 3 months”: it seems to me like saying: “you have low risk to have brain cancer, but the only way to know is to make a T.A.C.”.
What do you think: I need testing, or I “have a greater chance of harming you, like being hit by lightning” (9.28.2006)?
My doctor said: “to catch HIV with vaginal insertion, you need many long relationship with a HIV+ partner;  there are 0% average, you don’t need test”: is he wrong or right?
Thanks a lot.

[H. Hunter Handsfield, M.D.]

Your English is fine.  And your risk for HIV remains very low.

The estimated risks for vaginal sex (1 in 1000 male to female, 1 in 2000 female to male) are derived from analyzing the apparent routes of infection in AIDS cases reported in the United States, compared with estimates of the frequency of unprotected vaginal intercourse.  No single STD clinic, including my own, sees enough patients with HIV to make any statistically valid comparison between the clinic's own experience and the broader estimates.  In any case, those estimates are very rough; the actual risk may be very much higher (or very much lower) for any particular exposure, depending on things that typically people do not know:  whether or not the partner is infected at all, how recent the infection is, whether the infected person is on treatment, whether other STDs are present, and other factors.

Your doctor is exactly right:  Almost all heterosexually transmitted HIV infections in industrialized countries (N. America, Western Europe, Australia, etc) occur in the regular sex partners of infected persons--not in people with single, casual exposures.  I never recommend HIV testing for people with single exposures, except in particularly high risk situations, such as anal or vaginal sex with a partner known to be infected.  Persons with occasional unsafe sex are wiser to simply get tested periodically, such as once a year, and not worry about particular sexual exposures.

Finally, do not hold me (or any other expert) to identical expressions of risk, or numbers of patients seen with a particular condition, every time we respond to a similar question.  Nobody's memory is perfect.  I don't know whether my clinic has seen zero, 1, 2, or maybe even 5 cases of heterosexually acquired HIV over the years.  The point is that it is very rare; the exact numbers don't matter.

I hope this helps.  Best wishes--  HHH, MD

[o_g]

I had a similar case happen with me in Rome whereby the condom broke and the exposure would have been max to max not more than 30 seconds. I have been feeling sick ever since last 6 months. On a 12 week battery of tests including HIV, Hep-B and HSV-2, my HSV-2 test came out positive. I am not really sure about the concept of industrialized nations because even in US more than 25% people infected with HIV do not know if they have the infection. I have had each and every possible symptom and it scares the hell out of me knowing the possibility that herpes inreases risk of hiv transmission. For me, I can not term my exposure as a low risk also as most of the vaginal encounters are termed on this forum. So, I think, the concept of low and high risj are very relative to a aprticular case. Mine was low risk till 12th week when I discovered my HSV-2 IgG to be 1.310 on 1.0 scale. Its then when my low risk turned to high risk.

[robespierre]

Thank you very much, Doctor.
To quote the comment of o_g: here we are talking about HIV, not herpes, and i'm very happy to know that you didn't take HIV from that contact.

[o_g]

I was talking in reference to HIV only and singling out situations which increase the possibility of HIV infection as per what Doc has mentioned in his post --- "whether other STDs are present". I am touched that you feel happy for me but the ordeal ain't over yet.. :-(

[robespierre]

When I said i'm happy, I was talking seriously