worried about high risk exposure

Dr. Hadsfield,

I am really worried about a recent exposure.  Last week I was in Seattle for a multiday trip w/ friends. You have a beautiful city and I hihgly regret that the story I am about to tell has been occupying my thoughts since leaving. A group of us went to one of your better known strip clubs.  I met a dancer there and ended up exchanging numbers.  A day later we ended up meeting up after a night of drinking. This wasn't for money, and my efforts to clarify that fact nearly ended the whole event as she claimed she doesn't do that and didn't want to be w/ anyone who did.  We had condom protected vaginal sex(she provided the condom), but the condom unfortnately broke towards the end of the act.  We stopped as soon as we noticed, which couldn't have been very long afterwards(maybe 20 or 30 seconds) as we had just switched positions and the condom was still intact.  Here's what I know;

-she was a 19 yr. old white female who was realtively new to stripping
-non IV drug user
-it's been roughly a week and I have been symptom free, outside of tremendous stress
-claimed she was clean and seemed as worried as I was about the condom breaking.  neither of us were willing to proceed w/out one.
-there was other minor making out, during which she briefly gave me oral
-the lack of alchol and numerous cameras in your clubs lead me to thinking there isn't alot of sex for money going on

My questions are;
-what testing pattern would you reccommend?
-is this as high risk as i think it is?
-is this the stage where I would be highly infectious and should avoid contact w/ a long-term girlfriend?
-what is the HIV rate in Seattle?  Is it common amongst your CSWs?

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Thanks for your question and for your kind comments about Seattle.  We agree it's a great city!

For people in your situation, one of the things that makes Seattle great is that heterosexually transmitted HIV remains rare; and in the past 25 years in the public health STD clinic, I doubt we have ever diagnosed HIV in a 19 year old white woman who wasn't an injection drug user, immigrant from an HIV endemic country, etc.  In other words, the odds your partner had HIV are very nearly zero.  It was smart for you to use a condom, but in this case its failure doesn't mean especially high risk for HIV.  Even when a woman has HIV, the average transmission risk for a single episode of unprotected vaginal sex is around 1 in 2,000 -- i.e. it might take hundreds of exposures over several years before you might have a significant risk of catching it.  And oral sex is essentially zero risk for HIV.

In other words, the combination of your partner's background, use of a condom for most of the duration of sex with her, and the low odds of transmission is she is HIV positive, it is almost impossible you caught HIV.  Therefore, from a strict risk assessment standpoing, testing for HIV is optional.  Of course, you may still want to do it for the additional reassurance you will gain from the negative result.  If so, you could have a single duo/combo test (for both HIV antibody and p24 antigen) at 4 weeks, which would be 100% reliable; or a stand-alone antibody test 6 weeks after the exposure.

However, you are at somewhat higher risk of other STDs, notably chlamydia (especially with a 19 year old partner); plus lower risks for gonorrhea and syphilis.  I recommend you have a urine gonorrhea/chlamydia test, which is accurate any time more than 3-4 days after exposure; and a syphilis blood test when you have the HIV test.  As for sex with your regular partner in the meantime, probably it would be safe -- but of course I can't guarantee that.  If I were in your situation, I would be comfortable having unprotected sex with my wife once gonorrhea/chlamydia testing was known to be negative; I wouldn't be at all worried about giving her HIV or syphilis.

I think those comments answer all your questions.  Best regards--  HHH, MD

[reallyworried11]

this is very helpful.  I appreciate it.