singapore csw

[sillyjimmy]

Hi Dr, I am a 28 year old uncircumcised male from Australia. Around four days ago I had unprotected vaginal sex with a CSW (met in bar) in Singapore. She was from north vietnam and probably in her early twenties. Initially she insisted on condoms (worried about getting pregnant) but we ran out and the last session of sex we had was unprotected (probably lasted 15-20 minutes). It was vigorous but she was well lubricated naturally throughout. Washed penis gently with soap water after. We also performed unprotected oral on each other. I didn't notice any sores on her and I tested clear prior to this incident for all STD's including herpes. I was drunk when the incident happened. Since then i am extremely anxious that I've caught HIV or other STD's. What are my odds for having caught HIV? I have read that HIV prevalence is very high in vietnamese CSW (Saigon - 70%?) and it is possible that she was operating in Singapore unlicensed (no testing). Due to language barrier I couldn't determine if she had tested clean for STD's or if she was licensed to be doing sex work there. I am aware of 1/1000 for uncircumcised male being avarage risk factor for hiv transmission but please inform me - presuming she was HIV, high viral load, other STD's what is the maximum risk for a healthy non STD young hetero uncircumcised male (non drug user)? On day 4 I have no symptoms other than slightly pink/irritated meatus (i've had this before/probably too much alcohol or bad diet). All other symptoms - lack of appetite, aches etc are hopefully related to my extreme anxiety. I did call our local PEP hotline yesterday but they suggested not to - risk is low (based on vaginal statistics and Singapore/Vietnam HIV stats) and said I could pursue a second opinion if i liked or get PEP at hospital. I am now outside of 72hrs but am scared I've made a big mistake by not pursuing PEP. Any information you can provide to help get me through the next 4-6 weeks would be greatly appreciated.
SillyJimmy

[Edward W Hook, MD]

Welcome to the Forum.  Based on your descriptions, I would not have recommended PEP for you either.  

Before I address your specific questions, I don't know if I should congratulate you or your sex partner for your reliance of condoms but I hope that next time you'll be sure there are more of them available when you are feeling frisky.  

The risk of HIV and other STDs is rather low. Your estimate that up to 70% of Vietnamese CSWs have HIV is almost certainly too high.  While I do not know the specific rate for Vietnamese CSWs, most CSWs do not have HIV or, for that matter, other STDs as well..  As an uncircumcised man, even if your partner had other STDs, your risk for infection would, on average be less than 1 in 1000, IF she were infected and odds are that that is not the case.  I should add that there is virtually no meaningful risk of HIV from your receipt or giving unprotected oral sex, even if she was infected as well.

My advice would be to get tested for the common STDs, gonorrhea, NGU and chlamydia at any time that is convenient for you.  As for HIV tests, it is too early and I would suggest that you wait until about 4 weeks after you exposure. Testing at that time will provide reliable results.  In the meantime however, please don’t worry- your risk of HIV or, for that matter, any other STD is low.  EWH

[sillyjimmy]

Tested negative via DUO at 27-28 days.

[Edward W Hook, MD]

This wil be my last reply to this anxiety driven series of "what if" questions.  My response regarding your small increase in risk, in the unlikely circumstance that your partner had HIV was based on the findings of multiple research studies.  The basis of this increase is the subject of conjecture and there are multiple hypotheses as to the reason.  And no, I will not go into those hypotheses.

As for ARS, you are, once again being silly.  First, you do not know you had thrush- in fact, white tongue coating of the sort you describe is not thrush.  Further, thrush is NOT a manifestation of ARS.  Further your temperature is not significantly increased and the combination of a mild sore throat and the temperature you report does not constitute ARS.

This thread will now end.  Any further questions will be deleted without comment.  EWH

[sillyjimmy]

Thank you Doc. I know you guys are constantly receiving anxiety ridden questions of little value but i have two more just to clarify the above. Is the relatively low increase in risk due to the fact that prior to the incident I was clear of chlamydia so possessed more intact mucus membranes during the vaginal sex? The slight increase thereby being due to her potentially having a higher viral load - more potentially infected hiv cells in her vaginal fluid fighting her chlamydia? Again, sorry for all the questions but I'm really struggling. My Dr here simply stated I was definitely at risk and need to test at 6 weeks (not much info to keep me sane in the meantime). Finally I mentioned ARS in my prior post (I know symptoms are not a reliable way to determine infection) but I've read majority of people experience bad sore throat, rash and high fever (triad). Doc also visually diagnosed an increase of thrush in my mouth but didn't describe it as an infection but a 'coating' (tongue only). She gave me fungilin for that. Does my mild sore throat and slightly elevated temp today of 37.2 degrees celcius seem suspicious? for the last week I've been around 36.5 consistently so maybe the slight increase today is due to anxiety - i've literally just been told I've caught Chlamydia.

Rest assured that will be all from me save final test results posted in a week or so.

Best,

Jimmy

[Edward W Hook, MD]

Your doctor is a wise man and you are over reacting.  The fact that you acquired chlamydial infection slightly increases your risk of HIV infection (which despite your unwarranted presumption) but not much.
Even if she had HIV, I would judge your risk for infection as less than 1 in 700-750.  

Just wait until you have your DUO test at 4 weeks and when it is negative, believe the result.  EWH

[sillyjimmy]

forgot to mention was diagnosed with chalmydia via urethra swab. Mild irritation of meatus etc but virtually asymptomatic - no discharge etc

[sillyjimmy]

Hi Doctor, update: I've been diagnosed with Chlamydia. I'm quite confident it is from the unprotected exposure with the csw in Singapore.

I am now really scared as I know chlaymdia increases both the transmission risk and and that of acquiring the virus. I am approaching 3 weeks now since the incident. Doctor, does this reality significantly alter the 1/1000 risk assessment you'd provided? Also, if I was to test now how reliable would it be? Can't eat, sleep etc; extreme anxiety. I've had a very mild sore throat but no rash (i'm aware of) and have been taking my temperature almost daily - it's normal. If ARS occurs would it typically have started approaching week 3? Please use this additional info to provide me some advise on testing and also to potentially provide me updated risks. If the chance is still slim (presuming she had HIV) I should be able to hold out till next week for a 4 week duo test. My Dr is telling me to wait 6 weeks since I have a baseline (clear) in December of last year (for hiv and all std).

[Edward W Hook, MD]

This person's calculations are far too high.  No change in my assessment of advice.

No, we have never had a client on our Forums acquire HIV frollowing a single unprotected exposure under the circumstances you describe.  

I agree that it is time to draw this thread to a close although you may wish to post your results of testing (which I am confident will be negative) for the person who added his comments when they are available.  That is up to you.  EWH

[sillyjimmy]

Hi Doc, sorry to trouble you again but do you have any thoughts on the above member post? His calculated odds seem very high. Anxiety/paranoia is getting the better of me despite my faith in your advise and expertise. Final question - in your time as an expert have you or your colleagues ever come across a confirmed pos male infected after a single unprotected vaginal encounter w/ high risk woman (south east asia, csw, idu, etc.)? I will not post again and will be getting a duo test at 4 weeks. Thanks so much for your responses.

[Anthonyg70]

Sillyjimmy,

Holy crap, your post reads exactly my scenario except I am 42, married and 2 kids...  I know, really stupid and amazing how alcohol really does give you poor judgement abilities.

I was in Singapore last week and spent a night with a csw from vietnam.  Hell it was 4 days ago as well, probably same bar with different girl!

Like you, my OCD kicked in and I have spent the last 24hrs researching all I can on HIV risk.  I did the same research on Vietnamese infection rate, viral load, viral type, etc.

Here are some numbers I came across:
Up to 40% infection rate for Vietnamese csw's
An infection risk rate of 1/263 for low-income/education areas

I assume the low 1/263 might account for a higher viral load due to lack of treatment.

With that said, my self calculation is 1in2 chance she was HIV positive and then a 1in263 risk, puts it at 1/526 or .17%

If you go with the 70%, then it would be a 3in4, using same 1in263 risk puts it at 1in350 or .28%

All these numbers does not make a difference in my mind.  I did something stupid and a risk of greater than 0 might as well be 99%.

I was not aware of PEP until it was already too late, so like you, I am kicking myself in the *** wishing I would have taken it more seriously immediately after.

I was thinking of HIV RNA at 12 days and then antibodies at 4weeks, but not sure it is even worth it at this point other than peace of mind, but even negative RNA test would still have me worried until the 4week test.

Good luck to you.   If you don't mind post your progress here.


To the DR., your confidence and assurances are helpful

[Edward W Hook, MD]

I considered the issue of other HIV types, including sub-type E in my original comments.

Not everyone who gets HIV develops the ARS just as not everyone who gets other STDs are symptomatic.  Nonetheless, the absence of symptoms is always a good thing.

My advice again is to not worry and to stay off the internet.  eWH

[sillyjimmy]

Thanks Dr Hook. So the 1/1000 takes into account factors like viral load, her having std etc? Two final questions. Leading up to my post on this forum I'd been anxiously scouring the net and uncovered some information suggesting subtype E (common in Thailand but also very similar to predominant Vietnamese strain) is far easier to catch via unprotected vaginal and oral also. Presuming she was infected with E, would this modify your original risk assessment significantly? Also, re ARS symptoms if they were to occur when would that be and if they do not, is that a good sign I am ok? I will be going for a test at 4 weeks precisely since I am so worried.