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Dr Sean Cummings  
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London, United Kingdom

Specialties: STD/STI HIV prevention

Interests: Hepatitis C, Men's Health, HIV Prevention

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Reducing risk of sexually transmitted infections and HIV in male and female sex workers

Sep 29, 2010 - 12 comments

Use of male and female sex workers is common throughout the world. Sex workers may be referred to as prostitutes, commercial sex workers, lap dancers, escorts etc but trade of sexual activity for money, food or drugs is the common factor.

A common assumption is that because of the frequency and number of change of sexual partners with commercial sex workers that they will be more exposed to sexually transmitted diseases and HIV and thus more likely to acquire, carry and spread STD/STI’s and HIV. As a clinician working in a clinic where I see many people, male and female, who have used sex workers, the concept of risk is one that generally occurs after the sexual event.

There is good evidence that male and female sex workers and their clients may represent a significant source of new HIV and other sexually transmitted infections. Condoms are very, very effective in reducing spread of STD’s and HIV but often they are not used for penetrative vaginal and or anal sex.

Many STD’s/ STI’s are easily treatable using modern antibiotic therapies. Ease of treatment however may miss the point. We know that gonorrhoea and also Chlamydia will increase the amount of HIV virus which is shed from both the cervix and also in semen of HIV infected men and women. Equally, concurrent infection with herpes 2 virus in the genital tract of either of the individuals will make HIV acquisition much more likely for a previously HIV negative partner.

Gonorrhoea, syphilis, chlamydia and herpes in the previously HIV negative individual engaging in unprotected penetrative sex with an HIV positive individual will markedly increase the chances of new HIV infection. These newly infected HIV positive individuals pose an exceptionally high risk of infecting other sexual partners because they are often unaware of the risks they have taken and unaware of the new HIV infection gaining rapid momentum in their body. New HIV infection will take a few weeks to generate often several million copies of HIV virus per ml of blood or semen making these individuals extremely infectious in the initial phase.

When contemplating exceptionally high background rates of STD and HIV in populations there is a correct tendency to view this as a feature of poverty and also developing societies such as Sub Saharan Africa etc. South Africa has the highest rate of HIV in the world. But there is a catch and that is that in different population pockets around the world, such as Washington DC in the USA, HIV infection rates in some sub-groups exceeds that of the South African HIV rate. Consequently, interventions to reduce the spread of HIV need to be universally applied and the notion that the highest rates are in the poorest countries is part of the picture.

Vickerman etc al, writing in the journal Sexually Transmitted Infections (2010:86:163-168) used mathematical modeling to estimate the impact of periodic presumptive treatment on the transmission of sexually transmitted infections and HIV amongst female sex workers. The female sex workers were of a group taken from Johannesburg.

The article started with the premise that periodic treatment of common STD’s / STI’s using antibiotics without pre-testing could reduce the rates of genital ulcer disease, gonorrhoea, Chlamydia. What was not known was whether reduction of these infections by interval treatments would also consequently reduce the rate of HIV transfer.

The conclusion reached was that whilst possibly optimistic assumptions had been made about the impact of blanket antibiotic use in high risk female sex worker populations in reducing onward HIV transmission, there was reason to believe that antibiotic interventions with good population coverage could noticeably reduce the HIV infection rate amongst female sex workers with previously inadequate STI and STD treatments.

Clearly the use of antibiotics themselves would only impact on the bacterial diseases and have no impact on HIV itself – but, because the bacterial diseases enhance the shedding and availability of HIV in cervical fluid and semen, reduction in bacterial contamination will reduce spread of HIV. This is not a substitute for condom use but as the accompanying Editorial points out, many vulnerable sex workers are often not in a position to enforce condom use.

A further weapon in the identification of early HIV before onward HIV transmission is the use of very early HIV testing methods. Confusion has reigned over the appropriate testing intervals and this has largely occurred because different and more sensitive HIV testing methods have become available over the last 30 years. The confusion has been compounded a little by the advice of government regulatory bodies in different countries who have tailored their advice to what they now about commonly used HIV testing methods on the ground.

In the UK 4th generation HIV testing methods using HIV 1 and 2 antibodies and also p24 antigen ( a core HIV viral protein) have been commonplace for many years and good experience has been gained with these tests.

A further advance has been the development for diagnostic purposes of an HIV 1 and 2 RNA PCR test which will identify extremely early HIV infection often before symptoms of Acute Retroviral Syndrome have appeared. This test can be performed from seven days post possible HIV exposure. The importance of such an early test is that it firstly enables early intervention in terms of medications if desired and secondly it allows for the opportunity to avoid infecting others.

Simultaneous early PCR testing will allow for detection of a host of bacterial and viral STD’s / STI’s such as herpes 1 and 2, trichomonas, gardnerella, Chlamydia, gonorrhoea, ureaplasma, mycoplasma, and hepatitis C and B.




Comments
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by helpplz1983, Sep 29, 2010
Great post doctor.

I had a sexual experience with a sex worker as well. http://www.medhelp.org/posts/HIV---International/Condom-Slipped-to-Half-and-She-used-her-hands-to-wash-my-Penis/show/1355557
Can you kindly give your thoughts on this? I was reading that there is a medicine you can take in 72 hrs if you have doubt about HIV. This will eliminate the possibility of HIV. Would you recommend that in my case?

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by athinker, Sep 29, 2010
Interesting post.

I think that prostitution is especially risky when it is connected to other social factors such as poverty and dependency or alcohol or drugs or other substances, since it is in those circumstances that a prostitute might be ready to forego safety for additional payment, whether such additional payment is offered by the client or by the prostitute.

Of course, lack of education would increase the problem.



Avatar_m_tn
by helpplz1983, Sep 29, 2010
Hi Dr Sean,

Can you also comment on sex transmission for uncircumcised penis foreskin. I read it is a adapter for HIV. If that is the case can I be infected as only half of the penis was covered. How much foreskin should be covered with condom? In india, people don't circumcise and condom tends to slip. Can you comment on this?

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by dd816, Sep 30, 2010
Doctor, does uncircumcised foreskin also pose a risk for Oral Sex, as exposure to the skin and cells in the foreskin is possible as opposed to circumcised people?

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by fattiee, Oct 07, 2011
hello there dr sean
                               can u help me please
                                                                i recently had treatment for gonnerhea on the 28th and had sex on the 6th and i had unprotected sex. the male ill sleept with was clean, dose that mean i have passed it on to him.
can someone please answer me please. thanks

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by Terrifiedguy321, Oct 16, 2011
Hello, I had sex with an escort/prostitute (call her whatever) in Italy when on a business trip 10 days ago. I have been an an 8 yr monogomous relationship other than this and this was my first, and a truly terrible indiscretion. I am beset with anxiety (have struggled to sleep, concentrate, eat etc) that  I have caught any kind on STI and have so far avoided sexual contact with my girlfriend since returning home as terrified of passing anything on to her.
To give you the full picture of events from the night, I had protected vaginal sex during which time I'm sure the condom remained intact. Nerves and alcohol got the best of me and I lost my erection during which time there is a risk that the lower part of the shaft of my penis would have come in contact with her vagina - although the head remained covered throughout. After this, she removed the condom and finished it off by hand using lubricant - my concern with this is that any vaginal fluid that may have contacted the lower part of my penis during intercourse may have been rubbed up upon the tip during the masturbation. Doctor, could you please give me your view on the risks of contraction of STDs - which in particular should I be most concerned about.  Anxiously awaiting your reply

Avatar_m_tn
by ms27infi, Dec 14, 2011
How about this unusual case of transmission happened in India.What is you view on this? Is this possible

Can HIV spread through saliva? Case has doctors thinking
Published: Wednesday, Feb 9, 2011, 1:03 IST
By Menaka Rao | Place: Mumbai | Agency: DNA

source :http://www.dnaindia.com/india/report_can-hiv-spread-through-saliva-case-has-doctors-thinking_1505249

HIV, according to experts, is not normally transmitted through saliva. Transmission of the virus from the host is possible when saliva is mixed with blood.

In an unusual case, which should make the experts revisit their earlier position, a 50-year-old man has contacted HIV through his son’s saliva.

The man was bitten by his 32-year-old HIV positive stepson. But the latter did not have ulcers in his mouth, which usually leads to saliva getting mixed with blood.

Documented instances speak of the presence of the virus in saliva, but transmission takes place only in the above case.

“The son had pulled out the thumb nail of his father. Since the wound was raw, the virus could enter easily,” said Dr Alaka Deshpande, who runs the Centre of Excellence ART clinic at JJ hospital. The patient had come to her last year.

To understand the case better, the doctors wanted to verify if the father carried the same virus that has infected his son. Deshpande then sent the patient to National Institute of Research in Reproductive Health for further testing.

Dr AH Bandivdekar and Dr Shivaji Jadhav from the department of biochemistry and virology did gene sequencing of the HIV virus in the father and the son’s blood and concluded that both viruses were the same. “This confirmed the source of the HIV virus. Also, the son’s saliva had a high viral load which may have also caused the transmission,” said Dr Deshpande.

Unfortunately, the father was not given post exposure prophylaxis (PEP), a short-term anti-retroviral treatment given to reduce the likelihood of HIV infection after potential exposure. The family doctor told him that the virus cannot spread via saliva.

“He was admitted to JJ hospital for meningitis. After four days, he told us about this history. His blood was then sent for HIV testing and he was discovered HIV positive,” said Deshpande. She stressed that family physicians should know about HIV infected human bites and should treat it with PEP, in which the treatment should start within two hours of the potential exposure.

The father’s viral load was more than 20 lakh then. “He was treated as per US guidelines so that the virus does not spread to other organs. After treatment his viral load came down.” This case study was presented at the International Conference on Emerging Frontiers and Challenges in HIV/AIDS Research by Dr Jadhav to show that HIV infected human bites should be treated with PEP.

source :http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083326/

Avatar_n_tn
by Kimlong, Jan 09, 2012
I was wondering if I (a female) gave a man oral sex and swolled his seamen could I get a tonsillar abcess or is it more likely unrelated or an STD??? I got a tonsillar abcess 4 days after giving a man oral sex. I am not sure if he is monogamous. I had strep for 50 hrs. then developed a tonsillar abcess. I hadn't ever had strep before or not that I know of...

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by adsingh9799, May 21, 2012
i had a protectect condem sex with call girl.. but i am worried because she remove the condem of another freind with right hand , and put my condem(new) with right hand also... and after exposure, 1 year in report i received non-reactive...should i worry or am i safe???

Avatar_m_tn
by adsingh9799, May 21, 2012
i had a protectecd condem sex with call girl.. but i am worried because she remove the condem of another freind with right hand , and put my condem(new) with right hand also... and after exposure, 1 year in report i received non-reactive...should i worry or am i safe???

Avatar_m_tn
by dude02, Dec 11, 2012
I recently posted about some bumps on my penis could you check my posts and reply to one? There's pictures added to them so it will help.  I could use a quick reply as I haven't seen my girlfriend in 9 months(or had sex since then) and she comes this weekend, so I'm urgently in need of a response.

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by tazbomb, Apr 17, 2014
Hi doctor, I hope you can help me.  I suffer with ocd and an irrational fear ( so I'm told its irrational) of hiv.  I would really appreciate if you could help me out with my query so I can get clarification on the matter and hopefully ease my stress levels as I'm 20 weeks pregnant! If clothes were to come into contact with the HIV virus via blood, and then they were in the laundry basket before they were washed, if it had rubbed off onto the basket, can the HIV virus then live in the laundry basket and be passed onto other clothes? Similarly if someone unawares touched something contaminated and then touched other things, e.g a handbag, has the virus then spread onto the handbag and can that person then spread the virus onto other objects? I would really appreciate if you could give me good clarification on these worries as i am in constant fear of the HIV virus living on objects that may have come into contact with infected blood.

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