Risk assessment

[ukman74]

Dear Doctors,

I am a 36 year old male from UK. Heterosexual, otherwise healthy, no drug use, Last HIV test March 2008-, negative.
Since then :
Had 2 girl friends , had steady relationship with each for 6 months each. Had condom protected vaginal sex always and occasional unprotected oral sex. Both are educated professionals . However had unprotected sex with one of them only in one instance- 2-3 times  in one night, 1 year ago. She is in her 40s, had just came out of a long term relationship and told me that she didnt have any other partners apart from husband. She said she  had been tested a few years back as part of investigation of ? infertiity and found to be negative.  She had however been treated for chlamydia.

Apart from this, had contact with around 7-8 escorts in the last 2.5 years. These are highly paid sex workers. Always condom protected  vaginal sex . Condom was intact all times and I took extra care when I withdrew to make sure there is no accidental slippage etc.. Had sessions of intense kissing . Oral sex was mostly protected but had 3-4 episodes of  of unprotected oral sex( both ways). Last session( protected vaginal and protected oral was 4 weeks back) . No anal sex.

I have no symptoms. Had a urine chlamydia test which was negative.

Based on this, how would you assess my risk of HIV and STDs?
Would you consider this a high risk life style and have you encountered patients with similar histories who had any significant STDs?
Should I test and if so , what tests ?

Many thanks

[Edward W Hook, MD]

Welcome to our Forum.  I'll be happy to make my assessment.  I would say that your risk for HIV is far lower than average and that the lifestyle choices you have/are pursuing will keep you healthy.  Let me provide a bit more detail.

1.  Your partners.  This is the most important variable to consider and I would qualify your partners as low risk.  HIV in heterosexual women who do not use IV drugs is very, very rare.  As for your escort partners, indeed most commercial sex workers also do not have HIV and I would add that it is important to remember that CSWs who insist on condom use are not doing it to protect clients but themselves.  Your CSW partners sound rather low risk within that category.  

2.  Kissing.  HIV is not transmitted by kissing.   Period. This is true for all kissing-deep, intense or otherwise.

3.  Vaginal sex.  Condom protected sex is safe sex, thus the vast majority of your vaginal sexual encounters are no risk for you.  In unprotected encounters, the risk of transmission of HIV is 1 infection per 1000-2000 acts of intercourse.  

4.  Oral sex.  I used to say that oral sex was very low risk but as time goes on my assessment is that it gets closer and closer to being a no risk event.  There are no credible instances in many years in which anyone has even claimed to get HIV through either receiving or giving oral sex and the few old case reports in which it was suggested to occur are not convincing.  I would not worry about HIV from oral sex.

I won't address your "have you ever" question.  Everyone is different and people do sometimes get struck buy lightening, just not often enough to worry about.

So, what would I do. As you continue to move forward I would suggest that every year or so you get tested as an exercise in "screening".  Why?  Because it is reassuring and serves to validate your current practices.  This I suggest periodic STD(chlamydia mostly)/HIV "screening" (testing in the absence of symptoms) because you have had multiple partners over a period of less than a year.  As a matter of personal protection, we recommend annual testing for anyone who has had either a new or two or more sex partners in the past year (we consider this to be health maintenance- we also recommend you get your blood pressure and cholesterol checked regularly).

I hope this comment is helpful to you.  EWH

[ukman74]

Thanks for the detailed reply.
I know this is an HIV only forum, but would you be able to clarify if annual screening is neceessary for syphilis, gonorrhea and herpes, if there are no symptoms?

Some  private clinic here offer throat swabs for chlamydia and gonorrhea in addditon to genital swabs. Are these of any value? Can one harbour these in the throat and pass it on to someone else?

[Edward W Hook, MD]

Currently gonorrhea and chlamydia are typically tested for in the same test so I suspect that will happen no matter what.  

In the absence of lesions I absolutely woulnd not suggest testing for herpes.  The possiblity of having a false positive test is far higher than the possiblity of getting herpes.  

Syphilis is a rare disease and unlikely but the test is quite reliable.  I see no reason not to get it but am confident that your risk of syphilis is very, very low.  EWH

[ukman74]

Dear Doctor,

I have just had a full sexual health screen today at a private clinic.

I had a rapid HIV test( INSTI) . This is a test marketed by Biolytical laboratories with a claimed accuracy of 99.96% after the window period.( http://www.biolytical.com/results.html)
This test is apparently licensed in Canada only at present as per the website of the company. However the UK HPA site states that accuracy can vary from 95-96%.

It was clearly negative.

The doctor who did it said I was low risk and that the test result was very reassuring. She said that the test is not designed to pick up any exposures in the previous 3 months.

My only exposures in the previous 90 days were:

1.Protected oral and protected vaginal with a sex worker in London , possibly of Egyptian origin, 66 days before the test.
2.Protected fellatio and unprotected cunnilingus with a British black escort 46 days ago.
3.Protected vaginal , protected fellation and unprotected cunnilingus with  the same british escort 37 days ago.

Would you consider this conclusive?

Since I wanted to be asoloutely sure, I requested a Duo/Combi test which has been done and the results are awaited.

I would value your thoughts on this.

[Edward W Hook, MD]

Your exposures did not put youat risk for HIV.  Your test results conclusively confirm this.  Your doctor is being a bit conservative in his recommendation for repeat testing.  You do not need further testing.  EWH

[ukman74]

Thanks
So even the exposure  6 weeks before was ok ?

I am  starting a new monogamous relationship soon and wanted to put my past behind me . Assuming I am in a stable monogamous relationship from now on, I dont need any further testing?

[ukman74]

Just to add that the clinic called to say that the Combi/Duo test done today( 37 days after last episode of sex) is also negative.

[Edward W Hook, MD]

You do not have HIV and, as your tests prove, you have no need to worry.  EWH

[ukman74]

Thanks very much doctor. I will put this behind me. This is my final post.

As a matter of personal education,  I have analysed this as follows , especially with regard to my last episode which was 35 days ago.:

1.It is extremely unlikely that a high class escort who uses condoms consistently in London has HIV (conservative estimate:  1 in 100 although it might even be lower, more likely 1 in 1000).

2.It is almost impossible that a single episode of unprotected cunnilungus and protected vaginal and oral sex led to transmission. (Theoretical conservative estimate for oral sex transmission 1 in 20,000. does this apply to cunnilingus as well?)

3.At 5 weeks after the episode, one would expect the combination of Insti( rapid test) and Duo( p24/antibody) test to pick up the vast majority of infections in an immunocompetent individual.(Theoretical conservative estimate of approximately 5% (5 in 100 ) chance of missing an infection at 5 weeks.)

So even if we take an extremely conservative estimate the final chance of missing an infection at this stage is 1/100 x 1/20000x 5/100= 1 in 40000000 or 0.000000025 which is as good as zero. ( To put this in perspective , the population of England is  49,138,831!)
(Whereas for practical purposes, the escort almost certainly did not have HIV, its not spread by oral sex and you would believe a 5 week Duo test)

Would you agree with this assessment?
Thanks very much for your time and advice

[Edward W Hook, MD]

You have successfully repeated my assessment.  You do not have HIV.  You need to move on. This thread needs to end now. EWH