Vaginal fluids- condom removal, incomplete coverage-- risk?

[TroubledSon]

About 7 1/2 months ago I had a brief sexual encounter with a woman in a SE Asian country. In the space of about an hour we had genital intercourse twice, each time with a different condom that, from checking after, I'm fairly sure did not leak or tear. Only ejaculate/climax during round 2. There was also some deep mouth-mouth kissing, but not a lot.

After this encounter, I heard from some friends of hers that she had contracted HIV from a past period of IV drug use.

My question is: Is there any chance that I exposed myself to HIV when I removed the two condom that had vaginal secretions on it? What would I have to have done if that in fact occurred? If there was a narrow band of exposed skin at the base of my penis during protected sex, is there a risk that HIV entered my bloodstrream there? What about secretions that get onto the general pubic area?

I have, knock on wood, not presented any noticeable symptoms of ARS as I've read about them, but they seem pretty vague. All the same, I've suddenly been overcome by crippling stress regarding this incident. Hopefully your assessment of my risk will help me start preparing me psychologically for what I really need to do- get a test. Could you please, however, explain to me the pathways of infection and whether those "unprotected" spots carry significant transmission risk? Is there something I might have missed that "got me"? Thank you so much!

[Edward W Hook, MD]

Many concerns, all of which have little basis. Brief answers:

1.  Sun spots and freckles - forget it.  No reason to raise the concern about HIV.
2.  Kissing.  Same answer.  Bleeding gums, gum disease do not change kissing (open or closed mount, deep or not).  It is still NO risk.
3.  Post coital washing. In theory this might be a little helpful.  How much is unknown- it has not been studies. Whatever effect it might have, it's minor compared to the big measures, i.e. condoms.
4.  Transmission is more likely with higher HIV viral loads. Successful therapy lowers loads, stopping allows them to rise (not spike). Being on therapy should reduce the risk of transmission.

EWH

[Edward W Hook, MD]

Your risk is quite low.  If you had not used a condom your risk of acquiring HIV would be about 1 in 1000 per episode and, thus after two exposures 1 in 500.  Proper use of a condom reduces your risk nearly another 100-fold, thus your risk, on a statistical basis would not be close to 1 in 50,000.  This is case despite the fact that nearly everyone who has sex with a condom is exposed to vaginal secretions in the context of sex. The odds are in your favor.

Now, more than 7 months after your exposure, is an appropriate time to deal with any lingering concerns you might have an get your blood test.  This long after exposure, if you had acquired HIV (most unlikely), it would show up a positive blood test.  Thus if you get tested now, when your result comes back negative, you will be completely assured that you did not get HIV.  EWH

[TroubledSon]

I'm sorry- one more question: What is the effect of this woman having been on antiretroviral medication? If she were receiving a course of drug therapy at the time of my encounter, would that lessen the odds of transmission? What happens when an hiv+ person goes off their medication-- is there a sudden spike in viral load?

[TroubledSon]

I'm sorry- one more question: What is the effect of this woman having been on antiretroviral medication? If she were receiving a course of drug therapy at the time of my encounter, would that lessen the odds of transmission? What happens when an hiv+ person goes off their medication-- is there a sudden spike in viral load?

[TroubledSon]

Dr. Hook-

   Thank you so very much for shedding some truly saving light on this concern- that is, my underlying worry that the fact that "nearly everyone who has sex with a condom is exposed to vaginal secretions in the context of sex" was some how a potential spoiler even when condoms were used. I feel an enormous sense of relief. Now that we're on a roll, I was wondering if you could dispel a few "urban myths" I also heard about hiv:
- I have been living for a while in a sunny climate, so I have a mild tan on my hands and arms. However, on the backs of my hands there are some faintly darker freckling/zones. Could these also be a sign of incipient hiv? This may sound absurd but once you hear something, it has a way of planting itself.
- While kissing is repeatedly explained as a no-risk behavior, what is the worst case scenario in temrs of, say, one partner's gus being abraided by vigorous brushing and the other partner having sores in the mouth? This was most likely not the case during the encounter I've described and you've responded to, but are there any "significant" dangers in the oral area?
- What is the effect of post-coital "washing"? If I showered with soap and water and/or used purell hand sanitizer in my genital area a number of minutes after sex, might this "mash" the infectious fluid into my tissues or "lead" it up to the tip of the penis, or is the virus sensitive enough that these measures "kill" most of it?

Once again, thank you so much. I am forever grateful for your advice (even if the answers to these subsequent questions, should you be so good as to answer them, might get me worked up again...) and will let you know on the results of my test.