Risk Assessment & Advice

[Gman45]

Dr. Handsfield / Dr. Hook,

A few days ago I had an encounter with a transsexual sex worker in SE Asia. I did the following:
(1)    Gave her oral until she ejaculated – fully condom protected. She then removed the condom & cleaned / dried up with tissues
(2)    She then gave me oral – again fully protected.

However, during her giving me oral, she assumed a 69 position, with her flaccid penis brushing against my face and lips. During this act (which lasted about 5 minutes) I briefly, and gently, took the head of her penis into my mouth three times, each time for about 10-20 seconds. There was no rubbing or friction involved. I didn’t take the penis in deep and it didn’t touch my throat or top of my mouth, however, there may have been small amounts of still moist semen present (I didn’t taste anything). I immediately swilled my mouth with cold water afterwards. In addition, I'd had a meal 6 hours earlier and used a toothpick (which may have caused small cuts in my gums). I was angry with myself afterwards for straying from completely safe to potential exposure!!
  
I am very anxious & guilty regarding this episode. I would be grateful if you could give me a risk assessment and testing required (if any). I’m most concerned about any risk of HIV & Herpes but also any other STDs that may be a possibility (if any given the brief, and gentle, unprotected oral). It is difficult to get decent testing where I am. I took 1g azithromycin as a prophylactic treatment 12 hours post exposure.



I am most worried about potentially infecting my wife.
  
Many thanks in advance for your advice.

[Edward W Hook, MD]

(1) Can I consider the HIV conclusive (i.e. it was taken on the 28th day post-exposure - is this the valid time frame or a touch too early - I'm not sure exactly how you count the days)

Yes, these results are definitive.  

(2) Is the syphilis conclusive at this time-frame or do I need a further test at 3 months (I know there are different test types & am not sure which if this is the valid test from 4 weeks)

The risk of syphilis was quite low to begin with. While theoretically your test could become positive at 3 months, realistically the chance that you acquired syphilis and will now have apostive test is close to zero.

Take care.  EWH

[Gman45]

Dr. Hook

Anxiety got the better of me and I decided to test for peace of mind for the event described.
I got the following results at 27.5 days post-exposure:

-  HIV 4th Generation Ab/Ag (Roche Cobas Elecsys HIV Combi) - Non-reactive
-  Syphilis TP Ab - Non-reactive
-  Throat swab & urine Chlamydia/Gonorrhea by PCR - Not-Detected

My final questions:

(1) Can I consider the HIV conclusive (i.e. it was taken on the 28th day post-exposure - is this the valid time frame or a touch too early - I'm not sure exactly how you count the days)
(2) Is the syphilis conclusive at this time-frame or do I need a further test at 3 months (I know there are different test types & am not sure which if this is the valid test from 4 weeks)

Many thanks once again.

[Edward W Hook, MD]

Gonrrhea does sometimes resolve on its own.  More importantly however, gonorrhea is easier to prevent than transmit and your exposure was of minimal risk.  As I said before, you need not worry.  EWH

[Gman45]

Dr Hook,
One follow up question if I may.
I've been doing some reading of the forum and realise that there is a risk for gonhorrea, that may not be negated by the azithromycin. Given that the oral was minor, shallow and with minimal/no fluid transfer is it reasonable to assume that the risk is low (very low) and, even if I was unlucky enough to contract it the risk of passing it on to my wife through deep kissing or cunnilingus is very low. and finally, the infection would likely resolve on its own within months.

That's all Doctor. Thank you once again

[Gman45]

Thank you for your advice. Once again you have really helped me get over my anxiety. I really need to stop these very occasional encounters because the anxiety far outweighs any pleasure associated with thte event!!
Best regards.

[Edward W Hook, MD]

Welcome back to our Forum.  This was a low risk exposure and probably not something to worry about. Even if your partner had an STD, oral sex is an inefficient way to transmit STDs, you used a condom for most of your exposures, and, although it was not something that I recommend, the azithromycin you took would reduce the risk of other bacterial STDs.  Your partner did not have genital lesions so your risk for HSV is miniscule as well and, unless you develop  suggestive lesions in the two weeks following your exposure I would not be concerned.  Certainly there is no reason for a HSV blood test.

As for HIV, your unprotected oral activity was sort of oral sex (and sort of kissing his penis which is a no risk activity) and the quoted figure for HIV risk, if one has oral sex with an infected partner is less than 1 in 10,000 and, in my estimation that is too high. Some experts state there is no risk at all from oral sex.  In your situation, I see no reason for concern and really don't even see a medical reason for testing.  

I would not worry, o not recommend testing of any sort, and do not consider your wife to be at risk.  EWH