Cunninlingus w/ traces of menstrual blood + Cold Sore!

[iamwor]

Hello. I performed a cunninlingus on a woman who's at high risk of HIV (can't confirm if she is + or -) and obviously this was very unwise. I had a cold sore on the bottom lip. In addition, we had (protected) sex and I noticed that there was some traces of menstrual blood on the condom. Hence, cold sore+menstrual blood is now freaking me out.

In addition, I had some traces of that menstrual blood on my fingernails from foreplay.

Can you tell me if I am at risk? I am really worried and went to the hospital today to get preventive measures. They did a quick test (negative) and then we talked about nPEP. I started taking it today about 3-4 after potential exposure.

I would like to know:
1) how much of a risk I took, i.e. it is of course "possible" I am infected correct?
2) what I should do with regards to nPEP? I can continue and do the full 28 days until this is not advised in my situation (I have received first 4 days of pills so far)
3) whether I am at risk for my significant other. I really don't know what to do and would hate to pose any risk for her

looking forward to your guidance and opinion

[iamwor]

Thanks. I wasn't sure b/c of the 'window period'. That's why the Dr. I saw wanted me to continue PEP. He said I should have her do PCR instead b/c it doesn't have that large window period, but I read PCR can give false positive etc.

If standard antibody is OK then we might just do that. I appreciate your insight, the people I saw at the clinic were definitely less knowledgeable (e.g. Dr. pointed out a 98.9% efficicay in PEP, which contradicts everything I read -----usually says around 70% at most)

[H. Hunter Handsfield, M.D.]

A standard antibody test is all she needs.  If negative, as almost certainly it will be, you definitely can stop PEP.

[iamwor]

Thank you. I had my follow-up appointment at the clinic today and the doctor suggested I continue with the treatment, despite the fact that I am feeling nauseous. He said the only reason that I should discontinue is if we test the person I was in contact with.

So I ended finding the woman in question, and she said she gets tested every 6 months and is "clean". That'd be obvisouly great if true. She also agreed to get tested this Wednesday. So we will do that. For her, what test would you recommend? The standard one has that 3 month window, so wouldn't it be useless in my case (again testing her, not me). What about the PCR test? Would it be a long wait?

I hope I can find relief when she gets tested and discontinue PEP, as it is interfering with my normal life. The woman in question also mentioned having been bit by a dog...that contributed to freaking me out even though she said her own Dr. reassured her and that the dog wasn't sick. I think she is on medication for this, hence I am mentioning it in case it could interfere with some of the HIV tests. In particular, a false positive PCR would be very very scary.

What a waste of time and energy because of my stupidity. I hope all is well. Please just let me know what to do with the woman in question this Wednesday, as it may be the key to deliverance. Thank you!

[H. Hunter Handsfield, M.D.]

Obviously if you could not have been infected, you are not putting your regular partner at risk.  And if there were significant risk you were infected, you would have to use condoms anyway, even with PEP -- or avoid sex with your regular partner for 3 months.  PEP is not a substitute for abstinence or condoms.  In other words, it's either both no sex (or consistent use of condoms) and PEP, or neither one.  If I were in your situation, it would be neither one.  But the decision is yours, not mine.

[iamwor]

Thank you very much Doctor. I have contacted clinic and will follow-up in a few days with a physician (the ED only gave me first 4 days).

In the meantime, I need to ask you a delicate question (and I promise this is the end of thread):

Am I now putting my significant other at risk? We have been together for 5 years and I obviously don't want to lose her. Hence I cannot tell her about it, but since we have been having unprotected sex for years, it would be very suspicious if I now wear a condom for the next 3 months.

The worst thing that I could foresee happening is me remaining unaffected if I continue nPEP but infecting her...I could never forgive myself. If nPEP makes me feel horrible for a month that's a small price to pay for what I've done and I would continue. My question however is: can I be infectious now and put her at risk?

Thanks again. Please trust this was my last question.

[H. Hunter Handsfield, M.D.]

It is true that heterosexually transmitted HIV is more common in Russia than in North America.  However, (legal) immigrants are usally tested for HIV and the chance your partner was infected remains zero.

With the brief exposure you had, I am even more convinced you were not at significant HIV risk.  My comment about PEP, however, should have said that you should discuss continuationg or stopping with the doctor/clinic who prescribed it, and not make a decision to stop on your own or solely on the basis of my advice.

[iamwor]

Dear Dr. Handsfield: thank you for your prompt response. The woman in question is indeed a commercial sex worker, from Russia, but working in the U.S. I assumed there was a high chance of risk then.

The cunnilingus was very brief and I used my tongue only, never put the sore in contact. I hope she will be ok and I realized this was a very stupid thing to do (hence why I stopped right away).

I have an important follow up question: you mention in 2) that: "but now that you're on [PEP], you probably should continue"

Can you please indicate what you meant? For instance, does stopping increase chances of getting HIV (from that contact) or something else maybe in the future? I do not know the consequences of stopping and I am only at day 1.

Thanks again. This site is very helpful.

[H. Hunter Handsfield, M.D.]

Welcome to the forum.

HIV has never been reported to be transmitted by cunnilingus, either to or from an infected woman.  And although you apparently feel your partner may be "high risk" for HIV, you don't provide enough information to judge that.  If she is simply a commercial sex worker or a woman with many sex partners, and if she is in the US or other industrialized country, the chance she has HIV is probably under 1 in 1,000.

As for your cold sore, there is no evidence that HSV-1 enhances HIV risk.  It's sort of interesting, and the reason isn't known -- but unlike HSV-2, no association has ever been found between HIV risk and HSV-1.  Oral exposure to infected blood could involve some risk, but pretty low.

To your specific questions:

1) This was a very low risk exposure -- probably close to zero risk for practical purposes.

2) Most experts would not recommend PEP in this situation; I certainly would not.  The only exception might be if you knew for sure your partner had HIV, or if she were at especially high risk -- and even then, I wouldn't recommend it.  But now that you're on it, you probably should continue -- or discuss it further with the doc who prescribed it.

3) STDs are rarely transmitted by cunnilingus.  There is a slight possibility of oral gonorrhea, and perhaps syphilis or a second oral herpes infection, if your partner had a genital HSV-2 infection.  You are at no known risk for other STDs.

The biggest STD risk in this circumstance, by far, was genital herpes for your partner, due to your apparent cold sore.  You should not have put her at risk like that -- unless you informed her of your oral herpes outbreak and she agreed to go ahead.  If you didn't discuss it with her, you should contact her and do it now.

I hope this helps.  Best wishes--  HHH, MD