Rightfully panicked or not much to worry about?

[boston40]

Three weeks ago I employed three CSW, three of which performed protected oral, one of which I had protected vaginal sex with one of which I had protected anal sex (around 5 minutes of) with but the condom broke.  Around 2-3 days later had night fever, woke frequently to urinate and had inflammation around groin and lower back but no discharge.  5 days after I returned I had my yearly physical and all tests were done including a urine culture and hiv test.  All tests were negative.  11 days after I went to a local STD clinic as pain in groin and urethra was getting worse.  They took a swab of my urethra saw a high white blood cell count and diagnosed me with NGU.  They also did another urine culture and everything negative but was diagnosed doxcycline for 7 days.  I took all antibiotics but over the next week experienced fatigue and joint aches.  I presumed they were a side effect of the doxy but became nervous and thought may be symptoms of ARS or primary HIV infection.  I have finished my antibiotics and although the NGU symptoms are gone I believe I still have some ARS symptoms.  Today is 24 days since I returned and I have nausea and think I may have swollen lymph nodes (although there is nothing visible to the naked eye).  I have not had a fever over the last three weeks but my sleep is disrupted, I wake often and sometimes wake with a slight sweat.  I have not had bad diarahea but my stool has not been as consistent since I've returned.  I also have had a slight cold over the last few weeks and still feel slightly fatigued and listless.   Please advise as to whether you think I should be tested immediately or whether you think my anxiety has gotten the best of me.  The problem I have is that many websites are so general with their description of ARS that I do not know how severe the symptoms of diarhhea, flu, nausea, swollen lymph nodes etc. need be to warrant getting test again.  Also, should the fact I had NGU make me more concerned I may have HIV?  
TY

[H. Hunter Handsfield, M.D.]

Of course.  You can conclude that from my comments above.

Thanks for the thanks--  

[boston40]

Thank you so much.  I respect your columns immensely.  I couldn't take the anxiety any longer and went to get a OraQuick Advance Rapid HIV-1/2 Antibody Test.  It was negative!! At 25 days the counsellor said I fall within the 3-6 week window period for the test and I should not be worried.  Do you concur?

[H. Hunter Handsfield, M.D.]

Bottom line and then some discussion:  I see no serious concerns about HIV, although for reassurance you probably will want to be HIV tested.

The NGU diagnosis probably was correct, although it is possible you are one of the minority with that diagnosis due to urinary tract infection with E. coli or similar bacteria that typically inhabit the rectum.  This might explain the inflammation (lymph nodes?) in your groin, which is uncommon with chlamydia or other garden-variety causes of NGU. But with those symptoms clearing up on doycycline, you should have no future problem with it.  HIV does not cause lymph node inflammation or enlargement only in a limited area, but occurs body-wide.

In the US and other industrialized countries, HIV infection is relatively uncommon in CSWs, despite what you might assume or might have read.  And in any case, all the exposures you describe were zero risk for HIV transmission, except for the anal event with condom failure.  And even there, the chance of transmission for any single exposure is 1 in a few hundred exposures.  Finally, your symptoms really do not suggest ARS, which doesn't cause most of what you describe and almost always is associated with significant fever, which you don't mention.  And as you already, ARS symptoms themselves are very nonspecific, i.e. even typical symptoms usually are due to other things.

So as I said above, for peace of mind have an HIV test, ideally 6-8 weeks after the anal exposure (or at whenever suggested by the STD clinic).  You can expect it to be negative.

Best wishes----  HHH, MD