High Risk Exposure - In Need of Professional Assessment/Advice

[Torontowoman]

Hello Dr. Hook and/or Dr. Handsfield,
About a  week ago I engaged in heterosexual sexual activity that included unprotected oral sex, protected vaginal sex, and anal sex - which began as protected one but became unprotected since the condom broke (intra-rectal ejaculation did not occur). Within about 40 hours I visited Emerg. in order to get a PEP starter kit, but with the advice of my GP and Emerg. MD I decided NOT to go ahead with it due to the severity of the meds' side effects, cost, and because I was advised my risk wasn't high enough to warrant starting PEP. I hope and pray that wasn't the mistake of a lifetime. Now on to the details: I am a 29 year-old female who lives in Toronto, Canada. I was recently tested negative for HIV and other STIs. My partner: He's a 33 year-old heterosexual male who doesn't know his current HIV status. He performed the test yesterday and is now awaiting the results. He's been residing in Canada for the last two years, and prior to it has been living in Eastern/Central Europe. My partner assures me that to the best of his memory he's always been using condoms in sexual encounters. I don't know at which point the condom broke, but the whole session must have lasted somewhere between 5-10 mins. When I asked my partner to exit, I noticed the condom was at the base of his shaft and he was exiting me with a naked penis. Once again, intra-rectal ejaculation did not occur. Afterward, I also noticed mild bleeding from my rectum/anus. Questions:  Are you able to tell me my numerical risk knowing the details of the case? Would you have advised for/against PEP, again knowing the details? I know the risk lies somewhere around 1/200 with a confirmed HIV+ person. What about when the status in unknown, no ejaculation occurred, and the person is heterosexual? Should I keep a close eye on possible symptoms in the weeks to come? Please give me your professional opinion and numerical odds considering the circumstances. Thank you in advance!

[Edward W Hook, MD]

Welcome to the Forum. I'll be pleased to provide my perspective.  If you had come to my practice, I would not have recommended PEP either.  Clearly the decision to use PEP involves weighing the pros and cons.  You have outlined the problems with PEP well and I will not repeat them.

As for the reasons for using PEP, the question really comes down to how risk was your partner and, from what you say, your partner was not high risk.  Here in the U.S (and I think figures are similar for Toronto) fewer than 1 in 10,000 heterosexual, non-IV drug using men have HIV.  It sounds like your partner falls into this category.  Even if he did have HIV, your highest risk exposure was receptive rectal intercourse and transmission from infected to un-infected persons occurs in this situation less than once in every 100 exposures. thus mathematically, when we consider both your partner and the risk of transmission in the unlikely circumstance that he had HIV, your risk for HIV is very, very low (mathematically less than 1 in a million).

If your partner's test is negative, my advice is to stop worrying completely.  If it is positive, we should discuss things further but additional testing would be warranted (sorry, not going to get into the "what ifs" at this time).  

I hope my comments are helpful to you. EWH

[Edward W Hook, MD]

Glad we could help. take care. EWH

[Torontowoman]

Thank you, Dr. Hook, for your professional opinion. That is exactly what I was looking to get rather than a series of "what ifs". At this time not much is left but to wait, hope and pray for a favourable outcome. There are lessons to be derived from all of this if God willing I am spared this time. I really thought I was being proactive by using a condom for every sexual intercourse, but nothing is perfect and condoms do fail at times. Maybe the way to go about it is not to engage in sexual activities until a partner's status is known (although even in that case scenario they may still be in their 'window period'). In any case, thank you.