Condom Breakage - Independent SW in Singapore

[stupid_sgp]

Dear Doctors,

I have extensively read your forums and your advice surrounding likely HIV transmission following a broken condom. I would like, however, you guidance on my course of action given my specific circumstance. Approximately 40hrs ago, while in Singapore, I engaged a Mongolian independent sex worker (that I met at a high-end hotel bar that is heavily populated with independent sex workers that travel to Singapore for approx 4 weeks at a time). Following some petting, she requested a condom for oral, following which we proceeded to have vaginal intercourse. She was relatively dry and foolishly we did not use lubricant. I noticed a change in sensation and withdrew to discover the entire head of penis was exposed. I had been frequently checking the condom so I am confident the exposure was likely to be well inside 30 secs. I washed with soap and water. I told her I was clean (apologise for the use of that word - but there were language difficulties) and she stated she was as well. I did not specifically ask her testing history. She then proceeded to provide unprotected oral to me (surprising given her initial stance) and then fitted another condom and we finished penetrative sex quickly. No damage to this condom. Questions as follows:
1. Given the nationalities involved, and informal nature of the sex worker, do you consider my risk to be high?
2. In these circumstances, would you recommend PEP to one of your patients?
3. I am attempting to contact the girl in question to encourage her to accompany me for a HIV quick test. If this proves possible and the result is negative would you recommend I take no further action apart from a test at 6 weeks?4. Any further advice on appropriate screening time for other STD's?

Thanks and Regards.

[H. Hunter Handsfield, M.D.]

Welcome to the forum. Thanks for your confidence in the forum and for reading other threads for questions similar to yours.

As you probably found in your research, even if your partner had HIV, unprotected vaginal sex carries a risk of somewhere around 1 in 2,000 of transmission for each exposure.  Given the brevity of the exposure after the condom broke, you can safely assume your risk was still lower.  You probably also read that most commercial sex workers don't have HIV, regardless of their geographic origin; and that most people don't lie about HIV status when asked directly. Finally, oral sex, even without a condom, is exceedingly low risk for HIV transmission, if any risk at all. (Many experts believe there is no risk.)

All the business about washing etc after the exposure is pretty much irrelevant.  Such actions are not likely to change the risk.

To your specicc questions:

1) No. I consider the chance you caught HIV to be very low, probably less than one chance in a million.

2) For sure I would NOT recommend PEP in a circumstance like this.

3) Even if you can't contact your partner, I would recommend no further action.  From a risk assessment standpoint, I don't even think you need HIV testing at all.  Of course you are free to do it if you will gain additional reassurance from the negative result.  For definitive results, you could have a combo test (for HIV antibody and p24 antigen) at 4 weeks, or a stand-alone antibody test at 6-8 weeks.

4) The risks for some other STDs are somewhat higher, but still low.  If you desire testing other than HIV, I would suggest a urine test for gonorrhea and chlamydia, valid any time more than 3-4 days after exposure; and perhaps a syphilis blood test at 6 weeks or more after exposure.  I don't recommend any other testing.

I hope this has helped.  Best wishes--  HHH, MD

[H. Hunter Handsfield, M.D.]

You're welcome; I'm glad to have helped.

[stupid_sgp]

Dear Dr HHH,

Thank-you for your advice. In the interim I have made contact with my partner and she is willing to accompany me for testing. She has also had concerns following the incident - which of course I fully respect. Her concerns reassure me of her health consciousness - and it is only appropriate that I provide her with similar assurance.

I will take your advice regarding the testing regimen to pursue.

I do greatly appreciate the advice you have provide both to me and countless others on this site.

Thanks and Regards.

[H. Hunter Handsfield, M.D.]

And I really don't think you need go out of your way to talk your partner into HIV/STD testing. But if you can contact her and she is willing, then gonorrhea, chlamydia, HIV, and syphilis are the ones to test for.