Unprotected vaginal sex

[worriedtotheextreme]

Dear Doc,

Here is the situation I have gotten myself into which has made me worried sick:

I am a married man but I have made an enormous mistake.  I had never cheated on my wife nor did I ever imagine I could cheat on her until a couple of weeks ago when I was away on a business trip.  Prior to getting married, I had a few sexual encounters with escorts/prostitutes which were always protected with a condom (in fact, it was never a question---they always took one out and that was that).

Well, this time was different.  I was "in the mood" and I asked around to find out where I could find a "cheap prostitute."  I was referred to an online listing and I found one for very cheap who came to my hotel room.  She did not have a condom with her (nor did I).  I'm a complete idiot but I proceeded to have unprotected vaginal sex with her (it lasted not much more than 5 minutes).  Since this encounter, I cant stop asking myself why this woman would have unprotected sex with me (why I would is a whole different story and one I cant understand either).  But back to her, if she would do this with me, then clearly she does this with others, correct? I have no idea if she has HIV or not but I have been worried sick and have avoided having sex with my wife since.

My specific questions:
1. How would you characterize my risk of getting HIV given this specific scenario?
2. Do I need to get tested for this isolated encounter of unprotected vaginal sex with this prostitute?
3. Can I have unprotected sex with my wife?
4. Is it even heard of to get HIV from a single episode of unprotected vaginal sex assuming she were indeed HIV +?
5. Finally, from reading some other posts, I know that you feel the presence/absence of ARS symptoms are not particularly reliable. However, what is the earliest post-exposure that the symptoms can begin? ("my symptoms" started only 7 days after the exposure).

Thank you.  I have made such a big mistake and am praying that all will be ok.

[worriedtotheextreme]

Thanks Doc.  If ok with you, can we wrap this thread up with the following so that I am clear on your advice? I promise I wont ask further questions after this.

1.After the additional information I provided you, do you still recommend testing for all STDs including HIV?  If you think I do need the testing, I want to get as much of it done this week if possible to get it over with (which is barely over 2 weeks from the exposure).  What should/could I get done now (and what should I repeat later)?

2.Is it common to get other STDs (ie non HIV) from a single encounter?  And if true, then if one gets gonorhhea/chlamydia from the single encounter, is it still exceedingly unlikely that they would also get infected with HIV from that single encounter (even if they had HIV)?

3.Finally, just to clarify regarding my possible ARS symptoms I described above (ie sore throat, cough, diarrhea, and mild fatigue but no high fever or rash), having these symptoms begin 7/8 days post exposure and resolving by day 12/13 post exposure is NOT consistent with ARS, correct?

Thanks again for everything doc.  I am praying for both myself and my family that everything will be ok.  I want to do the right thing starting immediately.  Your advise (and reassurance as appropriate) is greatly appreciated.

[H. Hunter Handsfield, M.D.]

Multiple usernames is against MedHelp rules.  You will at least receive a warning from the web administrator, and your privileges under either or both names may be terminated, especially if by using multiple names you have exceeded the limit of 2 questions every 6 months on the professionally moderated forums.

[regretfulandscared1641]

ok, so I took your advice.  I am exactly 15 days since the exposure.

I had the urine GC and chlamydia tests done today (will get results in a few business days).  I also had NAAT testing done (which I believe is the HIV DNA PCR test) which also will take several business days to come back.  However, as part of the blood work, they automatically do a rapid HIV ELISA test (uni gold) and it was NEGATIVE.

Can I be comforted in any way about the recent exposure given the negative Ab test, albeit only 15 days post exposure? (just trying to actually get some sleep these days and have some leftover fingernails).  I plan to have it repeated (along with syphilis) at the 6 week mark per your advice.  Although you felt my "ARS symptoms" were too atypical and too early, I was hoping that if I did have early symptoms, that maybe the ELISA would have been positive if those were true ARS symptoms?

Finally, how reliable will the HIV DNA PCR drawn today be?

Thank you, thank you, thank you.    

[H. Hunter Handsfield, M.D.]

1) Yes.  I already mentioned the ones to be tested for, but at 2 weeks only the urine gonorrhea/chlamydia tests will be valid.

2) "Common" is relative.  I have no way of accurately judging whether your partner actually has an STD, but it appears she is at significant risk.  Maybe only a few percent chance you were infected, especially since you have apparently had no symptoms.  But high enough that if I were in your situation, I would get tested before having sex with my wife.

3) Those symptoms don't suggest HIV, which doesn't generally cause cough; and as we said the symptoms came on too soon and absence of fever is also evidence against it.

My closing advice is that you see a knowledgeable provider, e.g. your local health department STD clinic, then follow their advice about the details.  If you live in Denver or are still there, the Denver Metro Health STD clinic is one of the very best in the country if not the world.

[H. Hunter Handsfield, M.D.]

Thanks for the additional information; it does help.  The good news:  Heterosexually transmitted HIV is rare in Denver, and to my knowledge the frequency of HIV in sex workers is generally very low, well under a 1% chance she is infected and maybe closer to 1 in 1,000.  Not being African American is the important issue in relation to race/ethniticity.  (This isn't an anti-AA racist statement.  It's just a fact that HIV rates are much higher in AAs than in other racial groups in the US.)  I would be much more concerned had this occurred in, say, NYC, Miami, Washington, or other large eastern cities.  Denver has a minor hetersexual HIV epidemic compared with such places.

1) This is a different sort of encounter than most of the others you refer to.  You asked for a cheap date and that's what you got; and you found someone who obviously is not a consistent condom user.  Both of these elevate the STD/HIV risk compared with most questions about escorts.

2) In my 35 years in the STD business, I have never seen HIV acquired in a one-off sexual encounter.  It is quite rare.  And in the 7 years of this forum, nobody has reported catching HIV after an encounter they were nervous about.  You aren't likely to be the first.

3) A 2 week antibody test isn't very helpful; well under half of newly infected persons are positive by that time.  A combo test (for both HIV antibody and p24 antigen) would be better, but still only about 50% reassuring at 2 weeks.  It would be 100% at 4 weeks.

[worriedtotheextreme]

Hi. Thanks for your reply.  Please allow me to fill in some of the details you were asking about and to provide you with a little more information as well as a couple more questions.

The location of the encounter was in Denver, Colorado.  I am not exactly sure of her ethnicity (not african american) but probably a mixed race (ie white/latina or something).  I do not know if she is/is not an IV drug user.  I do not know if I will be able to recontact her.  Does this information help?

A couple of follow up question because I feel a bit confused (and scared by your answers):

1. Is my encounter significantly different from others that I have read on this forum where a person had unprotected vaginal sex with a female escort?  I have read some of your other replies saying that you do not typically recommend testing for HIV in those settings (ie a single episode of unprotected sex with a prostitute).

2. I'm sure you have heard of single unprotected encounters where people have acquired other STDs (ie gonorrhea) but have you ever encountered a scenario where a male contracted HIV from a SINGLE episode of unprotected vaginal sex?

3. If you still recommend testing, would it be ok to get the HIV test 2 weeks post exposure? (in other words, perhaps not definitive, but would a negative test at this point be at least somewhat reassuring?)

Thanks again.

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  I understand your concern and will try to help.  The bottom line is that you are at ow risk, if any, for HIV.  The risk may be higher for other STDs.

Certainly this is a high risk situation; an inexpensive sex worker who does not use condoms frequently is obviously unsafe and there is a good chance she is infected with one or more STDs.  However, it is difficult to be specific or to judge the HIV risk.  In most areas of the country, well under 1% (probably usually no more than 1 in 1000) sex workers has HIV.  However, this varies with several factors you don't mention, some of which you may not know.  What city is it?  Is she white, African American, or other?  Is she an injection drug user? Can you contact her to ask whether she has HIV and, if so, whether she is on treatment for it?  (Most people don't lie when asked directly.)  If she doesn't know or hasn't been tested recently (for STDs as well as HIV), perhaps she would agree to be tested now.  It would of course be very reassuring if she were to be tested with negative results.

Even if she has HIV, the chance of transmission during any single vaginal sex encounter (female to male) is low, average once for every 2,000 events -- equivalent to having sex with infected women once daily for 5 years before infection would be likely.

So all things considered, as far as HIV is considered, the odds are strongly in your favor.  However, if you were to learn she does have HIV, or if you are in a setting where HIV is known to be especially common in sex workers, you should find a doctor or clinic with experience in HIV and its prevention; s/he might recommend early testing by PCR, in addition to waiting a few weeks for antibody testing alone.

To your specific questions:

1,4) See above.

2) You should be tested for HIV.  Also for other STDs.  In particular, I suggest urine for gonorrhea and chlamydia and, after 6 weeks, a blood test for syphilis.  Also be on the lookout for common STD symptoms --

3) It would be wise to avoid unprotected sex with your wife for the time being.

5) You learned correctly.  ARS symptoms -- usually a combination of sore throat (usually quite severe), fever (101 or higher), and body-wide non-itchy skin rask -- typically start 10-14 days after exposure.  7 days is definitely too soon.

To reiterate:  the odds are strongly in your favor.  Still, if you get more information that puts your partner in an especially high risk category, then you should get yourself into care with an expert and then follow his or her advice.  Don't rely primarily on this or any other online source.  But let me know if you can fill in some of the blanks and perhaps I'll have additional advice.

Regards--  HHH, MD