broken condom, period, and other complications

[nynyny]

Dear Dr., I live in NYC.  My first question concerns a highly-educated, non-drug-addicted, Caucasian woman that I began seeing recently.  She works for a non-profit organization full time, but has lately been stripping at a Manhattan club part time for extra cash.  We had protected sex several times, and she was highly vigilant before our first encounter to learn my STD status.  (More on this below.)  She claimed to have tested negative across the board within the last month or so, and to have had no had unprotected sex within the window period.  The third time that we had sex, she was on her period (I did not see any vaginal blood, but it was dark).  The condom broke.  I don't know for how long we had unprotected sex.  I was unable to wash my penis off before switching condoms (though I was able to dry it off).  Two more potentially relevant details: I may have herpes.  A past girlfriend of mine was diagnosed with herpes, only to be told after a later test that she didn't have it.  I had symptoms while with her once that might be from herpes.  I developed a whitish, glistening, sensitive and itchy sore or lesion that lasted about a week, then went away.  The second relevant detail is that I am uncircumcised.  My question is whether I am at significant risk for HIV acquisition from this encounter and ought to be tested (from a risk-assessment standpoint).

My second question concerns a very different personality.  A few weeks ago I went to a club in a rough part of Brooklyn and made out vigorously with a 36-year-old black woman of dubious status.  Why dubious status?  First, she claimed to not use condoms.  Second, she is married to someone in prison.  Third, it was not obvious that her job didn't involve having sex with club patrons on a regular basis.  I did nothing other than make out with this woman, but I did have a cold sore that was bleeding on and off.  Am I at risk for HIV acquisition as a result of this?  Thanks so much for your help.

[Edward W Hook, MD]

No, if the fact that she she was having her period at the time of your exposure was important, I would have mentioned it.  EWH

[nynyny]

Thanks so much.  One final question:

You don't mention the significance of the fact that the woman with whom I had an unprotected exposure was on her period.  Does that change anything?

Thanks again.

[Edward W Hook, MD]

As I said, your risk for HIV from the single sex act you describe is small.  What is small enought?  I do not know. that is a personal decision. The best thing to do however would be to use condoms until you are tested.  EWH

[nynyny]

Thanks so much, Dr. Hook.  

One follow-up:

I have a regular sex partner with whom I typically have unprotected sex (for various reasons).  We have had unprotected sex once since the condom-breaking incident.  Am I putting her at serious risk for HIV acquisition by having unprotected sex with her before receiving a test result at the 6-8 week mark?  Or is the risk that I got HIV at the condom-breaking incident sufficiently small so that it is safe to have such sex (as far as HIV is concerned)?

Thanks again.

[Edward W Hook, MD]

Welcome to our Forum.  I have several comments which I hope you'll find helpful and will get directly to them.

1.  It sounds like you are in the habit of asking your partners about their HIV and I presume, other STD status.  congratulations.  You can learn a lot about partners in this way and hopefully such discussion will guide your decision making.  People typically tell the truth.

2.  Your risk.  IF you have herpes, that is statistically associated in epidemiological studies with a modest increase in risk for getting HIV, if exposed.  You do not know if you have HSV.  Your history makes it a possibility but by no means a sure thing.  It sounds as though you have not had recurrences of your genital lesions so HSV may not have been the cause of your sore.  In addition, that you are uncircumcised is also associated with modestly increased risk for acquisition of HIV as well.  When each has been studied, genital HSV-2 infection is associate with about a 30% increase in risk which being uncircumcised is associated with about a 50% risk.  In each instance however, all the other possible contributors to risk for infection were controlled for.  Thus in studies of circumcision, you can be completely sure that many of the persons studies also had genital herpes.  Thus, your OVERALL risk associated with both of these factors cannot be computed by adding the factors I just mentioned.  For these and other even more complicated scientific reasons, your relatively increased risk from being uncircumcised and possibly having HSV is rather small an difficult to make a precise estimate of.

3.  Partner assessments.  I agree with your assessments.  The first partner you mention is has a rather high risk side-job but all else puts her at low risk for HIV.  You have had a single unprotected exposure.  You are at no risk whatsoever from your activities with the second partner who you did not have sex with even though some of her life circumstances are associated with higher HIV risk.  You cannot get HIV from kissing, even vigorously.

Putting all of these factors together, your overall risk of infection is low and not something to become worried about.  On the other hand, there is no reason for you not to test, not only for HIV but for other STDs at a time that is convenient for you at some time in the future.  Testing at 6-8 weeks after your single unprotected exposure will give you results that you should have confidence it.  In the interim, I would not worry.  EWH