Two unprotected vaginal exposures with same CSW

[eagle3025]

Hello Dr. HHH or Dr. EWH:

My question is certainly not a very original one, and I have already reviewed many posts in the forum which are similar in nature, but I would still appreciate your guidance and medical advice regarding my particular case.

Facts:

I had two unprotected vaginal exposures with a CSW.  Each exposure was approximately 10 minutes in duration.  After each instance, I immediately cleaned myself thoroughly in the shower and urinated (although seemingly no statistical evidence this makes any difference).

The CSW was 19 years old and told she had been working as a CSW on weekends for past 6 months.  She told me she always uses condoms with all clients (although I’m doubtful as she did not use a condom with me) and the only person she had unprotected sex with was her ex-bf (6 mo. earlier).  Nonetheless, she did tell me when asked that she was checked for HIV for the first time 3 months ago, negative.  When I kept asking, she got annoyed and re-affirmed her negative status, even saying "if you want, we can go get tested tomorrow."  

My review of the forum leads me to estimate my real risk, assuming she was HIV+, would be .001*2=.002, or 1/500.  In Colombia, HIV prevalence in CSW is around 1%, likely much less in my case; still, let's assume 1% for the sake of argument.  So my math is .01*.002=.00002, or 1/50,000.

1) Would you agree my calcs?
2) Would you agree this was a low-risk event (obviously not no-risk)? And so I also assume that you wouldn’t consider PEP in this case?
3) Have you, professionally, ever encountered a patient who contracted HIV from a similar scenario with a single CSW?
4) I test once annually, last tested this year in February- all neg; would you recommend me testing in 6 weeks for this particular event, or just getting my regular annual HIV test next February?
5) In absence of symptoms, would you suggest testing for other STDs following this experience?
6) Should I realistically be worried or move on?

Thanks in advance.

[eagle3025]

Thanks doc.

[Edward W Hook, MD]

1.  I would not recommend PEP to a patient of mine following an exposure of the sort you have described.  Do you really think I would not give the same advice on line that I would give to my own patients?  How strange. I am sure that if you want PEP you can get it.  Decisions about PEP are a personal decision in which one should consider the likelihood that infection will occur, the likelihood of drug side effects ( less than 80% of people who start PEP complete it), one's personal anxiety and the cost of the drugs (expensive, typically in the neighborhood of $1000).   If you choose to try to find someone to provide you with PEP, please hold them accountable for all that goes with it (i.e. follow-up, answering your questions, etc).  

2.  Chlamdyia and NGU are the two most common "regular" STDs.  All STDs can occur without symptoms and the average onset of symptoms vary from STD to STD.  Your exposure was somewhat high risk for STDs, thus testing is reasonable.

3.  See above. Any STD can occur without symptoms, including HIV.  EWH

[eagle3025]

Thank you, Dr. Hook.  Just a quick follow-up, I'm sorry if it seems I'm splitting hairs.

Regarding PEP, the reason I ask is because I am still well within the 72 hour window where it may be effective.  You mention how you would not suggest PEP in this case, but, if a patient came to you with a similar case specifically requesting PEP treatment, would you go so far as to recommend against it due to risks of side effects outweighing risk of HIV infection?

Regarding STDs, you noted the risk was a "bit higher" for STDS.  What would you say would be my biggest STD risks from this experience?  When might I start experiencing symptoms, assuming that I had indeed caught something?  When could I be tested for STDs and would you still recommend testing even if I had absolutely no symptoms?

Regarding symptoms, you said "If you choose to be tested for other STDs (i.e. gonorrhea, chlamydia, etc) or develop symptoms, you may wish to get HIV tested as well."  Are you referring specifically to STD symptoms or HIV symptoms, such as ARS?  If the latter, are you saying I should be keeping an eye out for ARS symptoms?

Thank you again, and I apologize if I seem a big long-winded.

[Edward W Hook, MD]

Welcome to the Forum.  Your questions were quite specific so I will go directly to them.

1.  Yes, I agree with your calculations an assumptions.
2.  Yes, I agree this was low risk for HIV.  The risk for STDs is a bit higher.  I would not suggest PEP in such a case.
3.  No, I have not.
4.  Testing is up to you. As I mentioned above, I suspect you are at greater risk for other STDs than HIV.  If you choose to be tested for other STDs (i.e. gonorrhea, chlamydia, etc) or develop symptoms, you may wish to get HIV tested as well.
5.  See above
6.  I would not be particularly worried about this exposure.

Hope this helps. EWH