Condom slipped off with CSW

[concernedinct627]

Hi, Drs.,

I'm a 33yo white male, and have had sex now three times (condom protected oral/vaginal) over a period of months with a local woman who does sex work commercially (used to advertise, but now keeps a private list of clients).  She is white, non-drug user, ex-military with children (and an ex-husband), with one child born within the past year.  When I have asked about her testing history, she has said that she was tested extensively when her child was born, and tests every six months; she claims to be clear of STDs and HIV in particular but hasn't offered any more precise information.

I write because on the most recent time we had intercourse, the condom slipped off and vanished inside her when I withdrew after ejaculation.  I'm not sure if it slipped off during the intercourse itself, or after.  She disappeared to the restroom to remove it, did not seem overly concerned, and reassured me that she was clear of disease.  For some reason this only made me more worried, hence I would appreciate your advice:

1) Does the risk of HIV in this instance justify a course of PEP? (The event was very recent.)
2) Should I try to get her tested for HIV soon to get a clearer picture of my risk?  I will of course test myself after the window period, assuming no PEP.
3) For what other diseases should I seek testing, and when?  
4) I have a significant other whom I will see over the holidays (alas, for reasons of work we have been living on opposite coasts for the past year).  What advice would you give about my contact with her?  That relationship has been strained recently as you might imagine given our separation, but the separation may be over soon and I don't want to lose her over this indiscretion.  

Thank you in advance for your guidance.

[concernedinct627]

Just a quick update: the CSW and I sat down and had a long talk about the situation yesterday evening.  I think the upshot is that my fears were greatly overblown.  For my own peace of mind I'll get tested for gon/chlam/syph/HIV at the recommended intervals, but at least I hope you will agree that the need for PEP now seems low.

Basically, she was tested for everything shortly before her child was born, which was four months ago.  Doesn't inject drugs.  She has a clinic she goes to for STI testing every six months.  She says she has never been diagnosed with an STI in the past.  She always uses condoms with her clients.  And most importantly, the reason she wasn't too worried about our mishap was that the condom was intact and the semen still inside it, which seems to suggest it slipped off on withdrawal and not before.  

Thanks again.  I'll let you know if something disastrous turns up in the testing, although I'm now feeling somewhat more optimistic it won't.

[H. Hunter Handsfield, M.D.]

Thanks for the thanks.  I'm glad to have helped ease your concerns.

I imagine you are exactly right:  many (most?) CSWs probably are pretty good at judging the likelihood their clients have HIV or other STDs, and she felt comfortable that the possible condom failure had not seriously put either of you at risk.

[concernedinct627]

Thank you -- this is very helpful and encouraging.  I suppose the thing that worried me most was the CSW's fairly relaxed reaction to the mishap.  Overall, she seems like a very sensible and sane person, which is why I started seeing her in the first place.  Who knows, perhaps she doesn't think that I'm too big of a risk to her (and I can't imagine I am given a negative test within the past year and a very thin sexual history).  

Going forward, I will see if we can't at least take an oraquick test together, and I'll suggest a clinic visit (on me, naturally).  Failing that, I'll get the tests you suggest.  If it's useful to you and the forum to know the results, I'll post them.  

Thanks again.

[H. Hunter Handsfield, M.D.]

To clarify a middle ground with regard to testing and intercourse with your regular partner:  The risk of gonorrhea and chlamydia is very much higher than for HIV or syphilis; both of the last would be really, really rare in this situation.  As I noted, the gonorrhea/chlamydia tests are valid very soon.  So you could consider testing for those, and waiting until those results return before resuming sex at home.  But the chances of syphilis or HIV are really extremely low, and I would not recommend delaying sex with your regular partner for 6 weeks on account of such a low risk.

[H. Hunter Handsfield, M.D.]

Welcome to the forum. Thanks for your question.

Your partner may be a commercial sex worker, but it sounds like she is attentive to her health, wants to avoid HIV and other STDs, and works hard to achiev that. Most such women stay infection free.  After all, it's in her interst:  sex workers are at much higher risk from their clients than the other way around!  In any case, you describe someone who seems to be pretty certain she doesn't have HIV.  To your specific questions:

1) Criteria for PEP vary from place to place, and I can't say the local criteria.  But personally I see no need.

2) I don't even think this event is sufficiently high risk for you to even be tested.  Of course you are free to be tested anyway, if you will gain additional reassurance from your negative test result.  Or, even better, talk to your partner and go test tested together, both for HIV and other common STDs.  If her tests are negative, you will know you were not at risk.  (You might offer to pay for her test!)

3) In the absence of symptoms, the risk of other STDs also is low.  But for enhanced reassurance, you could have a urine test for gonorrhea and chlamydia (valid any time more than 2-3 days after exposure) and a blood test for syphilis (6 weeks).

4) Nobody would blame you if you decided to defer sex with your regular partner until you have been tested and negative.  But the risks are low enough that if I were in your situation, I would continue unprotected sex with my wife without worry.

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