Subject: 20% probabilities of transmission? (1/3/02)

Q. Dear John; three weeks ago, I had sex with a woman of unknown seropositive status, but with a history of many sexual partners that doesn't make me to be optimistical about her hiv + or - condition. We had, in two hours, two acts of 100% safe sex (fellatio with a correctly-used condom, vaginal intercourse with a new different condom), but other two contacts; 1) With a third condom, I tried to penetrate her, but this time I think I didn't insert my penis at all: the condom broke, I think as the result of touching, with the little space of it reserved for the seminal emission, with a point of her pelvis or her perineum free of any hole (anus nor vagina) [She was on all fours, showing me her back, I didn't feel any penetration on her, and, if any, had to be of simple external contact or a minimal insertion in depth and for a fraction of a second]. 2) I practised her a cunnilingus, without protection. I have a little pyorrhoea and I had bled a little from my gums about five hours before]

I went to see my doctor four days later. An excellent and widely recognized by his colleagues general practitioner, who prescribed me the VIH & STDs tests and told me about a probability of having been infected by VIH of 20% if the woman were VIH+. This is MUCH more than what I've found in all of the studies I've read. Could that odd be exact? Does the condition of Cuban of the woman increase the risks, because of different presence in the Caribe of another branch of the HIV? Is there any evidence that odds could be so bad, perhaps because of the intrinsic limitations of the classical studies using couples with one member vih+ and another one initially free?

The 17th day after the exposure, on the other hand, I began to have a little fever (very little), yesterday, on the 18th day, a little more, still few, anyhow. This morning I got up with more than 100F.( 101 in the morning, 103F at 12:00,  100 in the afternoon), a terrible headache and shooting sharp aches in my eyes, together with throat ache and a little coughing. Do you think that could be symptoms of ARS?

Congratulations on your excelent work! I'd thank inmensely an answer as I feel terrible symptoms of anxiety (even if I was prescribed alprazolam by my doctor in order to diminish them until I'll have reliable results of the tests). Thank you very much and I apologize on my bad English (I'm a foreigner writing from Europe). Best wishes for the 2002 that begins!

A. Thank you for the questions. To your first question about the 20% thing, I would agree that seems awfully high to me, and I would doubt that would be an accurate estimate of your risk. The risk from a single exposure is generally quite low, and in the exposure you describe, I would think the likelihood would actually be very low. Even with condom breakage, the risk is still low because even a broken condom will provide at least some protection, and if you never actually penetrated her, there would be no risk at all. The risk of performing cunnilingus on a woman is also quite low, although bleeding gums may increase that risk, but probably not by much. If I were to make a guesstimate on what your likelihood actually is, I would put the percentage at something more like 0.01%, which is practically negligible and probably still higher than the actual percentage. The studies I have seen on single exposure sexual risks has never been as high as 20%. Even with the most risky sexual practice (unprotected receptive anal sex), the estimate is somewhere between 0.3% to 3%.

The fact the woman was Cuban would have no bearing on the risk factors. To the best of my knowledge, the various strains of HIV do not affect how infectious they are; simply how they respond to treatment and how the disease may progress. Even with that, I have not heard that Cuba has any different strains than the majority of the world.

It sounds to me that the physician that you went to may not have a great deal of experience with HIV. He may be a terrific doctor in everything else he does, but many physicians are not particularly experienced in dealing with HIV and often have information that is outdated or incorrect. He may have also been trying to scare you into being more careful (although it sounds to me like youre doing an excellent job of protecting yourself anyway).

As for your symptoms, remember that trying to diagnose ARS or HIV based on symptoms is a fruitless task that will just generate more anxiety for you, the only way to truly diagnose HIV or ARS is through testing. Also, keep in mind, Im not a physician, but based on what you stated as your symptoms, I would think it is unlikely that those are ARS symptoms, especially considering the low likelihood of your being infected. It sounds more likely that they are due to anxiety or even just a cold. Coughing especially is rarely seen with ARS, and the shooting pains in your eyes sounds very typical of an anxiety reaction. If your symptoms persist or get worse, you may want to consult a doctor (a different one than you went to before).

This must be a very high anxiety time for you, which is perfectly understandable, and Im sorry to hear your doctor added to that anxiety. Just remember, your risk of infection is really quite low, so youre probably worrying over nothing. If this anxiety is controlling your life, you may wish to consider taking alprazolam to help alleviate that, although that is a drug that does make me a little concerned since it is a narcotic. Im not sure what sort of HIV resources are available to you in your country, but perhaps you could call one of them to seek some counseling from someone.

If you feel the need to test, which in your situation would really only be recommended to put your mind at rest and is probably not really needed from a medical standpoint, do so at 3 months following the exposure. The other tests available (i.e. viral load or antigen testing) would not really be recommended given your risk factors, and a standard antibody test should be fine. If the test is negative, then you have nothing to worry about. Best of luck to you through this and feel free to let me know how things turn out.


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