HIV exposure risk in compromised immune systems

[needshelp987]

Dear Doctor,

I'm having some very intense anxiety about what I perceive to be a risky sexual encounter within the last 12 hours.

Medical history: Male.  Splenectomy at age 10 due to spherocytosis.  Consequently, I received blood transfusions and was told years later at 18 that I had Hepatitis C because of those.  30 now, and have a very weak immune system.  Last year my lymph nodes were examined for lymphoma through a PETCT and bone marrow biopsy.  It was not conclusive for cancer.  Somewhere I have also contracted HPV and have two small warts on my penis shaft that even after removing come back.  Also worked at a hospital where I got MRSA, and had a staph infection and subsequent week long hospitalization.  Presumably have internal hemorrhoids (blood with every bowel movement wipe).

Activity:  Homosexual encounter, mutual massaging, naked touching of each others penis with hands (back and forth so there is a good chance there was pre cum or semen swapping involved), me receiving anal fingering, and receptive anal sex with a condom.  When he inserted his fingers into my anus he seemed to cut inside of me with his fingernails.  There were a lot of my own fluids being mixed around because of the receptive anal sex, and I'm worried that his semen from before the sex could have been mixed around before putting the condom on, especially while he inserted his fingers in me.  Also I read condoms aren't 100% effective for receptive anal anyway.  The partner is of very questionable trustability.  He told me his ex's last partner was found to be HIV+, although he assured me he has been tested twice since, one of those supposedly being after a six month period.

Does anything strike a concern with you?  Assuming he is HIV+ what is your risk assessment?  Should I immediately go to the ER to seek post exposure treatments considering my susceptibility due to my compromised immune system?  I'm having crippling anxiety right now.  Thank you for your time and consideration.

[Edward W Hook, MD]

Welcome to the Forum.  The activities you list include mutual masturbation and condom protected receptive anal intercourse (and condoms are effective when used for anal intercourse unless they break), neither of which is  a high risk activity for HIV acquisition.   That your partners' former partner had an ex partner how had HIV does not mean that your partner had HIV.  Even if your partner had HIV which is no more likely than it would be for another male partner, your risk of infection is quite small.  Had a condom not been used and had your partner been infected, your risk would be about 1 in 100 - you used a condom and don't know your partner's status making your risk lower.  I would categorize this as a low risk encounter.  Your splenectomy and hepatitis C do not change this.

So, should you get PEP. I would not advise it unless you know your partner had HIV or if the condom had failed.  On the other hand, 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, 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).  

I hope this comment is helpful to you in your decision process and has at least provided you with some data to base your decision making on.  EWH

[Edward W Hook, MD]

The issue of low risk if a personal decison.  In some people a risk of 1 in a million is too high, others accept 1 in 100 has being "acceptable" risk (I would not).  If I had to put a number on your risk it would probably be less than 1 in 10,000 and probably far lower.  You however have to make the decision.

My comment and assessment did include consideration of rectal masturbation as part of my assessment.

No, shaving would not in any way change my assessment.  

There are no lab diagnostics which will help you in the PEP decision.  If you choose to seek care in an ER, I would simply tell the person as you check in that you may have been exposed to a sexually transmitted disease.

I really do not think you need PEP but again, as I said before, this really is your own decison.  Take care.  EWH

[needshelp987]

Dear Doctor Hook,

Thank you for your prompt, concise, and well thought response in my specific consideration--and for your kind welcome to the forum (although admittedly I've been reading for years).  

When you say low risk, is that magnitude reason enough to worry, or do you mean it is considerably low enough as to not necessitate such concern?  I additionally wanted to comment (embarrassingly) that very recently (hours before) I shaved my entire lower body, does this increase my risk?  I've read other similar articles but does the time period make it exponentially worse because of the possibility of thousands of tiny open routes?  Also you didn't comment on the fingers in the anus, which I've read in your forums have never contributed to an HIV infection apparently, so I'm assuming that was because even if he had relatively low amounts of HIV infected semen on his fingers or cuts the risk is fairly negligible?  

Paralyzing fear here.  This stupid 'experiment,' if you will, is the last--the unbearable stress is definitely not worth it.  I'm still considering the PEP, however I'm extremely anxious about going to my local ER and I feel like the clock is ticking away for my possibility of a safe future.  Upon being seen by an emergency physician, how would you recommend I approach asking them if PEP is an option (they always ask you at reception "sooo, what are you wanting to be seen for" too..), and are there any lab diagnostics or monitoring of any kind that can assist in tracking an evolving infection to warrant PEP?

I can't express enough my sincere gratitude, and the appreciation of my family.  Thank you so incredibly much again, and for all that you've done for everyone on here not just myself, you're a kind soul.