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Unprotected sex with a HIV positive woman with a viral load of 700,000?

Sep 24, 2017

Hello Damon,

Unfortunately and stupidly, I had unprotected vaginal sex with a woman. At 22 hours post exposure, I started the emergency PEP treatment and am currently on day 4 of PEP. I also urged the concerned woman to under HIV ELISA (4th Gen) and HIV RNA and her results are as follows: ELISA - REACTIVE; HIV RNA - 700,000 IU/ml. My questions are as follows:

1. In terms of statistics, how likely are the chances of HIV transmission from a HIV positive woman with a high viral load of 700,000? Can I 100% assume that with such a high viral load, I must have most definitely contracted HIV infection from her, given that we indulged in unprotected vaginal sex?

2. How effective is emergency PEP treatment in case the virus transferred had a high viral load of 700,000? In other words, does the efficacy of PEP vary depending upon the viral load of the HIV positive person transmitting the virus?

3. My last question is unrelated to the above scenario but is a general question about HIV transmission from a HIV positive woman to a HIV negative man during vaginal sex - is it true that the fluid carrying infectious HIV virus is located deep inside the vagina near the cervix and not closer to the opening of the vagina? If yes, then would it be correct to say that the risk of HIV transmission during vaginal sex arises from the fact that by the penis hitting the cervix the infectious fluid from the cervix is pushed up the urethra of the penis thereby causing HIV transmission?

I shall be extremely grateful to have your expert insight.

Best regards,

Anurag

Response from Mr. Jacobs

Hi Anurag,

I'm sorry that an intimate encounter turned out to have such devastating consequences. I would not describe a sexual act as "stupidly", but more on that in the minute. Cheers to you for being aware of your risk factors, and taking immediate action to access PeP for protection. Let's break down your questions one by one:

(1) No, you cannot make such an assumption. It's true that the numbers you were given suggest she has a very high detectable viral load. Nevertheless, there is still less than 1% chance that you would have acquired HIV from this one exposure (https://www.poz.com/article/HIV-risk-25382-5829). I'm not saying it couldn't happen, but statistically it is rare for the insertive partner to acquire HIV this way.

(2) Unfortunately, we don't have adequate data that tells exactly how well PeP works. But the limited data we have tells us it is extremely rare for someone to acquire HIV after using PeP for 28 days, especially when they initiate it prior to 36 hours after the exposure. Given that you started 22 hours after the potential exposure, and assuming you stay on the prescribed regimen, that again reduces your chances of acquiring HIV from this encounter to nearly zero.

(3) I have not been advised that there are areas of a woman's body that are more likely to transmit HIV than others. When someone has HIV and a detectable viral load, she is capable of transmitting to another adult in any of her blood or vaginal fluids. So if her blood or vaginal fluids had access to the mucous membranes inside your penis or foreskin, then there was an opportunity for transmission. But again, it is rare for an insertive partner to acquire HIV this way, and even more unlikely after completing a 28 day regimen of PeP.

Now, let's get back to "stupidly". I understand that joyful sexual activities are often stigmatized by doctors, E/R workers, and even columnists at other publications. Perhaps labeling your own pleasure as "stupidly" is necessary when communicating with them, as it can be a great defense manuever to call yourself a name before someone else in a position of authority can.

But I hope as you take care of yourself the next 28 days, and see those subsequent HIV tests return as "negative," that you can do an honest assessment of your sexual enjoyment and risk without stigma or judgment. If you enjoy condomless intimacy with partners, as most men do, then you may wish to review what your options are for seeking this level of physical sensation while minimizing consequences.

PrEP ("PRE-exposure prophylaxis") is one option that many men and women are using in order to experience condomless intimacy with partners without fear of acquiring HIV. It does not prevent any other adverse consequences (such as pregnancy or STIs), but it does allow couples to create a sex life that feels more comfortable, intimate, and fearless, for both. One of the advantages of PrEP is that you must be screened for HIV prior to getting a prescription. In this case, if you and your partner had both been screened for PrEP ahead of time, she would have learned of her HIV status much earlier, and then had an opportunity to reduce her viral load before ever having this encounter with you. There is a global directory of PrEP providers listed at https://www.pleaseprepme.global/prepme-map/ .

I hope your current circumstance enables you to review, examine, and explore more practical ways for you to take care of yourself and experience pleasure in more proactive, responsible, and empowered ways. For more information about PrEP, please visit out library here at The Body.com: http://www.thebody.com/index/treat/tenofovir_prevention.html



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