Hi Dr. Bob, I had sex tonight with someone I met online. He says he is hiv negative and always practices safe sex. I bottomed and he used a condom. After he left I sat on the toliet and squeezed out of my rectum what looks very much like cum. I went to the trash and looked at the condom, it is not broken, but there is little fluid in it. How could cum get into my rectum if the condom didn't fail? I am stumped. To top things off (pardon the pun) I noticed a small bit of rectal bleeding afterwards. So, it looks like I've had semen in my butt and it was bleeding on top of that. What should I do? Should I try to get pep or what? I am worried. I always practice safe sex and I've never had anything like this happen before. I need advice. I am in Miami. I've donated in the past and I will donate again.
You present an unusual dilemma. If the latex condom was used properly and did not fail, your HIV-transmission risk would be essentially nonexistent, even with the mild rectal trauma and bleeding. What you expelled after sex might have been lubricant and/or rectal mucous. That there was only a small amount of fluid in the used condom may reflect a relatively small ejaculatory volume. Taking all these assumptions as true, again your risk would be essentially nonexistent. However, if indeed ejaculate did find its way into your butt and there was rectal trauma/bleeding, your potential risk increases. The status of your partner, despite his assertions of being negative, must be considered "unknown." Under this set of assumption, PEP could be considered. (Anal receptive sex with trauma/bleeding with partner of unknown HIV serostatus.) The ultimate decision to PEP or not to PEP may rest in the outcome of the following matchup: your degree of certainty that either the condom was used properly during sex and intact post-sex versus your inclination that it was indeed ejaculate that you expelled post-sex.
PEP, if you decide to take it, should be started as soon as possible and no later than 72 hours after the exposure. An HIV specialist should monitor you while on PEP. That specialist, after taking a more detailed history, may encourage you one way or the other regarding treatment. PEP or no PEP, you should plan on taking an HIV-antibody test at the three-month mark.