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Am I at risk: condom insideout, oral sex and ulcers?

Q: I had recently met with a guy a week ago just to have my first experience through an ad site. He’s a middle-aged married guy who also has no encounter yet with the same sex but occasionally had extramarital sex with women he personally knows (his most recent one was a month ago). According to him, he is DDF and always uses condoms with other women.

Before the meet-up, we agreed that we will use condoms while giving him oral sex. We mutually masturbated each other first using lubrication. Then, I put on the condom but it was on the wrong side at first. There might be some pre-cum at the tip when it was at the right side afterwards. I just did it for less than 5 minutes until he decided he isn’t comfortable with it. The complication with me is that I had a mouth ulcer during that time. It was probably 80% healed because there was minimal or no pain but still present.

Although I was thinking that the scenario was very safe, I’m still looking into certain details where I may get infected. I am worried about the presence of the mouth ulcer and possible pre-cum at the condom tip. Also, it might be possible that the lubricant in my hand which I used to put on the condom may have contained pre-cum as well and I’m not sure if it can be a source of transmission. I would like to know if the risk is significant. If it is, when is the earliest time I should go get tested? 

Ask an Expert’s Health Educator has said:

 A: Thanks for your question. If the man you had sex was HIV positive:

  In terms of transmission from the possible fluids on your hand – there is no direct risk of HIV transmission here unless you had open bleeding cuts present on hands.

 In regard to any transmission risk from oral sex – oral sex is really only ever considered a significant risk when it is unprotected, with ejaculation in the mouth AND when open cuts or ulcers are present. Considering you had an ulcer and there is a possibility that infected fluids were present on the outside of the condom (either as a result of you first putting it on the wrong way or from any fluid left on your hands), a risk of transmission does exist. Having said this, transmission via this route is very uncommon and if your ulcer was partially healed this would lessen the risk. All things considered, it would be a good idea to get tested, especially considering that other sexually transmissible infections (such as gonorrhoea and herpes) can be transmitted via oral sex, and are much more easily transmitted than HIV.

 I would recommend testing for HIV at approximately 3 months after the date of the incident (it would be worth getting a full STI check at the same time though). Three months is the standard time needed for someone’s body to respond to HIV after being exposed. Waiting three months allows the standard HIV test to be most accurate.  As a guide, everyone who is sexually active is recommended to test at least once a year anyway, and many men who have sex with other men are recommended to test approximately every 6 months. If you are experiencing any symptoms in your mouth or throat, I would recommend a general sexual health (STI) screening as soon as practicable.

 In response to your use of the term ‘DDF’ (Drug and Disease Free): terms like DDF (which are really common on hook up sites) are negatively loaded: they ostracise and can unintentionally cause offence to those who are living with infections like HIV. The term is also misleading: worldwide, the great majority of HIV transmissions occur due to unprotected sex rather than drug use. Many people who use recreational drugs are not living with any STIs and vice-versa. As a strategy, DDF (aka serosorting) is often not reliable. In Australia for example, it’s estimated that a third of new HIV infections are transmitted by someone who is unaware that they have HIV. Nevertheless, if you wish to use the strategy and limit having sex with only those who are HIV negative and are willing to trust your sexual partner’s knowledge of their status there are more reliable questions to ask. As an alternative, consider asking their status directly and, if negative, when their last HIV test result was and whether or not they’ve had any unprotected sex since that test. The option many end up going for is simply to practise universal caution and practise safe sex with everyone.

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HIV Disclosure: don’t ask don’t tell policy?

Q:Thank you very much.The information you provided was indeed helpful, but one more question let us say upon complying with the requirements assuming there was no hiv status requirement for us to submit, does the state also practices don’t ask don’t tell policy? thank you.

 Ask an expert’s lawyers have said…

 A: In the Employment sphere, there are very few situations where your HIV status will be relevant to your work (provided you are able to perform the inherent requirements of the job).

There are only a few areas where it will be relevant. These include health care workers who undertake exposure prone procedures (as described in the previous answer), defence force personnel, and applicants for some classes of commercial aviation licences.

Everyone who applies to join the Australian Defence Force is tested for HIV. If you are HIV positive, you will not be accepted into the Force. Existing employees also have to undertake regular testing.

In the event that you decide to disclose your HIV status to your employer, they have a general duty to keep that information confidential and in many cases will be subject to Privacy laws. However, in practice, if your employer does breach your confidentiality it may be difficult to obtain a satisfactory remedy once the information has been disclosed to another person.

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Please note, this question and answer relates to a previously asked question which can be found in the archives here: http://askanexpert.tumblr.com/post/48343461860/visas-and-working-as-an-hiv-person-nurse-in-australia

PEP, HIV Testing and the window period when getting test results

Q: I stepped on a bloody needle in Thailand and have been put on PEP. I’ve been taking the meds for 2 weeks now and am feeling pretty lousy. The doctor said that there is a test I can do at 10 or 14 days that can tell if I got it or not, is this true? Do I just go to an Australian hospital to get the test? Can I stop PEP if the test tells me I didn’t get HIV?

Ask an Expert’s doctor said:

This is an interesting situation.

You say the needle was bloody as in blood stained or is that an explicative? Also you do not state which drugs you are taking.

Normally in Australia we would not consider PEP for such an injury but  admittedly the frequency of HIV infection in Thai IDU is higher and blood on the needle may affect the risk assessment.

The doctor may be referring to one of two tests.

1) There is a test that under normal situations will detect HIV infection early and it is the standard screening serology test performed in Australia. It is usually positive by 21 days with confidence intervals around that of  10 – 40 days certainly better than the  upper limit of 3 months with the gold standard test of Western Blot which can take up to 3 months. It is relatively cheap. 

2) Nucleic acid amplification tests(NAAT) are very expensive but will detect viral RNA and would be positive in 10-14 days maybe earlier.

The complicating factor is the use of PEP which animal studies suggest may delay sero-conversion so the serology test may be inaccurate early – falsely negative.The NAAT is more accurate but I am not aware of any data on its validity in the situation of detecting failed PEP.

The simplest solution is to change the medication  to a regimen with a lower side effect profile.

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VISAs and working as an HIV+ person nurse in Australia

Q: I am a filipino, nurse by profession, I was diagnosed as hiv+ 2 years ago, in compliance with the medications, and has improving cd4  count, do I have a chance to study and practice my profession in your country? and what are your rules if someone outside your country who works in the field of health care whose recently-diagnosed with hiv? I just want to ask as well if Australia practices, if an hiv+ health care practitioners especially nurse are do you re-assigned workers to a less communicable department such as outpatient department and the likes. Thank you very much.

Ask an expert’s lawyers say…

 A:

There are a couple of questions here and so we will answer them in two parts:

Can a nurse who is HIV positive work as a nurse in Australia? Are there any restrictions on what kind of nursing work an HIV positive nurse can do?

If you are an HIV positive doctor or nurse, you can usually continue to work without any restrictions. However, you must not perform ‘Exposure Prone Procedures’. These are procedures performed in a confined body cavity where there is poor visibility and a risk of cutting yourself with a sharp tool, or on a tooth or sharp piece of bone. This restriction particularly affects surgeons, operating theatre nurses and dentists.

If you are an HIV positive surgeon, dentist or operating theatre nurse, you must seek advice from your professional body as to the types of procedures you may and may not perform or assist with. 

Can a skilled person, for example a nurse, who is HIV positive, obtain a visa to work in Australia?

Yes, you can apply for a temporary work visa. The main type of temporary work visa is the 457 - temporary Business (longstay) visa. The 457 visa allows the applicant to stay and work in Australia for the sponsoring employer for anywhere between three months to four years. It requires nomination by an approved employer. A person living with HIV will not meet the health criteria. If you do not meet the health criteria, you have the opportunity to have the health criteria waived. This is a complex process and we recommend that you obtain advice from a registered Migration Agent to assist you through the process.

For further information about the 457 visa and other migration options for people living with HIV, please download the HALC Migration Guide, available from our website at:

http://halc.org.au/wp-content/uploads/2012/10/positive-migration-guide.pdf 

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risk with low viral load and condom use

Q: What is the statistical risk for the receptive anal sex partner whose infected partner has a low viral load and consistently uses a latex condom?

A: Ask An Expert’s Health Educator said…

Research has yet to calculate such a specific statistical risk and the risk is likely too low to quantify anyway.

You have mentioned two good risk reduction strategies here (the positive partner having a low viral load significantly reduces the risk and condom use (with water based lubricant) is the gold-standard of risk reduction methods which on it’s own makes transmission highly unlikely).

Giving you a statistical number is the difficult part, for example whilst we know a low or undetectable viral load significantly reduces the risk of HIV transmission, it has yet to be established how much of a reduction it makes. Nevertheless here are some numbers for you:

It is estimated that the absolute per-act risk of acquiring HIV when a person has receptive anal sex without a condom with an HIV positive partner sits at about 5 per 1,000.

•               Add consistent condom use into the picture and the transmission risk is estimated to be reduced by 85% to 95%.

•               Add to the picture a low viral load and the risk reduces again. As some guide, in one study investigators found a 60% decrease in HIV transmission after the introduction of effective medications in a population of gay men. Keep in mind however, this study did not consider or control for condom use in the men participating and it was reported that this 60% reduction occurred despite the increase of risky sexual behaviours in the San Fran men.

Obviously no method of sex is totally risk free but neither is walking across the road.

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Anonymous asked: Hello again! I had submitted a question on March 4th that seemed to have gotten cut off. Here is the rest: I know that saliva cannot pass HIV on its own, but what if there was blood /or if was completely blood? I don't know as I was never able to see it. I had not flossed since the night before and had not brushed my teeth since that morning (this happened in the afternoon-I had not eaten).I I didn't think that anyone would approve me for PEP for this, so I didn't pursue it. Was this correct? I

Your question has been answered and has been posted below the second part of this question: http://askanexpert.tumblr.com/post/45245786872/sorry-i-am-too-wordy-here-is-the-rest-i-took-an 

This answer also relates to your first post which can be found here: http://askanexpert.tumblr.com/post/44578049368/hello-i-am-writing-because-i-had-a-situation-arise 

Anonymous asked: Sorry, I am too wordy. Here is the rest. I took an Oraquick test at nearly 5 weeks post exposure. It was negative. Is this a good sign? Thank you very much for your time and consideration. I really appreciate it!

Ask an Expert’s Health Educator Said:

A: Transmission via the mucous membranes in the mouth is really very rare. In fact, most of the research indicates that spitting, even directly into the mouth carries a negligible risk of transmission.

 According to Australian PEP guidelines, your exposure would be classified as ranging from a risk that is so low that it cannot even be measured to being classified as somewhere between a low to moderate risk (if the droplet was indeed blood). To put a figure on it, blood exposure to the mucous membrane lining of the mouth has been estimated to occur less than once in 1000 exposures. As such, it is possible that PEP may have been available to you if you had presented within 72 hours after exposure (based on Australian guidelines). Keep in mind though, that from the information you have provided, it seems more likely that the droplet was saliva or a mix of blood and saliva. If this was the case, transmission is very unlikely due to saliva actually acting to inhibit HIV, and PEP would most likely not have been prescribed in this case.

 In your circumstance, testing is not completely out of the question, especially as it may serve to ease any anxiety you have about the risk of transmission. Testing negative at five weeks is good news, but to be sure, a retest could be taken at the three month mark after exposure as this will ensure that your body has had enough time to respond to any potential HIV transmission thereby allowing the test to be most accurate. Based on the information you have provided there is strong evidence to suggest you will test negative at three months as the likelihood of transmission was negligible. 

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