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Protected sex with a female CSW, but with a *potential* tear in the condom

Question: 

Hello.
Two nights ago I had sex with a female CSW and we engaged in unprotected oral sex(which I understand is negligible risk) and two seperate occasions of protected vaginal sex.

During the second episode of vaginal sex, the heater in her room got me fatigued so I took a few minutes to cool down. When we started again I felt a cool sensation on the tip of my penis, she usually applies lube to her vagina, the condom, or both-- which she did as we started to have sex again. However it felt much cooler than I would expect to feel from outside of latex so I pulled out, near immediately.

The condom had no visible signs of breakage, in fact the reservoir tip was elongated (I always pinch the air out of the tip when I roll it down) We decided that since it had been a while since I put the condom on we might as well put a new one on, as to not wear this one out.

If it makes any difference I'm uncircumcised (very rare in the US, especially rare in Los Angeles where I live), but my foreskin retracts completely, and I always roll the condom on after pulling the skin all the way back. For all intents and purposes, I apply condoms the proper way.

I slipped the old one off-- while I didn't notice anything torn or unusual when pulling it off-- I also didn't check carefully and it was dark inside her bedroom.

Now in the sober light of day I'm terrified because I have never had a condom break on me, so I have no reference point for how it feels what so ever.

Other than the loss of my virginity nearly 10 years ago, I have always worn condoms with every sex partner I've had, whether it be a girlfriend, a one night stand, or a sex worker.

And I know that just because she is a sex worker doesn't mean that she has anything, but never the less I'm worried, as I know that she does have a lot of partners.

I'm upset with myself that I did not run the condom under the sink to check and make sure it passed the water test-- I figured I was being safe enough, switching during the uncertainty.

I can't stress the fact that I really don't know if there was a tear or not, if so it was not an obvious condom 'pop' like my friends have told me about.

I'm so worried I'm nauseous, I can't leave my apartment or think about anything else. I just keep thinking what a stupid way to contract such a horrible disease, and while I don't see sex workers habitually, it is something I do a couple times a year when I'm lonely, and actually I only go to the same girl. I'm don't think I can handle the risks involved anymore.

I guess I'm wondering how much my risk is increased (been too scared to google it-- that always makes anxiety worse) and if it would be appropriate to take PEP, or if that's over kill. I would also like to know how soon I can get an RNA test, I know that the window is 2 weeks, but I've been wondering if that's shrunk at all over the years? Like how 6 weeks is a pretty good indicator for the antibody test, would a week be a decent indicator for an RNA/NAAT test?

Again, I don't know if the condom broke, I just don't know. I wish I could tell you. All I know is something felt different, but not in that "oh god it just got better' obvious condom break way. At least from what I've been told.

Thank you for your help, what you do is incredibly commendable and I'm sorry for any excess information, I'm just quite scared.

Answer: 

Hi and welcome to the AIDS Vancouver Helpline,

It sounds like you're feeling quite stressed and upset about this situation.

To start with, it sounds like you did everything you could have to be as safe as possible. It seems like you take your sexual health seriously, and I'm so happy to hear that. It also sounds like you're blaming yourself a bit for this situation. I want you to understand that situations like this do happen, even though you did everything right. The only way to completely avoid risk is to abstain from sex - and that's simply not realistic. With every activity we take part in in life, there is risk, but abstaining from activities that we enjoy in order to avoid that risk is usually not worthwhile. I hope that you can try to accept that this situation happened, and that it's not your fault!

Now, about the condom tearing... there is no way for us to know whether or not it tore at this point. The only way to know your status is to get tested. At AIDS Vancouver we recommend regular HIV and STI testing anyways for anyone who is sexually active. By getting tested, you will be able to ease your mind. That being said, let's talk about your risk. The estimated risk of acquiring HIV during insertive vaginal intercourse is between 0.03% and 0.09%, with an average of 0.04% (based off of a meta-analysis of 3 very influential studies). Or, we can say that in 10,000 exposures, transmission will occur about 4 times. With that in mind, let's think about your possible exposure... You were using a condom that may or may not have had a tear in the tip, as well as you stopped having sex almost immediately after feeling the cool sensation. I cannot tell you that your risk is zero, but I hope that this information will help with your anxiety. I have a feeling your imagination is telling you that your risk is much higher than the reality.

As for PEP, since PEP must be started within 72 hours of your possible exposure, it would be too late at this time to be effective. I'm not sure if you decided to go on it or not since you posted, but I wish you luck with either decision you made. In future situations, whether or not PEP is right for you is something you can discuss with your doctor.

For an RNA test, official guidelines still state that the accuracy is 90% at 10-12 days. Then, further testing is recommended to confirm this result. At 6 weeks the test is 95-98% accurate, and at 12 weeks you will have a conclusive result.

I wish you the best of luck in getting tested. Please know that you are not alone in the anxiety that you are feeling. Many others are going through similar situations right now. What will help is to accept that the situation happened, and that you are not at fault here. Yes, you had sex, and you shouldn't regret that! It's a normal part of life, and before you say that you can't handle the risks associated with it anymore, think about life in general: Would you stop going to work just because you could get into a car accident on the way there? Risk is present everywhere, and while it's best to avoid danger to the best of our abilities (like you are doing by practicing safe sex), a life spent avoiding activities because of that risk is probably not going to be worth living.

Here is a link to a module that might help you to tolerate your emotional distress. I think it could really help you out: http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=54

Warm wishes, Sabina

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