Help to assess level of risk from this encounter

[b2400]

I had a sexual encounter with someone who did not tell me he was positive.  I am wondering how infectious you think his semen and/or pre-cum would be given that I later found out that he:

Seroconverted 8/2012
Got on medicine 5/2013
Became undetectable 7/2013 (3 months ago)

I have read conflicting information about undetectable blood levels vs. semen levels - but the majority of the opinions seem to say it is still in semen even if the blood does not have it.  Another issue is that he had receptive anal sex with 4 men earlier that same night (I was unaware of this until later), and he also performed oral sex on all of them in the same night (and did similar things in the two prior nights - I don't have details but he's versatile).  So, he may have another STD (chlamydia or gonorrhea) which again raises the infectious factor.  These activities were all done in a bath house. 

So (1) Based on the above info, how infectious do you think he was?

And (2) Regarding transmission, I had a cold a week ago, and one tonsil still has a white dot pus / WBCs (I didn't realize this before - they are not tonsil stones).  That's another concern for me since his pre-cum got in my mouth and we had sex for 4-5 hours, so there was repeated exposure and some roughness / abrasion.  Some also got in my ass - briefly (via finger not penis). It's hard to even know, at this point, what fluids got where.  All I know for sure is that he did not cum in my ass or mouth - but pre-cum got in both locations.  He also performed oral sex on me, which I know is basically no-risk - but not sure if the risk is higher given he blew 4 other guys that night (and more in the prior 2 days) and may have had an oral STD.  He supposedly got HIV from topping...so I don't know - I guess anything can happen (if that's even true).  At the time, I had a bad ingrown fingernail that was swollen - and applying hydrogen peroxide to that burns like hell - so I am guessing this is considered "open" or it wouldn't burn - but more relevant - it would be receptive to infection given the WBCs present.  With all the contact, I am sure some pre-cum got on there too (via JO). 

Thank you for your help.

P.S.  I have been sexually active sine 1996...so I mostly learned about HIV during the hyper-fear era, so that is why this might sound overly paranoid.  I have always been pretty careful...I just have major surgery coming up that is going to prevent me from having sex for up to 6 months - so got a little more into the anonymous thing than I normally do (also, the medication may cause abnormalities in my pre-op labs so I would gladly stop it).  I have already read the posts about the different levels of risk from similar sexual behavior, but there are some variations here.  My friend on PREP just gave me Truvada because he & his partner both thought it was too risky.  But, I started it at 48 hours post... which isn't great.  I would stop it if it is unnecessary because of the side effects I am having. My stomach is going crazy and my urine is already dark and almost greenish from just 3 days of Truvada, so of course I am seeing a doctor this week.  It was just easier at the time to get it from my friend who said he has no side effects and was on it for a year.

[Andy Velez]

Let's keep this simple, B. The only confirmed risks for the sexual transmission of HIV are unprotected vaginal and anal intercourse. As long as condoms are used consistently and properly for those activites you'll be well protected.

It's not clear to me from your comments as to whether or not you have had unprotected anal intercourse. Please clarify if I am missing something.

[b2400]

Hi Andy,

Thanks for your quick reply.  There was no receptive anal sex.

I know this has been debated ad nauseum - but the oral sex risk is part of my concern  (http://hivinsite.ucsf.edu/InSite?page=pr-rr-05  and
http://www.poz.com/articles/348_2126.shtml (paragraph 3)

Since he had sex with 4 guys that night (and the two nights before) he may have a secondary STD like chlamydia or gonorrhea which raises the risk:  http://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm  (also on the first link).

And, it is in pre-cum / has been transmitted by pre-cum: http://vimeo.com/18978846 

So I am just trying to sort through this information because on one hand - people say you cannot get it through oral sex (or precum doesn't have enough) but on another hand, people say you can & it's more risky if the person has another STD (and multiple bath house partners in a 3 day period make me think another STD is probable).  And, last - I had some kind of white patch on my tonsil and an infected cut.   (I can't find this website now - but it was a university website explaining why infected skin or mucosa is higher risk than in-tact or broken skin)

Sorry my posts are so long - I am trying to get it all in w/ the restriction before paying.  I don't think I'll need enough help to have to ultimately start paying - but there's the info I am working with.

Is there any way to know if someone is undetectable in blood - how much that corresponds to their semen?  Would 3 months of undetectable mean anything? 

[jkinatl2]

Given that performing oral sex (fellatio) is considered close to no risk even with  high viral load, and the person is on meds - you had no risk for HIV even if he had a secondary STD.

The caveat for seminal viral load blips only applies to unprotected anal and vaginal sex. Moreover, the studies you cite did not record the seminal viral load count, nor did they verify if the viral particles found were viable.

None of the sites you cited mentioned the three serodiscordant studies of which you are undoubtedly aware, which lasted ten, five and three years on two continents. In these studies serodiscordant couples used barrier protection (condoms) for anal and vaginal sex, and no protection whatsoever for any form of oral sex. No infections were linked to oral sex in any of these studies. This, of course, comes as no suprise to people aware of the powerful HIV inhibiting properties of saliva, which breaks down the glycoprotein shells surrounding HIV and render it incapable of infection.

In short, even taking into account your caveats, our risk assessment regarding fellatio remains unchanged.

You had no risk in the scenario you described.

[b2400]

Maybe my doctor is being too aggressive...  I just got back from there and he wanted to give me a rocephin shot again without even getting a positive  gonorrhea result...he wants me to complete the full 28 day PEP.  I am not giving him any different facts than I am stating here.  He is an infectious disease doc from Africa - so he has seen a lot of HIV/AIDS.  Maybe he is going overboard?  He said it IS "low risk" and I kept saying "I really think it's no risk - except the other STD caveat" (which you said has nothing to do with oral anyway) and then he just acted like there's no point to stop the PEP because it's more risky to go off. When I said I had diarrhea from it & my pee was green, he said "that shouldn't happen." Well, it's the first side effect listed...and it says to tell your doctor if your urine is dark.  ugh.

I didn't understand this: "Moreover, the studies you cite did not record the seminal viral load count, nor did they verify if the viral particles found were viable. "  I am not sure what this referred to.

Btw - I didn't write one line in my last post right - there was no unprotected anal - but there was like 2 minutes of anal with a condom (me on the bottom). So, my doctor kept insisting that the condom may have broken (in the 2 minutes)...because I said I didn't "inspect" it after (and he didn't ejaculate) so he really wants me on the drugs (he said no ejaculation doesn't matter).  I said I highly doubted it broke in 2 minutes... but he didn't seem to like that answer.  He also saw the white dot in my throat and just said he didn't know what it was.  That's weird to me..for an infectious disease doc.  He just said "it's not thrush" (duh). Btw, I asked him and his secretaries if a lot of HIV patients come in there - and they said a lot do (and he's right by a big gay neighborhood where all those crazy ads for that belly fat reducing drug were on every bus stop last year).

I am going to go to a dedicated STD clinic tomorrow so I can just probably stop taking this stuff.  I think they will mostly agree with all of you.  In the meantime, he sent me to Quest with a dozen labs - He also had me tested for Hepatitis AB&C, Syphilis, Chlamydia and Gonorrhea through urine and oral (I don't think any of this will even be positive yet if I got it - but he said he wants a baseline). 

I know about the serodiscordant Truvada study... and honestly there is a lot to read on this - and yes, I saw the oral study (or studies) referred to in a post somewhere - but never a  link to the actual text anywhere.   Can you send me the link?  I have tried looking on google and google scholar and it's not coming up with my search terms.  A case of oral transmission did come up when I searched, but it was a case report dealing with a drug-using prostitute so I am going to ignore that one.

Well, this is my last post - so thanks for your help.