What are the ways HIV can spread?

Hello doctor,

I was traveling with my daughter in a train compartment. She is three years and seven months old. At around 2 am, she wanted to pee, so I took her to the washroom adjacent to our compartment, but it was locked, and the other was very dirty. So I took her to another compartment washroom. It looked somewhat clean, but near the left footrest, there were around four drops of blood (wet blood). As she could not hold it anymore, I allowed her to pee while sitting in a squat position. The blood was very near to her left foot, somewhere in between the toe and ankle. Her foot was very adjacent to the blood. However, she did not keep her foot on it. Blood was towards the inner side and not on the outer side of the foot. She was wearing Crocs style slippers with six to seven small circular holes on the upper side of the slipper and there with two very big elliptical shape holes on both sides of the slipper, and one more big hole on top (bigger than the elliptical hole on the sides).

I have attached an actual slipper image and a toilet image with a blue-colored circle depicting the foot and a red circle depicting blood to get a better idea of the situation. Apart from that, the foot entry point in a slipper was uncovered, and she was wearing full pants. Her lower leg portion and ankle area might be uncovered. When she started peeing, I saw the blood being washed down the sink by her toilet. One more thing: she has this habit of itching her feet and legs, and sometimes, it bleeds when she does that. I do not remember whether she had itched that time (before going to pee) or whether there was any bleeding after the itch. My questions are:

1. What is the risk of HIV if some blood droplets (after pee falling on blood) splashed onto her leg and feet?

2. What is the risk if some blood droplets back splashed into her vagina or anus?

Please consider the scenario that when initially the pee made the blood flow down the sink, while it was flowing down the sink, again some urine might have fallen on it (blood mixed urine flowing down), and it might have splashed.

I am a very worried father. I did not know that her pee's direction was towards the left. If I knew I would not let her use that toilet.

Kindly help.

Thank you for your response doctor. It has helped me in easing my nerves and I am very relaxed now.

I think the urine did not fall on the blood directly and that it fell somewhere before it however the flow of urine made the blood to be washed down the sink. So in this case the chance of splashing might be low in comparison to the blood.

I have been dealing with HIV phobia since 2017 and I have had several tests over the years for trivial things. All were negative. Since I have HIV phobia, various what-if questions arise in my head, such as what if some droplets of urine mixed with blood dropped on her leg or feet, as well as other locations such as her vagina or anus, and then rubbed with skin or by the slipper on the way back to our seat. We came to our seats and slept covering ourselves with the blanket and sheet provided on the train. I was a bit tensed so I forgot to wash her legs, however after almost four hours, my wife washed my daughter's legs after reaching home. Should I worry or ignore all these things and any other additional what-ifs and move on with life without worry?

I have been in a relationship with my wife only for nine years and have not been involved in any kind of sexual behavior with anyone. Furthermore, I do not do drugs like injection sharing and all.

Just to be clear, what type of wound/cut is deemed harmful, and how much blood is required to be at risk of infection? By what type of wound/cut, I mean how recent a cut/wound is considered dangerous?

Thank you for your reply, doctor.

As I previously mentioned, I am having what-if thoughts such as what if this and what if that in relation to the incident that occurred with my daughter on the train while she was urinating, as explained in my question and the follow-up question.

Can I disregard these thoughts, as well as any other what-if thoughts that may arise later, and go on with my life and entirely relax?

Kindly suggest.

Thank you, doctor. You have been a savior. So, I can relax now as far as HIV is concerned and safely conclude that my daughter is not at risk of HIV from the events that I described earlier. I can relax now for sure.

Hi doctor, sorry to open up this thread again. However, just wanted to confirm a few things for peace of mind.

In question 1 of my original and the first question I had asked: What is the risk of HIV if some blood droplets (after pee falling on blood) splashed onto her leg and feet?

I also mentioned that she has a habit of itching her feet and legs (pimple-like itching lesions on the feet and legs that children acquire from time to time), which sometimes bleeds. I do not remember if she itched at the time (before going to pee) or if it was bleeding.

So she might have itched a pimple-sized wound before having to pee, and the blood near her left foot (as described in my initial question) could have splattered into that wound after her urine dropped on it. Is this a risk?

Again, I would like to mention that I did not check to see whether she had any pimple-like irritating wounds that day, or if she itched them. Kindly help.

Thank you for the comprehensive answer, doctor.

In your reply, you mentioned maintaining hygiene like washing with soap and water.

In our case, as we were on a train, So we could not wash my daughter's feet at that time and we simply came back to our seats and slept. It was early in the morning. However, after reaching home my wife washed my daughter's feet with water and then bathed my daughter with soap and water.

Does it change your risk assessment or the risk will still be non-existent and we can completely forget this incident and relax?

The Six point explanation that you gave to make me understand the transmission was very good, however it has created some doubts in my mind because of the 4th point where you said "Maintaining hygiene is really important for any similar situation, this includes, thorough washing with soap and water and then drying the site". My questions will be related to my daughter's exposure only and I do not want to ask anything in general, because I want to draw a final conclusion out of this and do not re open this thread again because it must be frustrating for you as well to be back on this thread over and over.

Questions:-

1. You told that "Just the splash of a blood droplet over any sight of skin which had been abraded while scratching would not be sufficient enough for the infection to be transmitted." but in 4th point you said about maintaining hygiene as I said above.

2. Now my question is does that washing makes a difference in transmission risk and whether it needs to be immediate. I mean to ask that when you assessed my risk to be non-existent even with the abraded skin(of the sort caused by itching as detailed earlier), whether you assessed the risk presuming that I would have washed her immediately. If so what are your risk assessment now knowing that I did not wash her immediately with or without abraded skin(of the sort caused by itching as mentioned earlier).

3. When you say it is really important to maintain hygiene, which type of exposure do you refer to. Does my Daughter's exposure fall into that category. Whether there is known benefit of doing that as far as HIV transmission is concerned. If So, whether my daughter is at risk since we did not wash her immediately(Washing her after 4-5 hours of exposure is as bad as not washing at all).

4. Whether there is any harm if washing is not done immediately as far as HIV transmission is concerned.

5. In my case since I was on a train I did not wash my daughter immediately. We were able to wash her and made her bath after reaching home after 4-5 hours of the incident. What is the risk in this case of washing her after 4-5 hours and not immediately, considering the splash (as i have mentioned in detail earlier) and considering she might have itched her leg and feet(detailed in the last question). Although I did not check that day whether she had itched or not and if she did whether her itching caused her to bleed or not.

6. Your final risk assessment considering each and every detail that I have mentioned from that start of the thread till now. Is testing needed in this case.(No NABL labs are offering test for kids below 5 years due to unavailability of veins in kids). It is a humble request to you to give point wise reply to my questions (if possible). I know the questions are a bit long, but please spare me and just give a final risk assessment considering I did not wash her immediately. Thank you for your understanding and patience.

1. In your six point explanation detailing ways of hiv transmission you said "Even the direct contact of large amount of infected blood over the intact skin could not transmit HIV.". However in the previous reply point wise answers at point 4 you mentioned that "4. It would have been a concern if a splash of large quantity of blood over unbroken skin or mucosa splash." Did you mean to say that if there is splash of large quantity of blood on intact skin or mucosa and if the site is not washed immediately, then it is a concern as far as HIV transmission is concerned? Or you mistakenly wrote unbroken instead of broken skin.

2. By large quantity of blood splash, do you mean to say blood exposure of the sort a person might experience while helping accident victim?

3. So to summarize the whole thing, I can safely conclude that there is no risk of HIV transmission to my daughter in this case as detailed in my original question and subsequent follow up questions. I can relax and there is nothing to worry about as far as this train incident is concerned.I should move on in life and forget this incident. Than you doctor for your patience. I must say you are by far the best doctor that I have across because you have shown so much patience in answering my repeatedly same questions. (I am dealing with heightened level of anxiety and OCD, that is why my questions are repetitive in nature). But you have shown so much patience and have cleared my each and every doubts. I am very thankful to you.

Some more scenarios cropped up my mind and I wanted to clarify certain things related to the events described earlier. I have attached image of the type of itchy wounds that my daughter gets at times. I have attached image from some random day(image is not from the day of incident on train) and as I have said earlier I am not sure whether she had that wound on the day we were travelling from train and whether she itched it or not. The attached image shows healed/healing wound with scab on it. Although the attached image shows scabbed wound, however seeing the image I hope you can imagine how this wound look like when it is itched fresh and bledding. This is a just a representation to give you idea about the itchy wounds that she gets at times.I have circled the itchy wounds with blue colour. In the image the wounds are shown on leg, however it could be on feet also(not sure since I did not check). Blood splash Scenarios: a)When intially pee might have fallen on the blood which was near he left foot (image already attached for reference) b)Then when the blood started flowing down the sink and then pee might have fallen on it causing a backsplash Although you have answered almost all the questions, below are few more

1. After she was done with her urination we went back to our seat(middle berth) and then we went inside the blanket. Suddenly she said that she is having some itchy sensation. So I itched by rubbing the blanket on her feet or leg (I do not remember exactly whether feet or leg).Does this rubbing creates risk if she had the itchy wound(fresh/healing) with splash(scenarios of splash detailed above) onto it and then me rubbing blanket on to it.

2. If Scab is formed like this on wound, is it still considered a break in the skin or this type of scab is good enough to protect from getting HIV

3. If the splash had landed on vaginal and anal area and then while walking back, it might have rubbed with the female genital organs(inside or outside) or skin(Since I did not wash her as I had mentioned in my previous question). Is it risky.

4. If the splash had landed on the sort of wound (with or without scab) that I have attached and then while walking back it might have rubbed against the slipper(Since I did not wash her as I had mentioned in my previous question). Is it risky.

5. So overall, is it still non-existent risk considering these scenarios or any other scenarios that might come to my mind in future related to this event. I am Just a worried father who loves his daughter so much. That is why I have been returning with these sort of questions.

The image of the scabbed wound which I had attached was taken after a month of the incident and not from that day. I had attached the healed wound/wound with scab(because I do not have any pther image with fresh wound) and hence this image was just to show and give an idea of the type of wound that she gets at times although like I have said earlier I am not sure whether she had that wound that day or not and whether she itched that wound or not and if itched it had bled or not. I think there is some misunderstanding in interpretation of question. I will repost questions below:

1. In question 1 , what I wanted to ask was that: suppose she had itched the wound and then she went for urination and then the splash would have occured and that splash landed on the wound. This all happened in the toilet. Now after that we went back to our seat to sleep and then she asked me to itch. So now when I rubbed that wound, having already splash of blood droplet on it, with blanket. Would that be risky for hiv transmission in my daughter case. I am just talking about my daughter case and not in a general term.

2. As you had said earlier "Just the splash of a blood droplet over any sight of skin which had been abraded while scratching would not be sufficient enough for the infection to be transmitted". So now since I have attached the image of the kind of wound/abrasion she gets. What are your risk assessment. Please note that the image shows a healed wound, but I want you to answer considering wound when it might have been itched very recently with the context of splash that might have occurred in this particular case only. 3.In your reply number 2 above " Usually such superficial scabs do not pose a risk of HIV transmission. At the same time, it's not that such scabs are preventing acquisition of HIV. Importantly HIV transmission can not take place through the touch of blood over skin or not on fresh lesion."

3. a) By this statement did you mean to say that such scabs might lead to transmission.And if so, is my daughter at risk here if she had old wound with scab on it . Or whether you were talking about some other scenerios. Please elaborate. It's a request for peace of my mind.

3. b) If such scabbed wound could lead to transmission, then what about open wound without scab formation. Is it a risk for my daughter if splash occured in her case on open wound without scab.

3. c) When you say " Importantly HIV transmission can not take place through the touch of blood over skin or not on fresh lesion." What do you mean by last phrase "blood over skin or not on fresh lesion." Whether you meant that it is risky if splash occured on fresh lesion. If that is the case, is my daughter at risk here.

4. So now considering each and everything in this context as detailed by me during the course of 1 month of this question, do you consider this a risky scenerio. Or it is a no risk scenerio and that I should forget it once and for all and just relax. Ii is a request to reply in an elaborate manner in content of my daughter case only and not in general terms.

Pointwise answers would help me in clearing all my doubts that I have regarding this case. Please forgive me for the long post ma'am. Please consider my request of pointwise elaborate reply as I am dealing with heightened level of anxiety.