[Question #10258] Known HIV Exposure - Testing Window with Paxlovid & Protection of Others
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24 months ago
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I learned that I was exposed to HIV on July 4. It was oral sex, where the other man ejaculated in my mouth and I swallowed. (He denied having any STDs, but has now tested positive after several years without testing). The oral sex was rough, and he ejaculated far down my throat (versus more in the tongue/teeth area).
I’m unaware of any particular bleeding or sores, but have a history of gingivitis (some bleeding with flossing), allergies, and acid reflux that can inflame my throat. The oral sex also resulted in some vomiting, given how rough it was.
I developed COVID on July 24 and took Paxlovid—which contains 100mg Ritonavir— 2x daily from July 25 through July 29.
I had 4th Gen HIV DUO testing twice—July 29 and August 1 (25 and 28 days post-exposure). Both negative. I took the second test because I feared a rash beginning July 25 (and other common COVID symptoms) might be from HIV. I recognize now that is not possible, as you have said that current symptoms cannot arise from HIV yet produce nonreactive 4th Gen antigen/antibody tests.
I know 28 days is nearly conclusive. I wonder, however, if the Paxlovid (because of Nirmatrelvir/ritonavir) could delay detection. How confident should I feel in the 25 and 28 day negative tests, and when should I feel certain that I am not infected? I am scheduled to retest at 44 days, close to the 45-day CDC window. In the meanwhile, how should I restrict my sexual activities to protect others? Oral sex only, or no sex?
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Edward W. Hook M.D.
24 months ago
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Welcome to our Forum. Thanks for your questions. I'll be glad to comment. The exposure you describe was low risk. Estimates are that performing oral sex on an untreated HIV infected person leads to infection, on average, less than once in every 10,000 exposures (how much less is unclear because acquisition of HIV through this route is so very rare. As you also know, Ritonavir does have activity against HIV and thus could potentially delay HIV test reactivity. As you might imagine, there are no studies to quantify this effect and given your timeline the effect is likely to be low. What you can be sure of however is that the rash you experienced is NOT due to HIV- if it were your tests would have been positive after that.
Normally, given the very low risk of infection from exposures such as the ones you describe, I would say you could be 100% sure that you were not infected with the test results you have but given the ritonavir "wild card" I think your 44 day test is a good idea. The likelihood that you are infected is very, very low but given the ritonavir ingestion, my advice would be to stick to safe sexual encounters at this time.
I hope that this perspective is helpful. EWH
---p.s. I hope your partner has now sought treatment.
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24 months ago
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This is helpful, thank you.
He is receiving treatment now. As of today, in fact.
Two follow-ups, which I think may exhaust the practical advice you can provide.
First, do you think that a 44-day test (44 days post-exposure; 19 days following final Paxlovid tablets) would be fully conclusive, such that there is no risk in resuming usual sexual activities (with the proviso that I’ll be reinitiating PrEP once I’m certain of non-infected status)? Or is there some later timeline that I should target? And is there any other testing I should consider aside from 4th Generation Antigen/Antibody tests?
Second, can we clarify “safe sexual encounters”? I do not plan to do any penetrative sex, with condoms or otherwise, until I’m certain of HIV status. But is oral sex best excluded, too?
Thank you for your advice!
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Edward W. Hook M.D.
24 months ago
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There are no data to answer your questions about when results would be fully conclusive however certainly they would be at 6 weeks after completion of Paxlovid. I would consider an HIV RNA PCR any time more than 4 weeks after completion of Paxlovid conclusive. Admittedly, these are one expert’s informed opinion. Other experts might well feel that results would be conclusive both sooner or later. As I said earlier, this is really a data-free area.
Both receipt of oral sex and performing oral sex should be safe for partners.
Hope this helps. Wish there were more data. EWH
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24 months ago
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Understood. Thank you for your thoughtful answers.
Let’s assume that my partner was in a fairly acute stage of infection (the clinic seemed to think his infection was probably 3+ months old, but of course it’s hard to tell beyond noting that the 90-day rapid tests return positive). He reports being asymptomatic, although who knows if he hasn’t had a forgotten flu-like episode in recent months.
Given that his viral load conceivably was heightened, but that I’ve had two negative tests, what level of concern on my part is warranted? Is it likely in this case that my odds of infection at this point are on the order of 1/10,000 or less?
I must admit that I’m fairly anxious, even recognizing that oral transmission of HIV is rarely reported under any circumstances from receptive oral sex, and even recognizing that my first dose of Paxlovid was not until 21 days post-exposure, at the point where HIV is often detectable by 4th Generation tests. Am I correct to understand as well that while Paxlovid could theoretically delay the detection of antigen/antibodies, it would not cause previously detectable levels of antigen/antibody to become undetectable? (In other words, had antigen been detectable at day 20 or 21, could Paxlovid then have made it undetectable again at day 25?).
Thank you again for your time and consideration. I appreciate all you have shared, and hope that I will be pleased to obtain a conclusive negative test in perhaps another 3-4 weeks. Already you have provided great clarity on the “known unknowns.” Now I suppose we must wait, hopefully with peace of mind along the way.
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Edward W. Hook M.D.
24 months ago
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I don't mean to sound harsh but, with all due respect, this is a "what if" question in which you choose to not accept the opinion of the health care providers who are taking care of him. As I suspect you know, persons in the very acute stages of infection, during the acute retroviral syndrome have very high viral loads and are more likely to transmit infection than persons with lower viral loads. IF he was in the acute stage, the transmission of infection would be higher. How much higher?, hard to say BUT even if the risk of infection were ten times higher (i.e. 1 in 1000) then there is still a 99.9% chance you would not be infected. I urge you to stop these "what ifs". They serve no purpose other than to worry you and your preliminary test results make it very likely (no, I will not put a number on it) that you were not infected.
You are correct, the Paxlovid would not reverse detection of antigens or antibodies that are already present. EWH
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24 months ago
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You sounded candid, not harsh—and candor is a kind of compassion, too. Thank you for acknowledging that what-ifs are unhelpful, and doubly so in light of the low risks involved and the reassurance already provided by prior tests.
I will keep that in mind over the coming weeks and aim to turn my attention to more productive endeavors. Thank you again for your help!
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Edward W. Hook M.D.
24 months ago
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I'm glad you feel that way.
We provide up to three responses to each client's questions. Thus this thread will be closed shortly without further responses. I remain confident that you did not get HIV from the unfortunate exposure you described. Take care. Stay safe. EWH
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