[Question #1311] Advice and reassurance from testing.

85 months ago
Hello wonderful doctors!
I'll get to the point, been the worst 9 weeks of my life and I need some advice.

Day 0 - unprotected oral both ways and unprotected anal, I was insertive partner, with transsexual escort in Dallas. 
Day 17 - oraquick swab test, negative.
Day 21 - syphillis, chlamydia, gonorea, and HIV 4th generation test done via planned parenthood through labcorp. All negative
Day 29 - using stdcheck services I ordered a full panel of test.  Gonorea, chlamydia, syphillis, hep a/b/c, HIV 4th gen, and hsv 1/2.
They were done through labcorp. All were negative.
Day 59 - oraquick swab test, negative

Up to day 45 I had no symptoms of any kind, in fact felt great, other than anxiety. No fever, rash, sore throat, chancre, nothing!

Starting day 45 I was given penicillin v for and oral procedure. 250mg x 2, 4 times a day for 7 days. Essentially 500mg 4 times a day.

1) stdcheck says the 4th generation test is only 95% accurate at 29 days. Is it actually 100% conclusive?
2) stdcheck says the syphilis test is an RPR serology test, testing for Igm and IGg, and is 97% accurate at 29 days. Should I test again based on this test?
3) I have read conflicting information about the penV, would this stop the symptoms, cure the syphillis, or just cause problems for testing?
4) if I was lucky enough to have you as my dr, what would your advice be as far as testing now?

It's day 63 and I have had no signs or symptoms of any kind.

Can I move on with my life and stop stressing and learn from my stupid mistake? Am I safe to continue sexual relationships with my partner?

Thank you!

H. Hunter Handsfield, MD
85 months ago
Welcome to the forum. Thanks for your question.

Probably I don't need to give you the condom talk -- you've probably been giving it to yourself. But unprotected anal with a transsexual (probably anatomically male) sex worker? Really??!! That will be the last time, I hope! (The oral exposures don't make much difference. All oral sex is ls very low risk for HIV.) 

So it was a high risk exposure for sure. However, you were not infected. The HIV blood tests are among the most accurate diagnostic tests ever developed, for any medical condition. As long as testing is done sufficiently long after the last possible exposure, the negative result overrule exposure history or symptoms. That time is 4 weeks for the 4th generation test, so your 29 day result is conclusive. And your other STD tests also were conclusive. To your specific questions:

1) The test outfit is being consertative. 95% is probably the usual advice in this situation, but there are no reliable reports of anyone, anywhere in the world, having a negative 4th gen test at 4+ weeks who later turned out to have HIV. If somehow I were in your situation, I would not be tested further and would continue unprotected sex with my wife without worry.

2,4) The RPR, and syphiiis blood tests in general, are typcically considered conclusive at 6 weeks. The newer IgG and IgM tests have not been formally studied, however. In your case, you also have had no symptoms to suggest syphilis. The absence of a penile sore (chancre) by this time is itself good evidence against infection. The combination of no symptoms plus 4 week negative testing can be considered conclusive. Still, a considerative approach would be to have a final RPR and/or IgG syphilis test at 6+ weeks (i.e. at any time now). Even this is optional, but that's the only additional testing to be considered.

3) That dose of penicillin V would not reliably cure syphilis. It doesn't change my overall opinion or advice.

I hope this has helped. Best wishes and stay safe--  HHH, MD

85 months ago
Thank you!
Yes I have been over this a lot in my head about the absolute stupidity of my actions. Lots of late nights crying over my stupidity. It will be the last night for anything like that!

if I was your patient would your order the syphilis test now? Or just kick me in the butt for my stupidity and tell me to move on without it?
I respect your opinion since I have read more than 100 of your postings over the last 2 months.
H. Hunter Handsfield, MD
85 months ago
Thank you for the kind words.

I would not recommend additional syphilis testing in my own patient, and at a personal level, knowing what I know, I would not have another syphilis test. But I'm not you. Although I can give a virtually conclusive judgment you don't have syphilis, I cannot rule it out with 100% certainty. If you can live with "virtually conclusive", don't get retested. If you cannot, have another test now.

85 months ago
Thank you doc! If you wouldn't have the test done personally, that is a good indication that I do not need to either. 
Thank you again, for the talk, the advice, and guidance! As all the other post of yours I have seen, you have provided a valuable service. 
My mistake will never happen again! 
I hope that others will start to follow your guidance more about the 4th generation test being conclusive at 28 days!
Thank you!!
85 months ago
And just to confirm one last time, the HIV 4th gen test is 100% conclusive after 28 days? 
Just worried me with your reply about "no reliable reports"
H. Hunter Handsfield, MD
85 months ago
Yes, confirming 100% conclusive 4th generation testing at 28+ days after exposure.

Also don't disregard my other comments about your risk. If you'd like some simple math, we could assume the test is "only" 99% reliable at 4+ weeks (99% is very good!). If we also assume the chance she has HIV as 1 in 1,000 and then use a standard figure for average transmission risk for a single episode of insertive anal sex, about 1 in 500 if the receptive partner is infected, then the chance you have HIV, even without testing, would be 0.001 x 0.002 = 0.000002. That's 2 in a million, or 1 in 500 thousand. If we now assume "only" 99% test performance, it becomes 0.000002 x 0.01 = 0.0000002, or 1 in 50 million. In other words, you should not look at the test result in a vacuum. Also note that if we put your partner in the high HIV risk range of UK/London female sex workers, i.e. 1% instead of 1 in a thousand, the chance you have HIV is still only 1 in 5 million.

Finally, we stand by our advice on this forum about 100% reliability of the 4th gen test. Many testing services and public health agencies do not have the leeway (from their liability departments) to go beyond official information in the tests' package inserts, as approved by FDA, which explains statements like 95% at 4 weeks, or requirements for longer window periods (6 weeks, 12 weeks, etc) for conclusive results. But we can rely on the available scientific data, without the legality issues. Trust me on this:  no HIV/AIDS providers ever have patients with negative 4th gen tests at 4+ weeks who later turn out to have HIV, except maybe in rare special circumstances (gross lab error, partial treatment with HIV drugs for PEP, etc).

That completes the two follow-up comments and replies included with each question and so concludes this thread. Thanks very much for your kind comments about our services.