[Question #1851] Finer points on HIV

72 months ago

Dear Doctors,

I have already enquired about this scenario with you but would like to clarify some finer points after having done more reading/research. Basically I made the mistake of consorting with a CSW in Melbourne (Australia) a few weeks ago. Everything was protected, but just before putting the condom on, she applied some kind of substance to my penis. Most likely it was lubricant, but she displayed a rude/hostile attitude to me and was inconsistent/evasive about her nationality (first Thai then Chinese). This set off alarm bells, what if it was some infected vaginal fluid? She displayed poor character, although the testing/protection legal framework here is pretty good.

1) I know that it has been repeatedly stated, by yourselves and other highly experienced people, that hand-genital contact even with infected secretions does not transmit HIV. However, it is a globalised world with different subtypes of HIV (some purportedly more infectious). Could there be certain subtypes of HIV brought in from outside the Western world, that could break that precedent?

2) Your posts also frequently reassure patients who have had unprotected sex that the likelihood of getting HIV, even if the woman were infected, is 1 out of 1000-2000. However I think there is quite a bit of margin for error there, other factors are important like viral load and presence of other STDs. I've read that in some developing countries, the figure is more like 1/200. Surely that needs to be taken into consideration, particularly for questioners overseas?

3) I have decided to get tested as soon as I have crossed the window period. A negative result would be proof, and an unlikely positive result ought to be responded to with immediate treatment. I am apprehensive about living with HIV because there remain big hardships despite treatment, but nothing encourages me more than news of medical progress in the area. What are your views on future improvements in HIV prevention, treatment, or even cure?

H. Hunter Handsfield, MD

72 months ago

Welcome back to the forum. However, I am sorry to learn you remain concerned after the reasoned, science based reassurance you received from Dr. Hook as well as the Melbourne Sexual Health Centre. They are every bit as knowledgeable as Dr. Hook and I are -- indeed, MHSC is widely regarded as among the best STI/HIV/sexual health services anywhere in the world. But directly to your questions:

1) So far, no strain or type of HIV has been observed (or even suspected) to be more or less transmissible than any other. I suppose it's possible such an HIV strain may evolve someday, but I'm not sufficiently knowledgeable about HIV genetics and biology to know how likely it is. But if it hasn't happened among the millions and millions of infected people in the 30+ years of the known worldwide HIV epidemic, it's a fair bet that it won't. Certainly this is nothing to be worried about.

2) Exactly right -- the transmission probability undoubtedly varies widely, and there surely is a lot of variation around the statistics you quote. However, higher transmission risk doesn't apply to all "overseas" areas; in fact, it is largely limited to sub-Saharan Africa (and even there, the transmission risk probably is declining with improved prevention and treatment). Almost certainly the transnmission risk from sex workers in Australia (regardless of national origin) is similar to that in most western, industrialized countries. When higher per-exposure risks pertain, it's usually due to how recently the person was infected, presence of other STDs, viral load, use of anti-HIV therapy, etc. In any case, your exposure was condom protected, and there is nothing else about the details of the events -- as described in your previous thread -- that implies any risk at all.

3) It is wise for you to be tested -- not because you are significantly at risk (you were not), but because the negative results probably will settle your fears about it far better than expert opinion based on probability and statistics. As you probably know, the window period is now 4 weeks, using the 4th generation (antigen-antibody) tests, which likely is what you were advised at MSHC. For the reasons already stated, you can definitely expect a negative result.

Whole books have been written on your closing question. I'll just say that the success of antiretroviral drugs, both in prolonging life (to virtually normal life span) and preventing transmission, has been extremely gratifying, and a giant surprise to those of us who directly witnessed the dark days of the early HIV years ~1980-1995. There is reason for cautious optimism about curative treatment and perhaps an effective vaccine someday, but perhaps not for a few decades. That said, I would have said the same thing about life-extending antiviral therapy back in 1990, and was proved wrong only 5 years later.

Best wishes-- HHH, MD

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72 months ago

Thank you Dr Handsfield,

1) There is commentary and papers suggesting some HIV subtypes (like in South East Asia and Africa) may very well be more transmissible and virulent. For example, on Avert.org they state 'Some studies suggest that certain subtypes have a greater risk of transmission or faster disease progression than others'.

However this doesn't mean that there are contagious HIV strains out there which can be transmitted by hand-genital contact with infected fluids. I am sure that highly experienced experts such as yourselves have seen countless Americans infected abroad, and infected foreigners in America. The fact that no clear case of hand-genital transmission has been observed, in spite of the high frequency of such incidents, supports your view that sexual transmission only happens with unprotected penetration.

2) Developments in treatment have made a remarkable difference. Even newer HAART medications are far more effective, tolerable, and convenient than older ones. However it is still a big burden to take expensive pills the rest of your life, and there are all kinds of physical and psychological difficulties that treated HIV-positive patients must confront across a near-normal lifespan. My biggest fear associated with HIV is not the compromised immune system (which is very treatable), but potential cognitive difficulties- it is the fear of having one's intellect blunted by HIV. Nevertheless you do see HIV-positive intellectuals who remain sharp over the long term, one example would be the journalist Andrew Sullivan.

For once I am realistically hopeful that progress in treatment and prevention will be ongoing, continuing to make a big difference to people's lives, and ultimately leading to a cure/vaccine. Just yesterday there was news of scientists being able to identify a protein serving as a marker for latently infected cells forming part of the viral reservoir- that appears to be quite important.

H. Hunter Handsfield, MD

72 months ago

1) I am unaware of data to support the quotation cited, and am not familiar with avert.org.

2) Although not an expert in intellectual impairment or other neuropsychological aspects of HIV, I am unaware of data that such problems occur in people on effective ART, i.e. with documented good effect on viral load and CD4 counts. If this happens, it is rare. In fact, one of the very first documented benefits of the earliest HIV treatments (e.g. zidovudine [AZT], which is no longer used) was improved cognition.

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72 months ago

Thank you for your response Dr Handsfield,

Sometimes the fear of HIV is so strong it overrides objective considerations. To be fair, the episode was very low risk because (a) the substance was most likely lubricant, (b) licensed CSWs have extremely low rate of HIV in Australia, and (c) transmission by hand-genital contact is apparently unheard of.

(1) This permanently ends an unwise and mistaken period of my life where I've been exposed to CSWs. Looking back, I've also become concerned about a handful of exposures to CSWs in a part of Asia known for production of counterfeit condoms. Those exposures were certainly protected and the condom did not break, however if it was a fake one produced by an illegal manufacturer, it may not have provided the protection from STDs - despite looking and functioning like the real thing.

(2) I would very much like to simply forget and put the whole thing behind me. But nevertheless, wiser judgement would push me to take you advice and have a full STI screen (which I have never had) once the window period has been crossed. A negative result would be a great relief and close a dark chapter, a positive result would at least give me the opportunity to commence early treatment. I just dearly hope that if I test positive I haven't contracted one of those drug-resistant HIV strains floating around.

H. Hunter Handsfield, MD

72 months ago

I agree withour assessment of risk.

1) I find it hard to imagine a "fake" condom. Cheaply made ones may rupture more easily, but if they remain intact, protection is complete. The notion of microscopic leaks that allow transmission of bacteria and viruses (or sperm) is an urban myth. For example, a "water test" after sex is a waste of time.

2) Feel free to test if you must. There is no such thing as "drug resistant HIV strains floating around". All HIV infections to date have been treatable with standard, currently available anti-HIV drugs.

I think it's time to stop searching the web on all this. Like many anxious or compulsive persons, you're being drawn to "facts" that don't exist or that you misinterpret, and are missing the reassuring information that also is there.

That completes the two follow-ups and replies with each question and so ends this thread. Take care and stay safe.

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