[Question #401] HIV risk

92 months ago

OK, I'm asking for a friend.  He is too worried to do anything.  I figured if I show him this it might help with the anxiety he is experiencing.

Day 0:  Exposure was a handjob in a strip club.  I know you have said numerous times this is a non risk.  Here are the concerns:  There were two areas of denuded skin on the penis from receiving lapdances at the time of the act.  There was a high concern that the lady performing the act may have been an IV drug user.  Is this still a no risk event?

Day 2:  Feeling of fullness under both underarms with tender lymph nodes (at least suspected to be lymph nodes).  This has persisted off and on until day 44.  Over the course of this there have also been tender lymph nodes behind both knees.

Day 9:  negative 4th gen HIV test.  Negative full STD panel.

Day 13:  Due to tremendous anxiety, an HIV RNA PCR was ordered.  This was negative.

Day 34:  Due to ongoing anxiety, repeat STD panel and 4th gen HIV test negative.

Day 44:  Symptoms include tremendous ongoing anxiety.  The lymph nodes in the underarm are still tender.  There is lingering concern that HIV is the cause of these symptoms.

The patient is seeing his doctor to address the issues of anxiety and tremendous concern about the swollen lymph nodes.  He is seeing is doctor and having testing done to look for alternate causes of swollen lymph nodes.  He continues to be concerned about acute HIV being the cause of this.  His symptoms to this point include losing 15 lbs (in large part due to anxiety), swollen lymph nodes for 6 weeks, and a prolonged outbreak of genital herpes (not a new problem). 

I have reviewed many of your writings and have a few questions.  1)  Can the event truly be considered a no risk event?  2)  Are the test reliable at this point?  I know you have repeatedly said that 4th gen HIV at 4 weeks is 100% reliable, but it does not seem that there is reliable literature that supports this view.

Thank you so much for the thought that comes with answering this question.

H. Hunter Handsfield, MD
92 months ago
Welcome to the forum. Thanks to your friend for his confidence in our service. The quick replies to the two closing questions both are a firm Yes. For sure he doesn't have HIV. The details:

All hand-genital contact is no risk. There has never been a proved (or to my knowledge, even suspected) case of HIV being so transmitted, regardless of "denuded" skin. Also, "may have been" is weak evidence that the partner was in fact at high risk. And although injection drug use is an important risk factor for HIV, the large majority of IDUs are not infectged.

The symptoms described are not typical of a new HIV infection. Further, self diagnosis of lymph node inflammation or "fullness" is unreliable. The large majority of non-health-professionals who have such complaints in fact do not have significant lymph node enlargement. And in any case, a new HIV infection rarely if ever causes node inflammation alone, without fever and other typcial symptoms, and never occurs in only one group of nodes. It's a body wide problem, not something that would only affect nodes in the armpits.

Perhaps most important, the negative HIV tests prove without doubt that he didn't catch HIV on day 0. It is simply not possible to have HIV with those negative results. There are no exceptions, despite what he might have read about test windows, people who supposedly never develop positive tests. These are urban myths.

While genital herpes is not your friend's main concern, I will point out that outbreaks almost never last 6 weeks. In 40 years in the STD business, I've never seen it and have to suspect that something other than herpes explains those symptoms. It is rare if ever that recurrent HSV outbreaks last more than 2 weeks.

My advice to your friend is that he can definitely put HIV out of mind as a cause of his symptoms. Since they still concern him, he should follow through with his personal physician and take it from there.

I hope this information is helpful to him. Best wishes to you both.


92 months ago

Dr. Handsfield,

Thank you for your prompt reply.  Also, thank you for your availability.  Communicating with an expert is very helpful in reconciling some of the conflicting information.  I don't intend to quibble with you, but I feel like I should ask you some follow on questions.

I conferred with my friend, and as far as the HSV goes, that has been going on for approximately two weeks.  So, you are spot on that it has not been going on the whole time.

Are there any reliable studies that show the window period for acute infections can be identified with 100% certainty at 4 weeks.  The ibase site out of the UK quotes 95%.  In British Columbia, they quote 99% sensitivity for new infections at 6 weeks based on 4th generation testing.  I understand the sensitivity for all infections (to include acute and chronic) approaches 100% with 4th generation testing, but that is not the concern.  It's clear my friend does not have a chronic infection based on the negative test at day 9.   The concern here is excluding acute infection.  Your thoughts on this are greatly appreciated.

H. Hunter Handsfield, MD
92 months ago
The problem is that the systems by which one evaluates the accuracy of tests is itself flawed. What is the gold standard? There are reasons to be confident that many (most? all?) the official figures on test sensitivty are underestimates. The fact is that no HIV experts I know of say they have ever seen someone with a falsely negative 4th generation blood test 4 weeks or more after the last exposure (This excludes partially treated persons, such as those to take post-exposure treatment that doesn't work. But even here, it's a theoretical concern with few if any actual reported cases.)

And what if the true sensitivity is 99% (or even 95%) instead of 100% at 4 weeks, 6 weeks, or some other time? If the odds of having been infected are, say, one in a million, then a test with 99% sensitivity changers gives that person one chance 100 million of being infected. That's zero for any practical purposes.