[Question #4530] Condom Effectiveness and Testing Window

29 months ago

Hello Drs, I've learned more about sexual health from the hours reading your words than any other source. Thank you. 

 

29 days ago I had insertive intercourse with a 22yo latin male. It was brief with little friction. He said he was negative and tested 1 month prior. I verified the condom was not expired, put it on carefully & it stayed in place. After I verified no breakage. I don't think there was fluid exchange nor skin to skin contact unless the condom was microscopically defective. The CDC says use effectiveness is 80% but i've read your words that an unbroken properly used condom is "virtually" 100% effective. Is the discrepancy really that 20% of the time they're used incorrectly/break? Or that they could infact be used correctly and simply don't protect as well as the lab claims they do? If used correctly without breaking is there anyway it can NOT be protective? Was my encounter truly no risk? 

 

At 13 days & 13hrs I tested negative for HIV RNA & HIV 4th Gen. I've read that at that date the RNA is anywhere from "over 90%" to "100% accurate". Are my results definitive?

 

At 18 days post exposure I came down with a week long cold/flu. Sore throat, sore neck, stuffy nose, cough, post nasal drip, headache, decreased appetite, weight loss, 1 day fever of 99.6 (I generally run 97's), etc. It seems like a classic cold but the timing and some being ARS symptoms makes me nervous. With <48 RNA at 13 days, could enough virus replicate and antibodies develop in 5 days thereby causing these symptoms or is that impossible?

 

Given all of this do I need to retest or am I clear?

Edward W. Hook M.D.
Edward W. Hook M.D.
29 months ago
Welcome to our forum and thanks for your confidence in the Forum.  I appreciate your reading other client interactions as one of our goals is to provide out clients with information that they can obtain from reading our interactions with others.  

Condoms remain the most effective and most broadly effective means of preventing STI acquisition available. they also prevent pregnancy.  Those of us on this forum are "believers" and wish that  there was something we might do to enhance their use- we try.  I have published a number of studies on condom use and their effectiveness.  Such studies are quite difficult to do since our only practical way to evaluate condom use going forward is to ask persons about their recent condom use and practices.  Self-report however is subject to confounding by study participant desires to give investigators the results they are looking for and in some cases, embarrassment over the fact that while they "knew better" in the heat of the moment, people sometimes do not use condoms despite knowing that they should.  Further, our research has shown that sometimes people do not use condoms throughout sex acts, putting them on only when they believe that ejaculation is going to occur (bad idea) and, in about 1% of uses, the condoms do break.  All of this means that even the highest quality research is subject to measurement problems.  Our best estimates is that proper condom use reduces risk for the most common STIs like gonorrhea or chlamydia over 95% and risk for HIV more than 99%- not perfect but darn good, particularly when you remember that most people do not have STIs and most exposures to affected sex partners do not lead to transmission of infection.  

The CDC, as a governmental agency, tends to address the information they provide in a fashion which we believe is overly conservative.  My sense ifs that the encounter that you describe is no risk.

Your HIV test results are definitive.  Believe them.  Your current flu-like illness is not HIV and your test results prove this.  No need for further testing.

I hope these responses are helpful.  EWH
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29 months ago
Dr. H, I hope you had a good Thanksgiving. I admit it was exciting waiting to see who would respond to my question.  Your answers were what I expected and helped put me at ease. I try to ask broad enough questions to help other readers. Have y'all thought of compiling a FAQ to have in one location?  To follow up:



I appreciate learning that you personally researched condom effectiveness. I get that people don't tell the truth which is why the advice that "most people are honest about their HIV status when asked" has never overly resonated with me. What do experts attribute the difference in 100% effectiveness in the lab vs. your "best estimate" of 95-99% real-world protection when they are used correctly and properly and don't break?



Regarding HIV RNA testing, I read previously that you use 14 days as a conservative approach to the tests' conclusiveness but that some experts say they're conclusive in 9-11 days. Is either time a widely held belief? When you say my results at 13 days and 13hrs are definitive, is that based on my specific scenario?  Or the science of the testing window? i.e. would you recommend retesting if I had unprotected anal intercourse?  



Finally, i've read that not everyone gets ARS symptoms but that those who do, they are severe (i.e. persistent high fever, very sore throat, expansive rash etc.). Is this always a true statement? Or sometimes symptoms can be short or mild and not severe flu-like? Had I not tested neg would my non-severe symptoms have been indicative of ARS?. Thanks Doc!
Edward W. Hook M.D.
Edward W. Hook M.D.
29 months ago
Thanks for your thanks.  Part of the purpose of this forum is to allow access by others to information that we have provided to paying clients in the hope that the information will prove helpful and reduce the need for specific questions.  At the same time, we acknowledge that every person and situation is different and thus we try to answer each question despite the fact that many are somewhat repetitive.  Thus the open Forum serves as our "FAQ" site.  Admittedly it is not easily searched but hopefully it is helpful to some.  I'll go on to your specific questions:

Measurement of condom effectiveness is challenging as it is dependent on report by study participants as to how they used condoms.  In our own work, condoms are used incorrectly in a variety of ways including persons who engage in sexual penetration without their condoms, only putting on the condom when they approach ejaculation.  In other instances the condoms slip off completely during sex.  Finally, because study participants sometimes "know" that they should be using condoms but, perhaps out of embarrassment, claim that hey did.  All of these sorts of facts lead to an element of imprecision in measuring real life condom protectivity.   

Regarding RNA testing, estimates and the precision of the estimates from different studies vary depending on the size of the study and the numbers of infections that are observed.   Please remember that less (and, depending on the sort of exposure, far less) than 1% of exposures result in infection.  My response to you was based both on my knowledge of published studies of the appearance of HIV RNA following exposure and the specifics of your exposure (condom protected, unknown partner HIV status).  I see no need for further testing related to the exposure you have described.

Regarding the ARS, please remember that the S stands for the word SYNDROME which is a collection of signs and symptoms.  Syndromes typically have multiple causes and may occur in a spectrum of intensities.  Thus the ARS is a clue to recent infection which warrants further investigation.  Thus while the classical ARS tends to be characterized by severe symptoms, it is possible that there are milder forms as well.  OTOH, please remember that in the studies of at risk persons with possible ARS symptoms less than 1% of persons with the ARS syndrome have HIV, the others having the flu, other viral illnesses, and other unexplained non-HIV processes.

I hope that these replies are helpful to you.  I should point out that the purpose of this forum is to answer specific questions rather than the sorts of general questions asked above.  To completely answer these sorts of general questions however would take far more time and space than we have available.  I trust you will understand.  EWH
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29 months ago
Hi Dr. Hook, for my final allotted response, I have two questions related to my sexual health.  I am in my late 30's and openly gay.  I probably have 4-8 one night stands  (or "hookups" as we say) a year. I always ask about their status and when they were last tested and always use condoms for anal sex but not for oral sex and ultimately I cannot verify if they're telling me the truth about their status. I test for STDs regularly. I try to do everything right to stay safe.  

What are your thoughts on PREP in a situation like mine? Is it necessary and/or valuable? Is it worth the side effects (both short term and long term)? My insurance would cover it but my PCP provides little valuable insight for me. Are there any long term concerns I should consider?

What is your recommendation for the new guidelines on allowing the HPV vaccine for adults? I've read many times the words on this forum that most sexually active people probably already have some strains of it. But is it worth getting as a sexually active gay male to prevent any of the strains I may not currently have? Is the protection it would provide me worth it? I haven't researched it much. Are there risks? 

Thanks for your time and this valuable service you provide the world in regards to sexual health.  Cheers!
Edward W. Hook M.D.
Edward W. Hook M.D.
29 months ago
Thanks again for your confidence in our Forum.  I'll go straight to your questions.

PrEP.  In general PrEP is well tolerated and clearly has a dramatic on risk for acquisition of HIV.  From what you describe so nicely, you are practicing safe sex in a manner which makes you low risk for HIV. That said, condoms fail about 1% of the time and there are rare transmissions of HIV to persons performing fellatio on infected, untreated partners.  PrEP would reduce any risk to essentially zero.  For you I would recommend it as one more thing to keep you safe but this is personal choice and were you to not take PrEP I would encourage you to continue to do all that you are currently doing.  This reflect my own personal assessment.

HPV vaccine.  I believe in the vaccine.  It is well tolerated and highly effective.  I have always strongly advocated for use of safe and effective vaccines of all sorts.  Other than the expense which I suspect your insurance might pay for, there is little downside and potential benefit.  We have great confidence in the efficacy of the vaccine for preventing new infections and there is a possibility that the vaccine has a more modest (and therefore more difficult to scientifically prove) benefit in terms or helping existing infections not progress or even resolve (let me emphasize the potential benefit on existing infections is NOT proven at this time).

I hope these comments have been helpful.  Congratulations on your approach to your sexual health- it will serve you well.  As you know, this will complete this thread which will be closed later today.  EWH
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