[Question #454] Final STI question

33 months ago

Dear Mr. Hook

Dear Mr. Hunter Handsfield

I wrote 2 weeks before – my case was closed – but here my final mail. 

Recapitulation: oral active and passive intercourse, vaginal condom protected sex with a moldavian stripper/sexworker.

Day 4 after exposure : 1gr Azithromycin-Ratiopharm single dose – I overreacted

2 weeks after exposure : university dermatology clinic

-bloodtest – HIV (4th Gen. Combo), Hep B/C, Syphilis (useless: i know)

-urine test – Chlamydia, Gonorrhea

All negative

4 weeks after exposure:    

went to a otorhinolaryngologist (throat, nose, ear specialist) after advise from Dr.Hook. Told him the whole story and asked for a throat swab (pharyngeal gonorrhea). He check my troath and said: all looks nice. 99.9% nothing will appear on the culture if i do a swab. Just come back if something changes but nothing will change. Luckily all humans got a immune system ;-)

45 days after exposure (yesterday): 

bloodtest – TPHA Syphilis test (not TPPA) and HIV Combo 4th  Generation (i know – HIV-test was sensless but just for peace of my mind) directly in the STI labor. One hour ago all came back negative.

But they told me again: those test are not relaible if they did less than 3 month after exposure. I know that you say: thats conservative. But here they clearly say : thats not relaible.

I also didnt spotted any shancre till now – 2 weeks ago the specialist didnt noticed something too. And he clearly told me: you will noticed a oral chancre for sure!

So my last questions:

- have you ever seen a primary syphilis showed up after 45 days?

- Should i forget any further testing in 6 weeks and return to normal life. And shall I start having unprotected sex with my wife again? I’m not worried about myself. Im just worried to infect her with something. If that happens i loose everything important for me: kid & wife…

Kind regards

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
Welcome back. Sorry to hear you have had conflicting advice. But there isn't much we can do about that. Six weeks is definitely enough time for syphilis blood tests Iincluding TPHA)  to become positive, and 4 weeks is sufficient for the HIV 4th generation ("combo") test. Anyway, it is a mistake to focus on the test result as the only evidence about your risk and the likelihood of infection. You also have 1) the low risk nature of the exposure, 2) treatment (azithromycin) that almost certainly would have prevented syphilis if you had been exposed, 3) absence of symptoms to suggest any of these infections, and 4) negative physical examinations by your doctors. Combining those with the test results amounts to zero chance you caught either syphilis or HIV. 

To your speicfic questions:

1) This never happens and I have never seen nor heard of such a case.

2) Of course you are more worried about your wife and kids than you are about yourself. That's almost always the main reason anyone fears STDs. But it doesn't change the science or our advice. Should you have any further testing? My advice, like Dr. Hook's, is that there is no need. But now you have conflicting advice from your own doctors and you'll have to decide which to rely on. I would be willing to bet that Dr. Hook and I are more expert in these matters than your doctors are. Still, it's your choice. Even if you go ahead with additonal tests, I would strongly advise you to continue (or resume) unprotected sex with your wife. There's no way you can infect her with syphilis or HIV from the exposure you are worried about.

I hope this has been helpful. Best wishes --  HHH, MD

---
33 months ago

Dear Mr. Hunter Handsfield

 

Thank you very much for your kind words. Yes it doesn’t change the science – but difficult to understand that not all scientists or doctors proclaim the same facts. I read that also here in europe the new terms of HIV 4th generation tests changed at the End of 2014. All labs and aids federations  should proclaim, that 6 weeks after exposure the test is 99% safe (Eller et al: Reduction of HIV-Window-Period by 4th Generation HIVCombination Tests. Poster O-142, CROI 2013, Atlanta).

Great Britain even talks about 4 weeks. But i was in a lab and I also was in one of the biggest hospitals who told me explicit that they use the 4th generation test. But they still say: nope – 12 weeks. That really should be a discussion in the media. Perhaps testing is just not that bad business for them….

So should i listen to real experts or to people who made a urine test to check if i have pharyngeal gonorrhea ;-)?!?! I guess you know the answer. Otherwise i didnt searched for your help.

Thank you very much for advises. You do a really great thing for lot of people. I will forget about my worries and return to normal life.

Kind regards from europe

33 months ago
and just to get that right and to understand this disease: you say that never happens! So my bloodtest is negative after 6 weeks. But let's assume a chancre show up in my mouth 7 weeks after exposure. the blood test would turn positive at that point because the body fights against the chancre and produces antibodies? that would explain the 90 days who are written in the most websites and books.
Or would the test be positive as well (before the chancre) because he detect treponema pallidum or antibodies will be produced way before the chancre appear? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
Sorry I missed your first follow-up comment until now. Thanks for the thanks.

Re time to positive HIV tests: The actual data in humans aren't very precise. Few HIV infected people know exactly when and where they were infected, and it's pretty much impossible to follow such persons with precisely timed blood tests. So we're left with biological principles, animal studies, and scant data in people. Given the imprecision, it's easy to understand that different experts or agencies may adopt different policies. But I can say that neither Dr. Hook nor I, nor any HIV experts we know, have ever seen a patient with negative duo test (or antibody plus RNA/DNA test) at 4 weeks who later turned out to have been infected.

You're overthinking the syphilis blood test and symptoms. A chancre would not show up as late as 7 weeks; and the immune system reaction, prodcucing the antibodies detected in the tests, is not dependent on appearance of the chancre or any other symptoms. I'm not aware any data that it takes 90 days for the standard syphilis blood tests to become positive or that "most websites and books" say that. Such statements may be left over from older tests now rarely used. I've never seen anyone in whom it took more than 6 weeks, and that's the interval used in my and Dr. Hook's STD clinics. I imagine it might take longer if someone received antibiotic therapy that delayed but did not prevent development of active infection.

---
33 months ago
ah okay. i focused 2 much on the symptoms (chancre) than listen to the TPHA test. Just because this saturday (2 days after the blood test) i got a infected painfull spot at my gum straight above a backtooth. Day 1 red, day 2 white inside (more blotched than round). I was shocked - after 6 weeks daily body examination. Okay i also had a dentist appointment last thursday and its most likely a big canker sore (aphthea) but i guess you can imagine that i was shocked. so my final questions: you wrote: " it might take longer if someone received antibiotic therapy that delayed but did not prevent development of active infection"..you didnt overlooked that i took 1gr of azithromycin (not 2gr)? Also Dr.Hook said: " 1gr would have treated SOME syphilis" and you said "almost" - and if this is a chancre (i know, its an unusual place and they usually dont hurt, and i guess i rather would have a condom chancre if she was infected) the TPHA test allready where positive right? if you still say: "yes you right. no chance that you are infected - go on" the case is closed for me at this point.
Kind regards
(im sorry. i dont panic - its easy to treat i know. i just wanna get sure)
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
I can't think of any other ways to say it more clearly than I already have. Your own statement above is as good as any, so I'll let it go at that.

As for partial treatment, azithromycin doesn't count. It is inactive against some strains of T pallidum, but in those cases it is totally inactive. It doesn't provide partial treatment; it has no effect at all and can have no effect on the blood test results.

I suggest you re-read every word (carefully) of all replies and comments on this and your earlier thread. As for "wanna get sure", most people in your situation would have passed that threshold a long time ago!

Time to move on. Good luck.

---