[Question #5144] Severe ARS symptoms

24 months ago
Hi! Three weeks ago, I had a heterosexual encounter. The hiv status of the woman is unknown (but let's assume she was seroconverting, and thus had a high viral load). We had unprotected oral sex (I only received a blowjob, no other oral activities) and protected vaginal sex. In addition, mutual mastrubation occurred. 

10-14 days after this encounter, I started to have symptoms. Think about fatigue, headaches, extreme nausea (without vomiting) and unexplainable muscle and joint aches (strange, since I've been resting for the last week and I have a desk job). The nausea went away after a couple of days. However, three weeks after the encounter I'm still having severe muscle and joint aches (over my whole body, especially in my arms and legs). These symptoms don't feel like the ones I've ever had when I had a normal flu.... 

A sti and hiv test two weeks after the sexual encounter came back negative (I know, way too early). An insti self test yesterday (so three weeks after the encounter) was also negative (they only work 3 months after the encounter, but is that also the case if I'm already experiencing symptoms?). I'm waiting for the 4 week benchmark to do a new and more reliable test. What do you think about my risk for hiv, considering my symptoms? Although I know that in theory I only have a small to non-existent risk (but what if the condom teared without me noticing it...), the severe symptoms are really worrying me. In addition, you can find a lot of stories from people who had "safe" sex (just as me), and still got infected with hiv...
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
24 months ago
Welcome to the forum. Thanks for your question.

There is virtually no chance you caught HIV from the event you describe. I don't accept your permise that we assume she had a new infectsion with high viral load (almost certainly she did not) -- but even if she did, the chance of transmission is low from any single vaginal sex exposure. Further, there has never been a cse of HIV proved to have been transmitted by oral sex, mouth to penis -- not one. There have been claims by people who thought that's how they caught it, but none proved. And CDC has cacluated that such exposure carries roughly one chance in 20,000  of HIV transmission, if the oral partner has  HIV. That's equivalent to receiving BJs by infected partners once daily for 55 years before transmission might be likely. And mutual masturbation carries no risk either. (As for people claiming to have been infected despite safe sex, that's like reading about someone struck by lightning, then worrying you might suffere the same fate. Rare things happen, but that doesn't elevate one's risk. And most people with such claims are being untruthful or forget higher risk exposures. Just imagine the guy who receives a BJ on the street who is unaware that his wife already has HIV.)

As for your symptoms, they do not suggest a new HIV infection. The problem with lists of HIV symptoms is that everything listed also occurs with many other conditions, or often without explanation. It isn't just presence of certain symptoms, but the overall pattern, and yours doesn't fit. You also lack the most important and common symptoms:  sore throat, fever, enlarged lymph nodes in several areas, and skin rash. Without these, there's no realistic chance.

Finally, the tests are more reliable than you seem to think. A negative lab based blood test 2 weeks after exposure is at least 50% reliable, sometimes up to 80%, depending on the specific test; and your negative Insti at 3 weeks is 80-90% reliable. Finally, althought these results don't quite prove you didn't catch HIV, they do prove your symptoms are due to something else. These tests always are positive within a few days after start of ARS symptoms.

My advice is to have a final antigen-antibody (AgAb, "duo", "4th generation") HIV blood test 6 weeks after the sexual event. That will be 100% conclusive. In the meantime, do your best to mellow out. It is exceedingly unlikely you have HIV and you can expect a negative test result. Of course see a doctor about your symptoms if they continue to concern you -- but for sure they are not due to HIV.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD
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24 months ago
Well... I'm also having a sore throat (for sure) and an enlarged lymph node in my neck (as far as I can tell)...  Possibly I'm also having a light rash on my chest (but then again, I could be searching for it). So that's not really reassuring. Although the risk is theoretically really small (and some experts argue even non-existent), the symptoms are really freaking me out. Especially the nausea and severe muscle and joint aches are symptoms I've never experienced before during a normal flu...

You said the insti self tests tests are always positive a few days after start of ARS symptoms... The test was taken 21 days after the exposure and showed up negative. That was 11 days after I started to suffer from nausea (and a light sore throat) and 5 days after the muscle aches started. So it is safe to say that these symptoms are not from hiv? Even if the official site of Insti clearly states the following: "After exposure to HIV, it can take 3 to 12 weeks (21-84 days) for an infected person's body to make enough antibodies for a screening test to detect them. IgM is typically released around 3 weeks after infection which is one of the antibodies the INSTI test is designed to to detect. An individual may test positive in as little as 21-22 days after infection, however it can take as long as 3 months to produce a positive result". It seems to me that the test isn't reliable at all three weeks after exposure (21 days, the first positive results may appear...), even if you have symptoms... Or am I wrong? I have an extra insti test at my disposal (would be 24 days after my exposure), but I'm too afraid to use it atm.

Might I also ask why you say there's "virtually no chance" while most other experts tend to say there's absolutely no chance when asked about these risks and symptoms?


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
24 months ago
You're overthinking it. The statement you quote is a regulatory requirement that must meet FDA guidelines. And it says nothing about interpreting the test in the presence of symptoms. The symptoms of acute HIV infection are caused by the immune response to the virus, not by HIV itself. Antibody production is part and parcel of that immune response. Within a few days of onset of symptoms, a test for HIV antigen, antibody, or both ALWAYS is positive. There has never been a proved exception. Further, the statement says it "can take 3-12 weeks". That doesn't mean that it usually takes that long. Insti is usually positive by 3 weeks, nearly always by 4 weeks, and truly always by 6 weeks, despite the cautious wording required by FDA.

So once again, your test results PROVE your symptoms are not due to HIV, and also are strong evidence you were not infected.
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24 months ago
Thank you for your answer! Could you however refer me to a peer reviewed article which mentions what you're saying (i.e. "Within a few days of onset of symptoms, a test for HIV antigen, antibody, or both ALWAYS is positive")? From what I've read, the insti only detects the antibodies (incl. the early igM), which is 6 days later than the antigens, and 9 days before the Western Blot test? I'm sure you know the following article (D. COOK, M. GILBERT, L. DIFRANCESCO and M. KRAJDEN, "Detection of Early Sero-Conversion HIV Infection Using the INSTITM HIV-1 Antibody Point-of-Care Test", Open Aids Journal 2010, 176) stating that "The INSTITM POC test performs well compared with other POC tests for the detection of early sero-conversion HIV infection, but it may miss 20% to 30% of those detected by laboratory-based 3rd generation anti-HIV tests. Both POC and laboratory-based anti-HIV tests will fail to detect a proportion of infected individuals in the first weeks after infection". I'm willing to accept that this article doesn't say a lot about interpreting insti while a patient is already having symptoms (their definition of ARS is based on being able to detect the p24 antigen), but perhaps you can refer me to an article in a peer reviewed journal that backs up your story and would be able to reassure me?

Furthermore, I would like to let you know that I've taken another insti self test today (26 days after the encounter), which came back negative. My symptoms are still present. What is the value of this test (combined with the other tests I already took)? What are, according to you, the odds (you may give it a percentage) I contracted hiv from my exposure (to reiterate: receiving a blowjob (unprotected), vaginal intercourse (protected) and mutual masturbation)?

These are my last questions... Nonetheless, I would like to ask you to keep this thread open to let you know my final results once they come back (labaratory test 6 weeks after the encounter). I think that could prove to be extremely usefull for the readers of this blog.

Thank you in advance!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
24 months ago
Sorry, but this isn't a venue for scientific debate about the science of HIV testing or test interpretation. I have neither the time, energy, nor inclination to re-read the sources you cite. Like many anxious persons, you are delving into the internet in search of information that confirms your fears or preconceived expectations. (The famous statistician Nate Silver of fivethirtyeight.com wrote a book, The Signal and the Noise, in which he wrote [approximately] "Give an anxious person an online connection in a dark room, and soon he'll think his cold is the bubonic plague.") At risk of reinforcing that compulsion, here is the most recent scientific overview of HIV test performance and times to reliable results with various tests, the main source we use in our forum responses:  https://www.ncbi.nlm.nih.gov/pubmed/29140890

As for your current result and symptoms, I'll say once again that test results always overrule both exposure history and symptoms, no matter how high the risk at the time of exposure and no matter what symptoms are present. Your results still prove your symptoms are not caused by HIV. And I would estimate the chance you actually have HIV at 1 chance in many million, based on 1) low chance your partner was infected; 2) average risk from unprotected vaginal sex with an infected women about 1 in 2,500; 3) condom reduction in risk from vaginal sex at least 90%; and a test result that is at least 95% reliable at 26 days. I'm sure you know how to do the math to calculate a numerical risk from those numbers. So do your best to believe and move on without worry, especially if and when a final AgAb test is negative at 6 weeks. There is no realistic change you have HIV.

That completes the two follow-up comments and replies included with each question and so condludes this thread. I hope the discussion has been helpful, despite your obvious resistance to our advice. Please do not be tempted to start a new thread to further address your exposure and your HIV test results. Thank you and good luck.
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