[Question #5364] HIV concern

24 months ago
About 5 years ago, I met a guy online (I am male). On our second "date," in the heat of the moment we had unprotected anal sex with me being the top, finishing to completion. He is a middle aged, middle class, white Male . When I asked before and after, he claimed he was free of STDs but offered no objective reason for being such. 3 and 4 weeks after, I took an at home oraquick test. Both of them negative. I never experienced any ars symptoms but a couple of months after, I had a MRSA infection the dr attributed to "manscaping." I've only thought about this incident since then because I'm interested in donating blood and have become very worried. 
Given the facts, is it likely I contracted HIV? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
24 months ago
Welcome to the forum. Thanks for your confidence in our servcies. Sorry for the longer than usual delay in responding.

If a male has HIV, the average infection risk to a male having insertive anal sex is around 1 in 900. Since it seems unlikely he had HIV, your risk was far lower than that. So even before you were tested, you could be confident that almost certainly you were not infected. It's good you tested, of course. However, it was too early:  the home oral fluids HIV test is the least accurate of all HIV tests, and at 3-4 weeks would detect only around 80-90% of new infections. (It requires 3 months for best results, but even then it misses some HIV infections.)

Having had no symptoms to suggest HIV over the last 5 years, almost certainly you are not infected. The automatic testing of blood donors (actually a combination of tests) is 100% conclusive. When you get the negative result -- or when the blood center doesn't contact you with a positive result -- you will know for sure. Or you could have a lab based antigen-antibody (4th generation) test on your own. I'm confident it will be negative. I'd put the chance you have HIV at under 1 in a million.

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

HHH, MD
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24 months ago
Thank you Dr. for the sound, balanced advice. It sure beats the "you're all gonna die" approach that is promulgated on the web. I'll get tested but wanted to have a good night's sleep in the process. 

No worries on the delay. After all, physicians have lives too. 

It is a sad state of affairs in this country that a person with graduate degrees can be so abysmally ignorant about basic issues regarding sexual health.
I did have a couple more questions:
- after 5 years, what symptoms would suggest HIV. I'm generally healthy other than common illnesses that go around. Other than that, nothing out of the ordinary.
- is it true that an overwhelming majority of HIV infections result from months of repeated exposure and unprotected sex and not from one-time encounters? 
Thank you in advance for your help 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
24 months ago
Thanks for your kind comments. I'm glad to have helped.

Your follow-up questions give me an opportunity for one of my occasional blog-like replies that I can re-use for similar questions in the future. Probably a lot more than you expected, but I hope you find it useful.

Five years after catching HIV, probably around 50% of infected people would have symptoms attributable to HIV -- or, more precisely, to health problems from immune deficiency caused by HIV. But its an imprecise situation:  some of those symptoms are highly typical for immune deficiency but others are not; and some are so mild that people don't remember or report them. The indivudual who is blase about his health and symptoms might report none, including some serious clues about HIV; whereas someone who is obsessively aware of every ache, tingle or twinge might be classified as symptomatic on account of things that actually don't matter.

The main problems that would be most typical of HIV -- the ones that might trigger a test even in someone without obvious risks -- are unexplained weight loss; lymph node enlargements in various body areas; certain skin conditions, notably unusally dry skin body wide, and severe seborrheic dermatitis (dandruff), especially if it extends onto the face; white patches in the mouth (yeast infection, i.e. "thrush"); repeated episodes of certain infections, especially pneumonia (and sometime the first episode, if the cause seems unusual); and chronic or recurrent diarrhea. I'm sure there are others that don't immediatley come to mind, but these probably are the majority. Things that do NOT raise suspicion are common colds, even if frequent, influenza, viral diarrhea, minor aches and pains without other symptoms, and just about all the things you probably mean by "common illnesses that go around". And by the way, age and social circumstances also dicate the level of suspicion. With all these symptoms, it's a very different story for a 60 year old suburban housewife versus a 40 year old meth-using gay man who has multiple anonymous partners.

Any single exposure carries a certain amount of risk. But except for direct exposure to contaminated blood (needle sharing, infected transfusion), all exposures carry risk no higher than around 1 in 300 (the receptive partner -- "bottom" -- in anal sex with an infected male), and most sexual exposure range in risk from 1 in 1000 (penile to anal or vaginal) to 1 in 2500 (vaginal to penile). Those figures alone tell you that single exposurse uncommonly result in infection.* And the vast majority of people with HIV (e.g. the patients of the country's busiest HIV/AIDS clinics) have had hundreds of potentially risky exposures. That's not to say that care should not be taken, even for a single exposure:  you undoubtedly have been reminding  yourself for 5 years how dumb your sexual decision was at the time. But rather than looking at it as a cause for panic (which you did not do -- but this forum is dominated by questions from people with exactly that kind of reaction!) -- it should be a learning experience that helps assure it won't happen again (as seems to be the case for you)*.

And one more clarification. The risks quoted are averages. If unlucky enough to have sex with a very recently infected partner (before blood test positivity) or other cause for an especially large amount of virus in the blood and sexual secretions, the risk could be 10 times higher. Such exposures count for many (most?) newly acquired infections. OTOH, some infected people, especially those on HIV treatment, have such low levels of HIV that they never transmit. The risk figures I have quoted (from CDC) were calculated before most infected people were on anti-HIV treatment. Today the average per-exposure risks probably are lower than these estimates.

* If you can stand a bit more pontificating:  One behavioral dynamic among people at ongoing risk is "I've dodged the bullet so many times, I must be immune and/or surely my won't change." But it's just a numbers game. It's Russion roulette with a magical pistol with one bullet every 1,000 chambers (or 2,500 or whatever) instead of six. And among people at sufficient risk, luck always runs out.

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24 months ago
Thank you Dr. Handsfield for the insight. Looking at the list you gave, there hasn't been any health problems my way to give me pause. And you're right, it was definitely a lesson learned for me, completely out of character to do in the first place. It was the first and only time I've ever been careless in that regard. I regret being ignorant about testing windows, but oh well, we live and learn. 
As I mentioned before, I'm glad to get some sound advice to ease my worries a bit. My mind rests a lot easier knowing that most likely, I wasn't infected.

Thank you again for your time and godspeed 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
24 months ago
Thanks again for the thanks. I'm glad the discussion was helpful.---