[Question #5402] Confirmed HIV Exposure

23 months ago
Dear Doctors, 

Just over 7 weeks ago I received a blowjob and I gave rimming to a FTM trans person. 4 days after the event, they tested positive for HIV. After a discussion, they had severe flu like symptoms which ended about 3 weeks before my exposure (leading me to believe their seroconversion was very recent, this is backed up by their testing schedule.) 

As a result, I have been quite anxious about my own health. 14 days after exposure, I had a PCR RNA test which came back non detectable. 28 and 29 days after the exposure I had a negative 4th generation test. Exactly 42 days post exposure, I again had a negative 4th generation test. 51 days post exposure (today) I had a negative Insti test. 

However, 3-4 days ago, I began getting a rash (still have it) on my neck and upper chest areas, which is quite painful. I would describe it as feeling like it was blistering, but when looking at it, there are no signs of blisters. It is red at times, quite blotchy, but other times it looks basically the same colour as my skin, especially if I am in the bath or just woken up. 

So my questions are, 

1) How would you advise testing from here on out, providing my above test history? 

2) Could this rash be a result of ARS? 

3) Do you think I can safely resume unprotected sex with my partner? 

4) I know you say receiving a blowjob presents no risk for HIV, but what is your stance on rimming someone, especially one with a confirmed HIV infection? 

Thank you for your help. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
Welcome to the forum.

What an alarming event -- I understand how upsetting it as. I agree it seems likely your partner had an acute HIV infection and likely a high viral load. Nevertheless, your worries are over!

The modern HIV blood tests are among the most accurate diagnostic tests ever developed, for any medical condition. If done sufficiently long after the last possible exposure (and yours were done plenty long enough), negative results overrule all other factors. No matter how high the risk of HIV at the time, and no matter what symptoms you might have now or in the future, your test results prove conclusively you did not catch HIV. I will further add that receiving oral sex is zero risk for HIV (there has never been a proved case of transmission mouth to penis); and analingus also carries little or no risk -- regardless of acute infection and high viral load. In addition, your symptoms really are not at all suggestive of acute HIV. But even if they were, it doesn't matter in light of your blood test results. To your specific questions:

1) No further testing is necessary.

2) No, not possible. Rash alone never is due to ARS. But even if that were possible, the blood test proves otherwise.

3) You could have safely resumed uprotected sex with your regular partner after day 28. The negative AgAb (4th gen) test at that time, plus PCR at 2 weeks, is conclusive.

4) See above. Analingus (rimming) has never been studied in terms of HIV risk, but almost certainly it is low. I am anaware of any reported cases of such transmission. But to repeat (again) the most important message:  the test results rule. You could have mainlined HIV infected blood, and my reply would be the same. For sure you are home free.

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

HHH, MD
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23 months ago
Thank you Doctor for a very reassuring reply. 

Just a couple of follow up questions. 

1) I'd estimate the rash started anywhere between 45 to 48 days post exposure, is this too late for an ARS symptom, and as the rash is relatively localised (front of neck and upper chest), can ARS be entirely ruled out? 

2) I've done quite a bit of research into testing protocol (a blessing and curse of being a graduate student) and I just have a question on the Alere Determine rapid combo test, on the periphery of pertinent to my specific case, as I had the lab based 4th Gen at 6 weeks. I note many European countries follow the 6 week window period for the LAB BASED duo, but only European guidelines follow the 6 week window period for the rapid 4th Gen, with Sweden following at 8 weeks and other countries adhering to the 12 week "gold standard". In your professional opinion, what do you see as the window period for the 4th Gen rapid test? I note Sweden claims the antigen portion of the test is not reliable, so adhere to 8 weeks as they do for 3rd generation tests (for HIV 1 infection only, HIV 2 remains at 12 weeks) 

3) Is it possible to only experience one symptom of ARS or do they always come in some form of "bundle"? 

4) And just for reassurance, are my tests 100% reliable and certain that I did not acquire HIV from the outlined exposure? 

With all best wishes, 

W.


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
1) The timing and characteristics of the rash are irrelevant in light of the blood test results. You'll need to look elsewhere for possible causes.

2) There are many valid resources for HIV test performance. This is the one we use as the basis for advice on this forum:  https://www.ncbi.nlm.nih.gov/pubmed/29140890. The bottom line is that for all HIV tests that exist, the real-world performances are estimates, with various levels of precesion. Accordingly, the advice from various health departments and other agencies have room for intepretation and variability. Also, there are two aspects of test interpretation: time to positivity; and association with symptoms. Totally indepdent of exposure time, if a symptom is due to ARS, within a week of onset the blood test will be positive. No exceptions.

3) No sinlge symptom ever is helpful in judging presence or absence of ARS. Every one has multiple causes other than HIV. (In medical/epidemiologic terms, these symptoms are "nonspecific", i.e. not pointing to any particular condition.) It is always a mistake for persons worried about HIV to read such a list, say "Aha, I've got that one!" and therefore I have HIV. It is always the pattern of symptoms, in combination with physical examination by a trained professional, that matters. And indeed, the pattern of ARS symptoms is generally one of several symptoms simultaneously (onset within a few days of each other), generally starring 8-10 days after exposure and peaking at 1-2 weeks. I've never seen or heard of anyone with ARS with only rash or any other one symptom. 

4) OK, here's the main take-home message once again: Your results PROVE you did not catch HIV! Do not overthink it and ignore any and all further "what if", "yes but", or "could I be the exception" thoughts or questions that come to mind. There is no infoermation you will think of that will change my opinions or advice.

Got it?
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23 months ago
Hi Doc, 

Checking back in since I have had a painful rash across my stomach and back since Monday (56 days post exposure). The visual severity of the rash varies significantly throughout the day, disappearing almost entirely when I have just woken up to being pretty obvious throughout the day. The pain of the rash however is pretty much constant. 

I had a rapid 4th gen test the same day it appeared. 

Does any of this change your opinion/advice? 
23 months ago
The rash also includes my arms but nowhere below my waist. 
23 months ago
Final addition of information - apologies

The rash is not itchy at all. It stings if I sweat and is otherwise nearly constantly painful.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
No, this doesn't change anything. For the reasons already discussed in detail, I remain certain you did not catch HIV and your rash is caused by something else. I suggest you carefully re-read my replies above.

That completes the two follow-up comments and replies included with each question and so ends this thread. Do your best to stop worrying. See a doctor if your rash persists and/or you remain concerned, but HIV really is not an issue for you.
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