[Question #5454] Protected sex and PCR+4th gen tests.

22 months ago
Dear Drs, I have a wife and a small child both of whom I love very much but, by a stupid mistake I went astray and engaged in a fully protected oral + vag sex with a CSW. She was a call girl/escort type. The lady looked very clean, used one-time towels on her bed, provided what looked like Durex or Contex condoms, tho I never made sure. The intercourse lasted for  10 to 15 minutes, the lady unrolled condom with her mouth onto my penis, then we proceeded to protected oral and vaginal sex. The condom was visually intact after I ejaculated and definitely covered at least 60-70% of my penis when I withdrew. After the act was completed, my anxiety got the better of me and my personal hell started (nothing unusual, huh). As a result I completed two tests in a widely known Russian private lab: one for HIV-1 PCR RNA (detection limit - 80 iu/ml, which, as explained by their technical support equals to 123 virus copies in ml), and a 4th gen Ab/Ag test on an Abbott Architect assay. Both tests were completed on the 26th day post-exposure. The lab claims that with such detection limit this test is conclusive on average in 10 days. My questions are as follows: 1. Three well-trused HIV counselling sources in Russia told me that a) there was no risk for HIV in my situation and hence no need to test at all and b) my PCR and 4th gen tests on the 26th day post-exposure effectively rule out any possibility of HIV. I know that you advice PCR+Ag/Ab (or simply Ab) on the 28th day post-exposure. Does a two-day difference, in your opinion, matter in my case? I had no symptoms that I could relate to HIV ARS. 2. I also had no STD symptoms, so need to test for those, right? I also contacted the lady afterwards and she said she is clean (tho definitely no assurance here). 3) Can I resume unprotected sex with my wife? The intercourse took place in Kazan (Russia).
22 months ago
Dear Drs,
As there is no EDIT button for the already posted questions, allow me to double-post to correct myself:
the line "I also contacted the lady afterwards and she said she is clean" should obviously read "I also contacted the lady afterwards and she said she is [in the] clear", as obviously "clean" or "unclean" are obviously improper words in the context of STDs.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
Welcome to the forum. Thanks for your confidence in our services. Also for your understanding and sensitivity about your partner and concern for (politically?) correct terminology!

Directly to your questions:

1a) I agree this was a very low risk exposure, with a partner unlikely to have HIV (although the frequency of heterosexually and sex-worker-related HIV is a lot higher in your country than western Europe or North America).

1b) Correct that the negative test result is nearly 100% conclusive, and probably there is no measurable diference between 26 and 28 days. However, in rare cases the AgAb tests can take up to 6 weeks to convert. About a year ago we revised our advice accordingly on this forum, i.e. from 4 to 6 weeks. Even now, the combination of the exposure risk and test result make it virtually 100% certain you don't have HIV, but if you feel you need an absolutely conclusive test result, do it again at the 6 week mark.

2) "No need" for other STD testing? True, at an absolute risk level:  with condom, a partner who seems to be "clear" (and probably clean!), and no symptoms, it's very unlikely. But most people in your situation are further reassured by negative test results. You could consider a urine or urethral swab gonorrhea/chlamydia test (make sure it's a DNA test -- my understanding is that blood tests, generally very unreliable, are in common use in eastern Europe) and a syphlis blood test at 6 weeks.

3) While I cannot guarantee sex with your wife is safe, the risk is exceedingly low. If I were in your situation, I would be continuing sex with my wife without worry, i.e. accepting the very small risk something will turn up with testing.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD
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22 months ago
Dear Dr. Handsfield,
Thank you for your expertise. It has now been over 6 weeks with no symptoms at all. Can i rule out syphilis and gonorrhoa at this stage as there has been no sores or discharge from the penis?
Also by reading this forum, i was under impression that a combination of a hiv pcr rna test plus a 4th gen ag/ab test is considered definitive at 28 days (against only ag/ab which is definitive at 6 weeks) . I have had both the HIV-1 RNA PCR test and the ag/qb test negative at 26 days. Do i still have to do the ag/ab now? If i am not mistaken, Dr. Hook was also saying that even hiv pcr rna test alone rules out hiv any time further than 10-20 days.
22 months ago
Good day,
Kindly requesting a feedback...
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
Yes, that combination of HIV test results -- AgAb and PCR at about 4 weeks -- is 100% conclusive. It is technically true that negative PCR by ~20 days is conclusive, but most experts also recommend an antibody test (or AgAb test) at 1 month in addition to the PCR.

For gonorrhea and syphilis, absence of symptoms by 6 weeks is almost 100% conclusive. But for absolute certainty, you need a urine test for gonorreha (and chlamydia) and a blood test for syphilis. I am sure they will be negative, and if I were in your situation, I would not wait for the results before having sex with my wife.
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22 months ago
Dear Dr. Handsfield,
As it is my third & final allowed message for this thread and my questions have all been basically answered, I would like to take this chance and first of all thank you and Dr. Hook for the job splendidly done on educating people on STDs, safe sex and testing for so many years!  Proper education leads to proper awareness, and that is something that is difficult to achieve with Internet overabundant with downright false information and, at times, confusing statements by the medical workers (at least in my country).
Secondly, as the dust has settled, I decided to use this situation and get a bit more knowledgeable about HIV testing in general and PCR RNA in particular. So, please allow me to shaer  a few theoretical issues that I was able to dig up coomunicating with local experts. I highly doubt this info will be of any practical use to me, but just consider me a strange person lol. Kindly correct my understanding, if I am wrong:

1. The threshold for the HIV-1 PCR RNA test I completed was 80 iu/ml, which, as explained by their technical support, equals to 123 virus copies in ml. If I understand correctly, an individual, if HIV-positive, will initially undergo a so-called "eclipse" phase, when nothing, even RNA/DNA tests, is able to detect the virus and/or its products. The phase lasts for approx. 3 days, after which the viral load skyrockets to tremendous amounts, and by 3 weeks time and  it is reliable to assume that there are thousands of virus copies in each ml of plasma which is way above the detection threshold of the test.
2. PCR RNA test is known to have a higher false-positive rate as compared to the 4th Gen Ag/Ab test. However, there are extremely rare cases when, under certain configurations of testing parameters, a HIV-1 PCR RNA test may fail to identify certain subtypes of HIV-1. This is why experts recommend an Ag/Ab or Ab-only test in addition, as a fail-safe option to rule out even the slightest possibility of HIV.
3. As I understand, the instances of HIV-2 across the globe are so rare (except dedicated areas like West Africa) that it makes absolutely no sense to do a HIV-2 RNA test, even tho these are also available on the market. Also, in this case the Ag/Ab test serves as fail-safe option against HIV-2 as well.
4. Coming back to my case, am I correct to understand that testing 2 days prior the recommended date (26th vs 28th day P-E) make no difference also due to the fact that even the AB-only (3rd gen) test would be reliable at 28 days in combo with the RNA test, and in my case I also have the AG-part to make up for these 2 days.

Once again, thank you very much!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
The purpose of leaving threads open is for follow-up comments to clarify the initial replies, not entirely new detailed questions -- in this case about the biology and performance of the various HIV tests. On quick scan (not reading in detail), all the statements in these comments are true; some of them suggest your research might have edcuated you on these issues better than I am. As you suspected, they do not change my overall assessment and advice.

That concludes this thread. I hope the discussion has been helpful.
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