[Question #5488] Handjob + 3 days of truvada + negative test 69 days post -> Conclusive???

22 months ago
Dear Dr,

On 1st January 2019, I was given a handjob during a massage. No other sexual contact occurred an I had ZERO sexual history till that point. Immediately after this incident, I was a bit alarmed and went to the ER in the nearby hospital on that day itself(this is in Taiwan). The ER Dr probably did not understand the nature of the encounter (could be due to their limited command over English). He did a baseline HIV + syphilis test on that very day and put me on truvada for 3 days. He asked me to come back on the 4th day for an OPD consultation.

On the 4th day, there was another Dr who stopped truvada immediately and showed me the negative report for the baseline HIV and syphilis test done on day 1 of the encounter. He suggested taking another test on the 30 day mark. I did not follow that exactly and when I went to my home country India, I did a p24 + HIV1/2 test 69 days post exposure. It was negative.

1) Now is this 69 day result conclusive ??? There seems to be a ton of confusing information about this on the internet.  

2) CAN TAKING TRUVADA ON DAYS 1,2,3 AFFECT A TEST ON DAY 69/70. I REALLY WANT TO KNOW THIS!

3) I generally get canker sores. However, I have noticed an increased frequency for the past 2 months or so. This is again causing me a great deal anxiety about its possible connections to HIV. Please help me.

I sincerely appreciate the effort you are putting on this forum to help people out.

Regards,
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
Welcome to the forum. Thanks for your question.

First, I agree with the second and disagree with the first doctor you saw:  PEP was not reasonable for this event. Hand-genital contact is risk free, even with infected partners who might use genital fluids or saliva for lubrication.

In theory, taking anti-HIV drugs might delay development of positive HIV blood tests, if PEP doesn't work, and most experts would recommend testing after PEP at 3 months. However, that's for a full course (a month) of PEP. Most likely 3 days would result in little or any delay. However, there has been non conclusive research on any of this:  all knowledge and recommendations are based on common-sense understanding of the biology of HIV transmission and positive blood tests. My opinion is that 3 days of PEP makes no difference at all in blood  test reliability.

You are exactly right about "a lot of confusing information about this on the internet." That's to be expected:  since there are no data and only personal opinions, those opinions and advice from them are all over the map. Maybe someday there will be more conclusive research on all this, but not yet.

The main thing to keep in mind is that your exposure was zero risk for HIV. Not only did you not need PEP, you didn't even need HIV testing. If your test had been positive, or if it becomes positive in the future, the first step would be to carefully cover other possible exposures that can explain it. Becuase you definitely could not have acquired HIV by the exposure described above. Therefore, I would advise you to stop obsessing about your HIV test results.

But of course I know you will not or cannot do that. So now to your specific questions (even though they're pretty well covered by what I've said so far):

1) Your current test result is conclusive. I am confident that 3 days of Truvada would not prolong the window period beyond the normal 6 weeks -- and your negative results are at more than 8 weeks. All is well:  you do not have HIV.

2) Probably not:  see above.

3) No single symptom, including canker sores, ever indicates HIV. You cannot read lists of ARS symptoms, see canker sores listed, then conciude your sores might be HIV. It is never any single symptom, only the patterns, combinations, and timing of sympotms. And it is impossible to have HIV symptoms and not have postiive HIV antibody blood test results. So your negative test shows both that you do not have HIV, and that any symptoms you have cannot be caused by HIV.

So all is well. Do your best to move on without worry -- especially since you weren't at risk to begin with!

I hope these comments provide the reassurance you seek. Let me know if anything isn't clear.

HHH, MD
---
22 months ago
Dear Dr. Handsfield,

Thank you very much for the reassuring words. I have read your reply carefully. Let me still ask you the following:

1) Has the official guideline on the testing period been changed? Is the new one at 6 weeks and not 90 days?

2) Does your assessment of the situation change given that the encounter and the testing were done in two different countries? This is probably a stupid question. HIV is never country-specific I hope?

3) What did you mean while saying "But of course I know you will not or cannot do that."? I somehow could not connect this sentence to the earlier ones.

4) Please pass one final remark. IS FURTHER TESTING EVEN REMOTELY NEEDED GIVEN THE TRUVADA THING?

Thanks and regards
22 months ago
Also adding:

5) Is the following scenario possible ? - The p24 antigen dies down after 6 weeks say but the antibodies are not produced at detectable amounts on the 69/70th day?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
22 months ago
1) There is no single "official" guideline. Various academic, public health, and HIV prevention programs have their own standards and not all are identical. Most now recognize 6 weeks as the time for conclusive testing using the now standard antigien-antibody (AgAb, duo, combo, 4th generation) blood tests, but not all have done so. Three months was appropriate for the earlier (first and second generation) antibody-only tests, but is outdated, even if some agencies haven't changed their formal recommendations. On this forum, we are liimted only by the science, without having to consider political, legal, and other aspects that color some agencies' advice. We have been promoting 6 weeks (and for a while, 4 weeks) for almost 10 years.

2) Almost all labs in most countries -- especially industrialized ones -- use pretty much the same tests and same automated test machines. There is no likely variation in test performance based on location.

3) I advised you to stop obsessing about your test results, then predicted you would not be able to do that. Seems I was right, wouldn't you agree?  ;-)

4) I see no need for any further testing.  As already discussed, I doubt 3 days of PEP makes any difference. If it does, it would only be a day or two, and you have already been tested 2+ weeks beyond the outside window of 6 weeks.

5) I'm told there are online sources that talk about a second window between positive antigen and positive antibody. It's BS. This doesn't happen because it cannot happen -- indeed, this is the beauty of the AgAb tests and the main reason they are so reliable. It is antibody itself that clears HIV antigen from the blood. Therefore, antigen cannot disappear until antibody is present and detectable by the test. Therfore, the AgAb tests are always reliable any time after 6 weeks.

You have one more comment and reply coming on this thread, but please carefully re-read all my replies first. Most likely anything that comes to mind has already been addressed, or the answer should be obvious. I'm not going to repeat myself!
---
---