[Question #5930] HIV or Mono from a brief encounter of unprotected sex

17 months ago

Hello Doctors!

First off, I am a heterosexual, middle aged male living in Canada. My last HIV test was two years ago which came back negative.

A year ago, I started to hang out with a woman who I believe was very promiscuous (possibly bisexual and open to dating other men, ect) and just to be clear, she was not a sex worker. I do not know if she had HIV or not; however, she did use condoms. We had vaginal intercourse several times (all condom protected) except for one or two very brief occasions that only lasted between 5 - 20 seconds or so when my unprotected penis entered her vagina. Afterwards, we finished with condom protection. Oral sex (both giving and receiving) was often or always without condoms. There was also lots of deep kissing in between. There was also one occasion that only lasted for a few seconds when we were going to try anal sex, but my penis (unprotected) only touched the outside of her anus and did not go inside. Zero anal intercourse.

Now, it’s been a year since I last had any unprotected sex. Since that time, I’ve had no symptoms (no rashes, no high fevers, no vomiting, ect) with the exception of minor colds. However, over the past couple weeks, I’ve been feeling extremely tired and fatigued. I had one small swollen lymph node (left side of the neck) and a swollen tonsil (right side of the mouth). I went to the doctor and he diagnosed me with a possible mononucleosis or mono infection. He gave me some antibiotics and prednisone to heal the swollen tonsil/infection. Since then, my throat feels much better and my lymph node has decreased in size. The doctor also checked my spleen and said it wasn’t enlarged. He gave me paperwork for some blood work (B12, Epstein-Barr, ect).

1. What are my chances of getting HIV based on the sexual practices mentioned above?

2. Are my symptoms due to an HIV infection or possibly due to mono?

3. If I decide to get another HIV test, will having mono affect the results of the HIV test?

Thank you!

H. Hunter Handsfield, MD

17 months ago

Welcome to the forum. Thanks for your oonfidence in our services.

Almost certainly you do not have HIV. A partner like you describe is very unlikely to have HIV, which is rarer in sexually active women than you might assume from media coverage. In the US and Canada, under one chance in a thousand in very sexually active women without special risks, like sex work, injection drug use, etc. Second, oral sex is risk free in regard to HIV; condoms work; and the transmission risk from a single episode of umprotected vaginal sex, if the female partner has HIV, averages 1 in 2,500. These statistics translate to roughly 1 chance in 2.5 million you have HIV -- zero for all practical purposes.

I am skeptical you have infectious mononucleosis. I don't mean to second guess your doctor, but mono is rare in middle age, with the large majority of cases age 12-25; almost everyone has been infected with Epstein Barr virus by their mid-twenties, mostly with no symptoms. Mono can cause fatigue, but contrary to common beliefs it's not the main symptom. A single enlarged or inflamed lymph node also is atypical; generally it's multiple nodes or none. The symptoms also are not suggestive of HIV. That's not to say there's no chance, but I will be surprised if you have mono. (I'm a bit surprised your doctor latched onto mononucleosis without mentioning HIV himself. In today's world, questions about HIV risk and testing for it would be much more common than worrying about mono at your age and with these symptoms. I have to guess he didn't ask and you didn't offer your sexual history.) In any case, your blood test for EBV probably will be positive however, as it is for >90% of healthy adults. If positive, additional testing can be done to judge whether the infection is active and potentially causing your symptoms -- depending on exactly what test(s) your doctor ordered.

To your specific quesitons:

1. It isn't impossible you have HIV, but the chance is extremely low, as discussed above. If you want even more secruity about it, discuss the situation with last year's partner. She likely will reassure you she isn't infected, or perhaps would agree to getting tested now. If negative, you'll know with even more certainty you can't possibly have it.

2. As discussed above, I doubt your symptoms are due to either HIV or mono.

3. There are no medical conditions or medications that have any effect on HIV test reliability. Any statements you find online or elsewhere reflect urban myths. Mono certainly has no effect on the HIV tests. In any case, you should tell your doctor your concerns about HIV and let him advise you about testing (which he probably will recommend).

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

HHH, MD

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17 months ago

Thank you for the quick response!

The doctor I saw was at a walk-in clinic. He mentioned that mono was definitely more common among younger folks (teenagers, college students, ect) but he did say that I could catch mono from just being around people in everyday life (coughs, touching door knobs, ect). I have kissed a lot of different partners in my day, so I’m not sure if mono just laid dormant and decided to come out of the woodwork now? I also followed up my visit with a trip to the emergency room to get a second opinion. The doctor there said that mono is common among 40 year old people. He also said that my symptoms sounded like mono but disagreed with getting blood work done as there’s so many other viruses than Epstein-Barr that can trigger mono. None of the doctors ever suggested getting tested for HIV or any other STD and no, I did not mention my sexual history. To be honest, I have never met a doctor yet who ever suggested getting tested for HIV whenever I showed up at a walk-in clinic or an emergency room with a cold or flu-like symptoms. Any testing I’ve had for HIV was done from my own request which all came back negative in the past.

Follow-up question:

With such a low risk exposure, is it safe to go on having protected sex with someone else or do you recommend HIV testing? I also have had no problems going to the washroom (peeing, ect) and have experienced no discharge from any other STD.

Once again, thank you very much for your help!

H. Hunter Handsfield, MD

17 months ago

As implied above, we try to avoid comments that can be interpreted as critcizing users' own doctors. The doctor(s) you saw are correct about mononycleosis syndrome having causes other than EBV, but my agreement with them ends there. Only 3-4 other causes are known, certainly not "so many". The most common non-EBV cause is cytomegalovirus, and EBV and CMV together probably cause at least 90% of cases. Like EBV, CMV is mostly acquired in childhood or young adulthood, usually without symptoms. Mono is not commonly acquired by the sorts of contact you mention. (This has been carefully studied. In the most classic research, few roommates of university students with mono got mono themselves or acquired EBV or CMV, and were no more likely to have it than non-roommate friends. The main nodes of transmission involve saliva, e.g. intimate kissing, and sex.) And sorry, but it is rare at age 40. Finally, I stand by my comment that fatigue alone not a typical symptom: >90% have fever, sore throat (often severe, mimicking strep throat), and widespread lymph node enlargements. My guess is the doctor(s) you saw are not infectious disease specialists, as are Dr. Hook and I.

I'm not surprised by your experiences with HIV related history and testing, especially by providers in urgent care or emergency departments; office practitioners in general are better. It's also an issue for other STDs. This is why patients concerned about HIV or STDs should raise the issue themselves if the doctor does not. Things are moving the right direction, however. Younger physicians, i.e. more recently trained, take the initiative more than older ones.

If you in fact have mono, whatever the cause, sex is a good way to transmit it. And because of the saliva connection, condom protection may make little difference. So if you assume you have mono, you should avoid sex for a few weeks. However, for all the reasons above, I am confident you don't have it and condom protected sex won't be risky.

Should you be HIV tested? For all the reasons we have discussed, the chance you have it is extremely low, but I can't say it's zero. My guess is you'll sleep better knowing for sure. If so, have an antigen-antibody ("4th generation") HIV blood test 6 weeks after the exposure described above.

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17 months ago

Good evening Dr. Handsfield,

Just giving you a quick update on my condition. You were 100% correct! I did not test positive for the Epstein-Barr virus. I went back to the walk-in clinic to receive my blood work results. The same doctor was on duty that day and was very surprised that I didn’t have mono after all. He was so sure that I had it. Apparently all my red and white blood cells are normal and my blood platelets look good too. However, my liver enzymes are elevated for some far out reason? I rarely drink alcohol, I exercise regularly and I am not overweight at all; so, I don’t know why my liver is elevated? The doctor at the walk-in clinic gave me some more blood work. This time to see if I have cytomegalovirus, Hep A, B, C and HIV, which I requested this time. I took all the blood work two days ago, so now all I can do is wait. The doctor at the walk-in clinic thinks my condition is due to some type of virus but he’s not sure what it is? This frightened me. He doesn’t think HIV is the issue as my blood platelets look good. He says that HIV likes to attack the blood platelets apparently? In any case, I would sleep a lot better at night knowing that I am HIV negative. I’ve also received the Hep B vaccine 20 years ago back in high school, so I don’t think I have Hep B? I also notice that my throat still feels a little scratchy and dry despite having taken the antibiotics (azithromycin) that originally took my swollen tonsil and lymph node away. I may be overreacting, but I am just terrified of catching HIV.

Thank you very much for all your help Dr. Handsfield!! I really appreciate this forum.

H. Hunter Handsfield, MD

17 months ago

Thanks for the follow-up information. But it is clear you have no STD and we don't get into non-STD issues on this forum. And the chance you have HIV is extremely low. I already suggested you have an HIV test to confirm you aren't infected, and I really have no more to say on the subject.

Thanks for the kind words about the forum -- that's why we're here! I'm glad to have helped.

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