[Question #6327] how to rule out his infection from a real high risk exposure

15 months ago
I had a unprotected anal exposure on the 17th of September in a Japanese bathhouse / partner status unknown. I was the insertive  role and brief around 5-10 mins max. did not get any symptom as of now and I tested several OraQuicks (finger blood)  administered by myself from 3rd week up to the 6 week mark (all negative) at 45 days I performed the Vidas His Duo Ultra in turkey and showed negative 0.0 Antigen and 0.05 Antibody, I also did several std tests Hepa C / B Gonorrhoea/VDRL/chlamidya/hpv. all negative. I continued to test for oraquicks till now and did my Insti rapid test at home at day 66 or 9.4 weeks (negative). my question is should I do a PCR and 4th generation at week 12/84 ? also after the 12 week mark should I retest at 6 month? I am worried about the elite controllers/hiv2/late seroconversion or low antibody levels. should I do other blood works? all the questions I saw in the forums are either low risk or pure silly. 

seeking an expert advice ,
thank you 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
Welcome to the forum. Thanks for your question. 

I can't judge the risk level of your exposure, because I have little knowledge of HIV frequency in gay men in Japan. But I believe it isn't nearly as common as in the US and Europe. If he was infected and not on HIV treatment, the average transmission risk is around once for ever 900 exposures. So all things considered, this probably was not a particularly high risk exposure. More important, you have had several negative blood tests. The antigen-antibody (AgAb, "duo", 4th generation) HIV tests are conclusive any time 6 weeks or more after exposure, so your redsult prove you were not infected. There is no need for PCR or any other tests. With the tests you have had, there is no such thing as late seroconversion or "low antibody levels" not detected by testing. And elite controllers have positive blood tests just like anyone infected with HIV.

As for your other STD tests, they too are completely reliable. You can be 100% confident you do not have any of the infections for which you were tested.

You definitely can move along without further worry. Let me know if anything isn't clear.

HHH, MD


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15 months ago
Thanks doctor,

you are right, there is limited information/research about the hiv frequency in Japan. however I believe it is high ( they don't get tested/they don't like using protection either/undereported figures and high std rates) however, it is very assuring what you had mentioned below (stupid impulsive behavior from me and wish if I've never did it but nothing I can do about it now).  
two things that puzzles me based on the research papers I read and one recently (2018) from Switzerland was very informative that some European countries consider 6 week conclusive for 4th generation tests however they mentioned an observational study and few cases outside the us that a second window period needs to be observed.
the second thing is people infected with no symptoms, they pass years without even knowing it. what explains that no symptoms? if they tested within that three month period would they be positive?
finally what is the actual percentage of people seroconverting after 3 month with new tests (4th generation) any reported cases? I am assuming as of now we don't have enough data that's why guidelines stick with 3-6month in some countries and hard topic to research but more interested to know

I read a lot of research papers in the past few weeks that kind of triggered my anxiety (bad idea) however got me more curious to understand HIV exposure/ infection/rare cases. ( my friend currently suggesting that I should switch my career to an immunologist). 

thanks
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
1,3)  I am unaware of any reliable reports of AgAb (4th generation) test taking longer than 6 weeks to become positive. Any delays beyond that are too rare to worry about, if they occur at all. I don't know what data the Switzerland paper found or cite, but we base our advice on a review published in 2017 (https://www.ncbi.nlm.nih.gov/pubmed/29140890), which was endorsed (unofficially) in an accompanying editorial from experts at the US Centers for Disease Control and Prevention (CDC). The reasons some resources still say 3 months (I know of none that still advise 6 months) have to do with legal conservatism, a hyperactive sense of caution, or often simply not keeping up with the times as test technologies evolved.

2) HIV itself causes no symptoms in anyone, aside from those who have symptoms with ARS. Those symptoms generally are gone within a few weeks, although enlarged lymph nodes may persist a bit longer. After that, symptoms due to HIV itself are few and far between, with subsequent symptoms due to infections, cancers, and other problems due to immune deficiency. The reasons immune damage proceeds more rapidly in some persons than others isn't well understood.

I agree wholeheartedly that the internet often is not a friend to anxious persons, perhaps especially those who don't have medical or other technical training in the subject of concern. Worried people tend to be drawn to information that reinforces their anxieties and miss the reassuring bits. The famous statistician Nate Silver (www.fivethirtyeight.com) wrote a book a few years ago about statistics, The Signal and the Noise. In it he writes (approximate quote) "Give an anxious person a computer with an internet connection in a dark room, and soon he'll believe his cold is the bubonic plague."
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15 months ago
Thank You Doctor,

I have nothing more to ask, I had read this previously (https://www.ncbi.nlm.nih.gov/pubmed/29140890) very informative and well referenced. that's why I decided to test using 4th generation with other std panel PCR at 6 weeks (45 days to be exact). my main issue that I live in a country where I can not risk it and perform a test therefore I had to travel abroad to perform a sensitive test. I was relying on oraquicks (ordered from the internet// lab version of the test not the home one) which I know are not sensitive as the LAB tests also adding to my anxiety and in doubt if those oraquicks won't work since I can't do any kind of quality controls to make sure that they will works as intended to be (sadly was my only choice during that time // could've done a PCR early and a 4th gen at 18 days and 30 days would've been ideal), however, when I used the oraquicks all of them showed the control line so I assumed it should be fine.

you can go ahead and close this question unless you have any other further advice for me and many thanks for this advice.

wishing the best for the people in the forum too.  

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
15 months ago
I'm glad to have been of help. Take care and stay safe.---