[Question #6748] Hep B - positive spouse

12 months ago

Hello Doc,

Firstly, thank you for all you do and your expertise.          

I messed up again.  My wife was just told that she tested positive for Hep B.  She went for a yearly routine blood test and the Hep B Surface Antigen was reactive. I believe I may have infected her and will be tested today.

The reason for my suspicion is because I had a recent exposure.  On Jan 25, I was on business trip in Kenya and made a very fatal mistake.  I had unprotected oral and protected vaginal sex. with CSW.  However, the condoms slipped off on me twice during the episodes.  I am not sure how long I was inside her after the slippage both times.  I freaked out and asked her about her HIV status.  She assured me she was HIV negative. Well, she did take an HIV test the next day and tested negative.  When I returned to US, I had HIV, syphilis and gonorrhea tests done – all negative.  I thought I was in the clear and did not even think about getting a Hep B test.  BTW – I don’t believe I have been fully vaccinated for Hep B.  I vaguely remember receiving only 1 shot when I was a teenager but never returned for the last 2.  I now feel sick to my stomach knowing that I may have infected my wife.  She is very scared and confused as to how she could have contracted the virus.  I will need to come clean with her at some point.

Here’s the timeline:

Jan 25 – date of exposure

Feb 3 – first time having normal sex with wife after returning from Kenya

Feb 21 – wife tested for routine blood work

Feb 25 – wife is notified to come back as something came out abnormal and needs retest

Mar 11 – wife received results of reactive to Hep B.  More blood work drawn.

Mar 12 – I will be going for Hep B testing

My question is –

1.       If I was indeed infected on the Jan 25 exposure, how soon would I have been contagious to infect others?

2.       Is there a possibility that my wife’s test is false positive?  If so, what would cause it and how common/uncommon does this happen?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
Welcome back to the forum. Sorry for you that this situation has come up.

It is conceivable you infected your wife with the hepatitis B virus (HBV), but it is unlikely. First, even a single dose of HBV vaccine probably has at least partially protected you, and perhaps completely. Second, the chance you acquired HBV from a single partially protected vaginal sex exposure is very low, even if your Kenya partner was infected. And oral sex is even lower risk.

Do you know with certainty that your wife's apparent HBV infection is new? Did her previous "routine annual" tests include HBsAg or other HBV tests? In any case, the follow-up blood tests being done undoubtedly will tell whether she has an active infection and perhaps clues about how long she has been infected. I'm assuming (and apparently so are you) that she hasn't had other potential exposures, sexual or otherwise. Has either of you ever used drugs by injection? Also, do you know for sure you didn't have it before January, i.e. tested previously? Even if it turns out you are infected, it won't necessarily be from the exposure in Kenya. Where were each of you born and raised?

1. Probably new HBV infections become transmissible 1-2 weeks after acquiring the infection.

2. I can't give a percentage for the frequency of false positive HBsAg tests, but it's rare.

I won't be able to say anything more until we know both the results of your wife's additional test results and your own test results as well. Let me know those results when available. In the meantime, my bet is that there will be an explantion other than you being recently infected and transmitting the virus to your wife. In the meantime, I hope these comments are helpful.

HHH, MD
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12 months ago
Thanks for your response Dr. Handsfield,

As for my 1st vaccination for Hep B, it was about 25 years ago.  I am in my late 40's now.  Would it still technically protect me?

It seems like new infection as surface antigen is reactive and surface antibody non reactive.  I am not sure if her previous lab tests included HBV panels as she switched doctors.  Your assumption is correct, I am certain she has not been exposed by any other sexual encounter or potential exposures.  We have never injected any drugs.  I don't know if I had it previously because I was never tested and  never thought to ask for it.  I was born in the US and she in Dominican Republic.  She relocated here a few years ago and I assume she had exam prior to receiving her residency green card?  She was examed I remember but not sure if Hep B was included in those requirements.

I just went to a walk in lab and tested for Hep B which I assume is just the initial screening for antigen?  If positive, I will need to follow up with my regular doctor. 

Our results should be in by this coming Monday.

Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
I agree with your interpretation of your wife's test results. She also needs tests of her liver function. It sounds like she's in a doctor's care; probably the doc is on top of all this.

To my knowledge, US immigration does not require viral hepatitis testing as far as I know. Her green card status doesn't necessarily imply she was tested previously.

You need more than surface antigen testing (HBs Ag). You should also have both surface and core antibody tests (HBsAb and HBcAb, sometimes called anti-HBs and -HBc). These plus HBsAg will determine if you have active infection, past infection (which might have reactivated recently), or may show evidence of immunity due to your partial immunization. That would be the conclusion if you were positive for HBsAb and neither of the others. On top of these tests, if there is any indication of current or recent active infection, you'll need tests of liver function. It would be OK to have the additional HBsAb and HBcAb tests on your own -- your might be able to contact the lab and request them without another blood draw. But if any hint of current or recently active infection, you'll need to see a doctor for proper evalution.

Let's hold off on any further discussion until all your test results are complete. At the same time, I would also be interested in knowing your wife's complete test panel results and/or her doctor's conclusions.
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12 months ago
I just received my HBs Ag results (non-reative).  Should I  proceed and ask for the HBsAb and HBcAb?  Would a positive on any of those could have infected my wife?  

Another curve ball - the blood work her doctor ordered was for Hep A and it's reactive!  I had assumed the  follow-up test would be for HBsAb and HBcAb.  I am so confused.  Note - I was vaccinated for Hep A, YF, Typhoid and TTDAP prior to my Kenyan trip.   Could Hep A and B infect at same time?  I don't know what to make of this.  I believe Hep A is mainly transmittable by contaminated food and water?  We did take a weekend trip to Dominican Republic on Feb 14th and dined out most of the time.   Also my wife has manicure and pedicure done almost weekly.  Could Hep A and B be transmitted through contaminated equipment at those salons?  Just trying to rationalize things in my head.

Here is her liver test details from first lab.  Is there something below that would have prompted her to be tested for Hep A as well?

Alumin - 4.2 g/dL
Bilirubin Total - 0.7 mg/dL
Bilirubin, Conjugated - 0.2 mg/dL
Alkaline Phosphatase -  53 U/L
ALT - 26 U/L
AST - 41 U/L

What other test should we ask for now?   Her doctor is just a General Doctor.  Should we look for a specialist for follow-ups?  What is the most common prognosis for both infections?  

Thanks.

12 months ago
Also - should my wife and I use protection until this is sorted out?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
Do you mean your wife was not positive for HBsAg after all? That she has had a positive test only for hepatitis A virus? If so, I'm guessing she was positive by IgG antibody testing and negative by IgM. If so, she has had hepatitis A in the past, or was vaccinated. One of these seems most likely, since her liver function tests are entirely normal. Although hepatitis A can be asymptomatic, it almost always causes elevated liver enzymes (alk phos, AST, ALT). In the unlikely event your wife indeed has acute or recent hep A, it's from a food or water source, not manicure or other exposures in a salon.

If your wife does indeed have positive HBsAg, then she still needs the expanded hepatitis B testing discussed above, and so do you. But based on what I think I understand now, this is all a big nothingburger and no further evaluation is needed. And no sexual precautions necessary.

Normally threads are closed after two follow-up questions and replies, but I'll leave this open for one more exchange. I'm looking forward to your responses to the questions above.
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12 months ago
She has not spoken to doctor yet.  Just received the positive Hep A result and the Hep B positive still stands.  Is there any remote chance that I could  technically have infected her with both infections - although I did receive the Hep A vaccine and non reactive to HBs Ag?  Otherwise, I will follow up with my doctor for the entire Hep B panel and ask her to do same with her doctor for more clarity.

Thank you so much for your help.  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
There's no chance you infected her with hepatitis A. Hepatitis B remains an uncertainty. I recommend you go ahead with the additional HBV testing discussed above (HBsAb and HBcAb) and that your wife both see a specialist who understands viral hepatitis. If you do it ahead of time, it likely will save time and perhaps save a second visit to the specialist. 

Since we are STD and not viral hepatitis specialists, there's really nothing more this forum can offer you. I'll leave the thread open for a final comment within the next 2 weeks, if you would like to let me know the outcome after at least your wife (and preferably you) have seen a specialist, along with any additional lab results available. In the meantime, you can relax about your sexual exposure in January. Almost certainly it is unrelated to your or your wife's test results so far.
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12 months ago
Update - my wife HBV VL BY RT PCR:

Hep B Viral DNA Quantitative (Viral Load) >10,000,000 IU/ML
Hep B Viral DNA Quantitative (Viral Load)  >7.00 log 10

I have no idea what's this.  She was asked to follow up with specialist.

I will be seeing my doctor on Wed.

12 months ago
Forgot to ask on previous post - can this mean she has Chronic Hep B?  Looks like it's a high viral load?  Was googling the test results and all I see is something about Chronic Hep B.

I understand we need to consult with viral specialist.

Thanks so much.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
Your own research has been good:  your wife has an active HBV infection with high viral load. With her normal liver function tests, I agree it's most likely chronic and longstanding, probably not causing serious liver disease at this time. But that could change, and she definitely needs to follow up with the specialist as planned. You need to see your doctor as well, but you might skip that and accompany your wife when she sees the specialist.  Your own doctor might refer you anyway, and the specialist's advice about testing you need might be more expert than your doctor's.

Any risk of HBV sexual transmission in this situation is from your wife to you, not the other way around. Indeed, the most likely scenario is that she's been infected for years and you have been protected by your vaccination, even though you only received one dose. In any case, almost certainly this has nothing to do with your recent sexual indiscretion. Depending on your further test results, the specialist might recommend you be re-vaccinated against HBV.

That will have to conclude this discussion. It has been interesting, and I hope you have found it helpful. Best wishes.
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