[Question #6781] HIV Concern and Symptoms

12 months ago

Dear Doctors,

Last Friday night, I had vaginal sex with an African American prostitute.  While I used a new condom for each of the two episodes of intercourse, the same condom was used for rough oral sex prior which left two cuts on my penis.  For this, I have reason to believe there was a hole in the condom and that in addition, it did not cover my entire penis (i.e. – new cuts).

Due to the uncertainty of the condom remaining fully on and if there was a tear, I began PEP 19 hours after the incident.  I was tested at 48 hours - all negative.

My only concern is HIV.  I’m very concerned due to odd timing and symptom severity.

-Tuesday-Wednesday: sore throat (hurt to swallow) and lymph node pain and discomfort under my jaw and going down my neck

-Thursday-Sunday: in addition to throat, the lymph node pain/discomfort under jaw and down neck is severe.  In addition, pain/discomfort under my armpits (nodes).  My throat hurts the most in the morning and I also feel my ears pop a little when I yawn.

I am concerned because I never had severe gland tenderness and pain under my jaw and down throat.

-If HIV entered my body, even if antibodies didn’t yet begin producing, can the throat/gland symptoms at 3.5-4 days be my body reacting early to the virus?

-Is it possible that if I started these early symptoms at day 4 that the virus already infected my body and it’s too late for the PEP to even work?

-I’ve read varying degrees of PEP effectiveness after 2 hours but within 24.  What’s your opinion on this (especially with having these symptoms)?

-Is there anything else I can do at this point besides continue the PEP for 28 days?

Thanks.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
Welcome to the forum. Thanks for your confidence in our services.

You really needn't be worried. This was a lower risk exposure than you might think, and your symptoms cannot possibly be due to HIV. Most experts probably would not have prescribed PEP in this situation, unless there were more information about the likelihood that persons like your partner are likely to be infected. And even if she had HIV, you may not understand how infrequently the virus is transmitted. For one episode of unprotected vaginal sex with an infected female partner, the average is 1 in 2,500. With an apparently intact condom, that becomes 1 chance in 250,000. If we assume a 10% chance your partner had HIV (which probably is too high), the likelihood you caught it would be 1 chance in 2.5 million. Which is why many experts would not have recommended PEP for you.

HIV symptoms cannot start sooner than 7-8 days after expsoure. Armpit or neck pain are not the same as inflamed lymph nodes; if no enlarged tender lumps, your lymph nodes probably are not involved. In addition, nobody can develop symptoms of new HIV while taking anti-HIV drugs for PEP. I have no opinion about PEP effectiveness except that it seems to be virtually 100% effective when started within 24 hours. I suppose in theory it might be still more effective iif started within 2 hours, but I think that is pure speculation, without scientific data behind it. In fhe event PEP fails and you get HIV symptoms, they won't start sooner than a few days after your last dose. Your symptoms suggest you have a cold -- maybe or maybe not from the sex worker. (Or COVID-19, depending on the frequency of the new coronavirus wherever you are.)

There is a downside of PEP you may not have considered. Many doctors and clinics where PEP is prescribed don't consider it either. Without PEP, testing to show you were not infected would be nearly conclusive by 4 weeks and 100% by 6 weeks. With PEP, you need to wait until at least 6 weeks after completing treatment, and some experts advise testing out to 3 months. So the duration of potential anxiety, until you know for sure, will be a lot longer. I'm not advising you to stop the PEP -- that's strictly between you and the doctor or clinic where it was prescribed. But you might discuss it with them.

In the meantime, do your best to relax. The chance you have HIV is exceedingly small. Let me know if anything isn't clear.

HHH, MD
---
---
---
12 months ago

Thank you very much doctor – appreciate the detail.  A few followups:

While the odds are promising and it seems ARS has non-specific symptoms, I remain concerned as the symptoms oddly began on day 4 and have worsened each day since. 

-Is it possible HIV could have entered my body and that the throat pain and gland tenderness/pain begin in 3-4 days with the glands reacting without full ARS symptoms yet showing due to it both being less than 10 days and the PEP?  If it’s unlikely ARS symptoms would show while on PEP, could I still be having gland and throat pain as a result of my glands and the PEP initially responding similar to them reacting from a typical virus entering the body?

-Would gland pain and tenderness typically be accompanied by a fever at the same time?  I’m worried as I have 2 of the 3-4 typical symptoms.  Although my glands are not enlarged, they are tender and painful under my jaw, down my throat and a little under my armpit (which has never happened before).  I'm worried if the meds are preventing the fever but the glands are my body naturally reacting.

-Does the fact these symptoms started 4 days after and worsened each day since tell anything?  My symptoms are the worst in the morning (also ears popping when I yawn – which I know isn’t a symptom) and hurts to swallow with the gland and throat pain remaining throughout the day.  Tylonol and Advil cold and sinus help a little.

-Can my body have been exposed to the virus in the 18 hours before PEP and that it got to my blood or glands making it irreversible for PEP to cure?

-I’ve read about a number of limited PEP studies with varying degrees of success.  Have you heard of or had any patients in which it failed, (within the 24-36 hour window) and if so, how often?

-Is there anything else besides PEP that’s recommended to minimize my chances in the next few weeks?

-I went to the doctor today regarding my symptoms and requested a strep test.  At first he said it was negative but then I took a close look and noticed a faint pink line in which he then said it was positive as any line at all indicates positive on the rapid strep tests.  He put me on Augmentin.  As mentioned, I haven't had a fever which seems to be a symptom for both acute HIV and/or strep.  Is it possible acute HIV causes strep or would it just cause a sore throat and not strep itself?  I’m worried that Advil, PEP and now Augmentin could be covering up the symptoms temporarily for an underlying cause related to my incident.


Apologies for all of the followup questions.  This is my last followup and I really appreciate your help and dedication to everyone's questions.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
You're seriously overthinking all this. I am trying to reassure with reliable science based evidence and advice. Please re-read my replies above and do your best to understand and believe them.  The answer to every one of your questions is no:  HIV does not infect in the ways your questions implies or cause symptoms so quickly, even if you had been infected. Which almost certainly you were not.

There are no strong scientific studies about how well PEP works. The "limited studies" you have found are all that exist. We have research in lab animals, but in humans we only have rough estimates plus the clinical observation that HIV is very uncommon in people who receive PEP within 1-2 days of exposure and who take all the drug as directed. The lack of detailed data is one reason you see varied estimates from different sources. 

As for your 18 hours question, if people are infected, the virus is always established in cells within a few hours, well before 18 hours and well before it is ever possible to start PEP, And yet PEP still works.  Nothing ohter than PEP would have any effect. But I stress again it is exceedingly unlikely you acquired HIV from the exposure described. If somehow i were in your shoes, I wouldn't even be tested for HIV, let alone seek PEP. 

Your symptoms don't suggest strep throat (or ARS), and it sounds like your test was negative. I'm guessing you talked your doctor into treatment that, in his best judgment, we would not have given. If you caught anything from the sex worker, it was a common cold or maybe COVID-19. In that case, you're at far higher risk of a serious outcome from that than from HIV. In any case, none of the medications you are taking would cover up PEP symptoms, which in any case cannot possibly start until you're no longer taking PEP. It is impossible they are due to HIV.

Please do your best to accept this reasoned, science based advice. You're seriously overreacting to a virtually no risk situation. Perhaps it will also help you to know that in the 15 years Dr. Hook and I have been moderating this and our previous forum, with thousands of questions from people worried about having HIV, not one turned out to have caught it. You won't be the first, If and when that happesn, I'm confident it will be a truly high risk situation, not a low risk event like yours.


---
12 months ago
Thank you very much doctor.  There was a faint pink line in the rapid strep test - when the doctor looked under light he noticed it and said I should take Augmentin for what seems to be mild strep and what may also be sinus congestion.  Between that and your insight into these symptoms not occurring so quickly let alone while in PEP - I will try to relax, finish the PEP for a few more weeks and take it easy.

Thanks again for the detailed responses.  I really appreciate it.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
12 months ago
I have no personal experience with the rapid strep test you describe. Based on other tests with similar technology, I am skeptical such a faint line is significant, but I defer to your doctor's judgment.

That concludes this thread. Thanks for the thanks. I'm glad my comments have helped. Take care and stay safe -- and (now wearing my public health hat), please carefully follow the COVID-19 prevention guidelines!
---