[Question #6809] Acute HIV, PEP, symptoms and testing

12 months ago

Hi Doctors,

I have a few followups from my initial concerns regarding vaginal sex with a female African American prostitute.

To summarize that incident, although I used a condom, there were 2 new cuts on my penis that I noticed after sex that occurred from rough oral sex and were exposed during vaginal sex.  I am also concerned if there may have been a hole in the condom based on the rough oral sex before vaginal that left the fresh cuts on the shaft. I did not use my mouth for any activity, no other recent sexual encounters.

I know this was a low risk situation, that PEP probably wasn't warranted and that I cannot base anything on symptoms.  A few followups:-

4-5 days after the incident, my glands were tender and I had a bad sore throat. 8-9 days after the incident through now (17 days), I’ve had  a severe sore throat, fatigue and intermittent body aches throughout the day (no fever or rash).  I've been taking PEP (truvada / isentress since 18.5 hours after the incident).  I've already had mono years ago (EPV) and followed up with my PCP yesterday who did some bloodwork due to symptoms (CBC, 4th generation, CMV, STDs)

1)How common is it that fever or rash would occur with the above symptoms if this was ARS related?

2)If there was a fresh open wound on the shaft for which HIV could have entered, does this mean it is higher risk than through entry into the urethra if it would be directly into the blood stream?  Could PEP still help prevent against infection, or would entrance into the bloodstream through a fresh cut make PEP pointless?

3)Most of my bloodwork came back normal except my CPK levels (850, never had an issue in my life).-I know symptoms while on PEP are unlikely and if they were to occur, it would be after discontinuing PEP. 

If these symptoms were related to acute HIV due to breakthrough, is it likely the 4th generation test would have been positive or could the PEP cause it to be negative while having minor symptoms and a raised CPK enzyme level?

4) What do you make of the raised CPK enzyme level? How likely is this to be caused by the 2 medicines after 17 days vs due to acute HIV?  Can acute HIV cause this elevation while having the PEP result in a  4th generation test?  It seems like only 10% of patients on PEP have raised CPK levels.  Can the acute HIV be impacting my muscles with the PEP suppressing antibody formation for the 4th generation test?

Thank you very much.

Edward W. Hook M.D.
Edward W. Hook M.D.
12 months ago

Welcome back to the Forum.  on this occasion I happened to pick up your follow-up questions and will be addressing them.  I have reviewed your earlier interaction with Dr. Handsfield and agree with all that he said. Further I would add that your continued symptoms despite the antibiotics you were given essentially prove that this was not strep and are consistent with one of the many community acquired illnesses that persons get from time to time.  In my opinion, the onset of your symptoms is coincidental.  Having said that, let's work through your follow-up questions:

1)How common is it that fever or rash would occur with the above symptoms if this was ARS related?

Fever is an essential part of the ARS as described.  its absence is further evidence that this is not the ARS.

2)If there was a fresh open wound on the shaft for which HIV could have entered, does this mean it is higher risk than through entry into the urethra if it would be directly into the blood stream?  Could PEP still help prevent against infection, or would entrance into the bloodstream through a fresh cut make PEP pointless?

There are strong scientific data that infections which cause genital ulcers are associated with increased risk for HIV, if exposed.  The reason for this increased risk is that as the body fights the infections which cause the ulcers, it aggregates the lymphocytes which are the "target" for HIV and therefore enhance risk for acquisition of infection.  Fresh cuts are far, far less clearly associated with risk for HIV. In the case of your exposure, I presume that your condom worked - when condoms fail they typically break wide open and thus I suspect that the cuts you noted were due to friction. That said, your risk is low and the PEP you are taking would eliminate any further risk for infection. 

3)Most of my bloodwork came back normal except my CPK levels (850, never had an issue in my life).-I know symptoms while on PEP are unlikely and if they were to occur, it would be after discontinuing PEP. 

If these symptoms were related to acute HIV due to breakthrough, is it likely the 4th generation test would have been positive or could the PEP cause it to be negative while having minor symptoms and a raised CPK enzyme level?

This is a relatively low CPK elevation.  it could well be due to the flu-like illness (body aches) that you describe.  I suspect that somewhere on the list of medication side effects of your PEP is CPK elevation but I would not be worried unless your muscle aches increase.

4) What do you make of the raised CPK enzyme level? How likely is this to be caused by the 2 medicines after 17 days vs due to acute HIV?  Can acute HIV cause this elevation while having the PEP result in a  4th generation test?  It seems like only 10% of patients on PEP have raised CPK levels.  Can the acute HIV be impacting my muscles with the PEP suppressing antibody formation for the 4th generation test?

See my comment above.  I suspect your CPK elevation is part of the flu-like, non-HIV illness you are experiencing.  That said, acute HIV can certainly cause CPK elevation.  If it were, even on PEP, a 4th generation, combination HIV antigen/antibody test would almost certainly be positive at this time.

I hope that this information is helpful.  EWH

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12 months ago
Thank you very much, really appreciate the detailed response.  A few followups based on responses and ongoing concerns:

1) Symptoms while on PEP - I've read contradicting info that if PEP wasn't working, symptoms would begin while taking PEP vs after PEP is finished.  Is it possible that PE is supressing the antigen and antibody formation and therefore lessening the symptoms or causing less typical symptoms instead of causing the typical symptoms (fever, upper body rash)?  

As mentioned, the sore throat began about 4 days after and remains, body aches at about 6 days and remains.  This weekend I had some hive-like reddish purple marks the formed a slight rash on my thigh which has somewhat disappeared and now have some groin pain directly about the penis (no enlarged nodes to my knowledge).  I know fever is usually a main symptom and rash is usually on the chest and throat and that symptoms are difficult to go by, but I'm wondering if PEP could be causing these less severe and more atypical symptoms.

2) 4th generation test while on PEP (test at 17 days which showed normal CPC, negative 4th gen, negative CMV and mono and normal CBC) - I know this also seems to be a gray area whether all testing would be negative while on PEP vs positive if there were related symptoms.  

Is it possible PEP could be suppressing both the antibody and antigen formation?  Or does it only suppress the antibody formation and not the antigen formation?  If HIV caused someones CPK level to increase (which remains a concern of mine) and/or was causing these throat, aches, fatigue and now minor thigh rash and groin pain - does that mean HIV would be in the blood and therefore caused the elevated CPK or could PEP be blocking HIV antibodies and antigens in the blood causing a negative test result but presence in the body still be causing the CPK elevation or atypical presentation of symptoms?

I appreciate all the detail.  I remain concerned over the high CPK level which I've never had before, ongoing atypical symptoms that have yet to resolve and timing of this all without resolution.

Thanks again.


Edward W. Hook M.D.
Edward W. Hook M.D.
12 months ago

It saddens me that you continue to worry.  Straight to your questions:

1. If you failed PEP and were going to develop symptoms (not all persons who acquire HIV develop symptoms) the would most likely occur while you were taking PEP, not afterward.  OTOH, in some persons being on PEP can delay symptom development.  If you were failing PEP and you had symptoms, your test would be positive as the symptoms are correlated with the presence of large amounts of circulating virus and the response of the body to the virus. 

2.  This question is a bit repetitive.,  See my comment above.  If you had symptoms due HIV occurring because of PEP failure.

As I've told you before, your CPK is elevated but not markedly so.  Elevated CPK can be caused by many non-HIV viral illnesses, by medications, and by exertion (after an intense workout it is not unusual for persons to have CPKs substantially higher than yours.  EWH

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12 months ago
Thanks you for the info doctor, appreciate it.  I have a few final followup questions before this thread is then closed:

My sore throat, body aches and fatigue continue (now going on 3 weeks and Saturday will be 4 weeks since the incident) and my 28 days of PEP finishes on Saturday.

In addition to the elevated CPK at 850, my HSV-2 IGG test came back at 0.96 (equivocal) with HSV-1 IGG and HSV-1 and 2 IGM as negative.  At my baseline testing, all bloodwork was negative.  The 17 day testing while on PEP for HIV 4th generation and also HIV PCR came back negative.

1) You mentioned that the 4th generation test even while on PEP would likely be positive if symptoms were related to HIV or if the CPK elevation was related to an acute infection.  I also read that since the Truvada and Isentress are anti-HIV medicines that suppress the viral load that this could cause a negative test (especially PCR) during PEP.

Is it possible someone could have symptoms due to the virus being in the body but that the PEP medicine is causing the tests to be negative by suppressing the viral load?  I know you mentioned that symptoms are correlated with the viral load but could the PEP be resulting in less severe and more atypical symptoms (ongoing body aches/malaise feeling, 4 day flat red non-raised rash on one of my thighs (at week 3) and increased CPK and 3+ week sore throat) if the virus has not yet spread and is being suppressed (and if antigens/antibodies have therefore not formed enough) but virus in the body which in turn is causing my body to respond as it would to a more typical virus for now (so if it's therefore not an acute infection and not seroconversion  but an early sign of the virus generally in the body)?  How likely is it that if symptoms or CPK was related to recent HIV  infection while on PEP that the PCR and/or 4th generation test would not come up negative at 17 days?

2) As mentioned, although a condom was used despite the potential of a small tear from the oral sex prior to vaginal, I find it odd that the HSV-2 is coming up as 0.96 equivocal at 17 days despite not being the case at baseline or ever before.  Is it true that condoms do not protect as well for HSV-2 as it does for HIV?   Since it seems HSV-2 takes 3-4 weeks for IGG antibodies to develop, is it possible HSV-2 is on the rise and is therefore coming up at equivocal at 17 days?  Does it mean anything that IGM remains negative but IGG is trending up?  Does IGM usually rise and drop before IGG-2 rises or is that not always the case?

3) This may be a dumb question - but could PEP meds be suppressing HSV antibodies just as it could be doing for HIV antibodies?

4) Could PEP be suppressing the HSV antibodies but could the equivocal HSV antibody test be a sign that there may be an HIV virus/infection in the body that triggered a potential HSV false positive with underlying HIV being the cause but coming up as negative due to PEP suppression of those direct antibodies/antigens?

I'm wondering if the slightly elevated HSV-2 could be a subtle sign of early HIV infection with the somewhat elevated CPK as another sign (but not elevated by more than 850 due to the PEP working) with PEP hiding the underlying cause.

5) Does PEP suppress both antibodies and antigens or just antibodies?  Out of curiosity, have you seen PEP within the recommended timeframe fail for any patients in you practice?  I know it's hard to gauge it's true effectiveness due to limited studies but am curious how often you've heard of it succeeding vs failing.

Aside from the 17 day test while on PEP with symptoms, I plan to test again when finishing PEP at 28 days, and then again 2 and 6 weeks after.

Thanks again for taking the time to respond and share your knowledge and for everything you do.  Sorry to take up more of your time but is the end of my ongoing questions.
Edward W. Hook M.D.
Edward W. Hook M.D.
12 months ago

Final Follow-ups.  My sense is that you continue to do yourself a disservice through searching the internet and that this practice may be misleading you and fueling your anxiety:

1.  There is no new information here, just a repetitive question. My answer is not going to change just because you continue to worry.  The presence of symptoms are due to the presence of the virus.  If your symptoms were due to HIV, your tests taken when symptoms were present would be positive.  . 

2.  Your equivocal  HSV-2 antibody test is far more likely to be a falsely positive test than to represent infection.  Further, virtually EVERY expert strongly recommends against the HSV IgM test as it has many false positive results and is virtually useless for clinical decision making.  you got luck and have a negative IgM which only serves the reinforce the probability that this is a falsely positive HSV IgG test

3.  No.

4. Repetitive, again, asking the same question is a different way will not change the answer.

5.  The second P in PEP stands for Prophylaxis.  A synonym for prophylaxis is prevention.  Persons on successful PEP do not develop positive antigen or antigen tests.  If they fail PEP, both tests will predictably become positive. 

As you point out, as this is my 3rd response, as per Forum guidelines, this thread will be closed without further responses.  I hope that the responses Dr. Handsfield and I have provided have been helpful.  I will, once again, suggest that you not worry and stay off the internet.  I am confident that your follow-up tests will prove that you did not acquire HIV from the virtually no risk exposure described in your initial post.  Take care. EWH

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