[Question #6956] Opinion on Situation

10 months ago
Hello,

Brief overview:

On April 1st I had a risky exposure in the form of an unprotected BJ, Rimming and Mutual Mastur. with a prostitute. I did not ask for unprotected BJ and stopped it as soon as I realized what was going on 2 minutes maybe (was very drunk). Next morning I contacted the girl and asked if I could pay her to get tested she said she was clean and tested regularly but did not want to entertain my paranoia, later she blocked my number.

This got me all messed up and at 16 hours post exposure I was started on PEP Truvada and Tivicay I am on day 23 now.

Testing:
HIV 4th Gen
Baseline - Neg
19 days post exposure - Neg

HSV-2
19 days post exposure - Neg

10 STD Panel
7 days post exposure - all neg
Except HSV-1 orally which I have had for years

Symptoms:
At around 7-8 days post exposure I noticed that my scrotum has become red and slightly itchy, not the shaft or anus just the scrotum. The redness inflammation covers most of the scrotum being more pronounced towards the bottom and posterior half. Redness is very defined from normal skin and middle line of scrotum is not red. Since then I have used cortizone cream and it seemed to make the redness more pronounced so I stopped. I have been using Lotrim Ultra antifungal but this also has little effect. I have had no lesions or pimples/fluid filled blisters on scrotum, shaft or anus, been checking everyday.

Questions:

1. Could the redness of the scrotum be a symptom of genital HSV-1 or HSV-2?

2. Could the redness be a side effect of the PEP?

3. Does PEP hinder the bodies natural immune response and could this redness be jock itch that is just not going away?

4. What else could cause a red scrotum rash? Slight itching, defined borders of redness, no pain or discharge and slightly shiny/scaly (not peeling) when I shine a light on it.

5. What is the correct timing for my follow up testing of HIV and HSV-2?

Would you recommend a 4th Gen at post PEP and the again at 6 weeks and 3 months?

And should I test for HSV-2 at the same time intervals?
10 months ago
Correction on May 1st not April 1st
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Welcome back, but I don't understand why you have returned. These are exactly the same questions -- with slightly different words -- that Dr. Hook and you discussed over several days, ending 3 days ago. Accordingly, except for question 5, my replies are very succinct. For more detail, I suggest you re-read your previous questions and Dr. Hook's replies.

1,2. Neither herpes nor anti-HIV drugs cause skin irritaiton or redness on the scrotum or anywhere else.

3. No, PEP does not interfere with the immune response to other medical conditions.

4. There are too many possible causes of such symptoms to make much more than a guess. The large majority of genital skin problems are not STDs, and that's where this forum's advice ends. (I have a book titled Genital Dermatology Atlas, with 300+ pages of photos and discussion. Only 15 of those pages cover STDs.)

5. It was a mistake to take PEP after such a low risk exposure. (It was truly zero risk. There has never been a scientifically proved case of HIV transmitted oral to penis.) One downside of PEP is that it delays the time to conclusive HIV testing, in case PEP doesn't work. So instead of testing 6 weeks after the exposure, you'll need to delay conclusive HIV testing to 3 months after completing PEP, prolonging the duration of anxiety. You should also be tested 4-6 weeks after completing treatment, which will be nearly conclusive -- but you'll need one more test at 3 months. As for HSV2, Dr. Hook told you there is no chance of it following an oral sex exposure and I recommend against any testing. The HSV blood tests aren't completely reliable anyway. But if you go ahead with such testing despite our advice, do it 4 months after the event.

HHH, MD
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10 months ago
Dr. Handsfield,

Thank you for your response and input on the situation. You are correct that some of these questions have already been touched upon by your colleague and I appreciate you weighing in yourself as well.

Regarding the PEP my doctor also told me that the situation is very low risk but just as you have stated countless times in this forum PEP is a personal choice. Also please understand that I have a family and this was the first slip in over 10 years of a happy marriage. Based on the situation and the fact that the prostitute gave me unprotected oral when I clearly stated that all contact must be protected (maybe she was high on something, the incall was very late at night)  and then blocked my number I felt that 28 days of PEP was the better option since HIV is a lifelong incurable decease. My choice is especially true now after the scrotum redness has appeared. But I respect both of your professional opinions that the situation was low risk.... but from what I understand not zero.

Regarding HSV-2, thank you for your input it does put me somewhat at ease. I will continue to monitor the area for anything herpes looking and see a dermatologist regarding the scrotum redness.

Questions:

1. Could HIV present as a scrotal rash? I read that it is usually a rash on the upper half of the torso and it somewhat resembles chickenpox in that it is a large collection of blisters but can present anywhere.

2. If this was HIV caused would my 4th generation antigen part be positive at the 19 days post exposure?

3. You must also understand my connection of the two “scrotal redness” and “exposure” since the rash came on shortly after the exposure. Is there anyway I can add a photo or google drive link to this forum so I can show the rash/redness. I have already showed it to the PA at the local clinic she said it looked like jock itch. Dermatologist will only be available in 10 days.

How long does it usually take for scrotal jock itch to clear up from antifungal? 1-2 weeks or 3-4 weeks I have read different things online.

4. Do you think it is safe to continue having sex with my regular partner? Or should I abstain until the 3 months clear testing?

5. What would the approximate conclusiveness of the HSV-2 IGG test be at 3 months?

6. At the 6 weeks mark and 3 months mark should I also have a HIV RNA TMA qualitative test along with the 4th Gen for 100% conclusiveness?

Thank you for your responses, your time and experience is greatly appreciated. And I apologize if some of the questions seem repetitive or dumb.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
You're serioiusly overthinking everything. Among other things, HIV is never transmitted to family members who are not sex or needle-sharing partners. Second, it is still pretty irrational, I would say, to take PEP when there is no risk of catching HIV! It may be a personal choice, but it should be a choice founded on science, not emotion. I disagree with "what I understand not zero". The risk was low enough to be zero for all practical purposes. Had you come to my clinic requesting PEP, we would have refused to prescribe it.

1) First, it is impossible to develop symptoms of HIV while taking PEP drugs. And no rash, scrotal or elsewhere, is ever the only or main symptom. 
2) Yes.
3) We do not examine clinical photos., which in our view comes too close to practicing medicine from a distance. Jock itch usually would clear within a few days of starting treatment, suggesting the cause is something else.
4) Yes, from an HIV or HSV2 standpoint, sex with your regular partner is safe.
5) 95%. It takes 4 months for 100%. But false positive results are not rare, and if positive, it will not be from the event described and maybe not herpes at all.
6) I don't see any reason for RNA testing as well as AgAb (4th generation) testing.
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