[Question #7557] Requesting expert opinion and guidance

55 months ago

Hello Dr. Handsfield and Dr. Hook: I hope you are doing well. I am seeking your expert guidance on a situation I had.

I am a Sri Lankan male in late twenties. Exposure happened in Colombo, Sri Lanka with a woman from Kerala (South India, early 30s may be), unknown status, who is high-risk (drug user) and was on her periods (slight). I did not know her much before the exposure. As a teenager, I was diagnosed with psoriasis and have been taking immune suppressor medications for it and it is well controlled without any active outbreak. I am seeking your expert opinion on HIV.

Exposure details:

-Unprotected genital to genital rubbing; there was blood inside vagina viewable through the inner lips; did not penetrate;

-Protected (condom) brief sex 20 minutes; due to stress, I had become not-tight and could not feel much, but condom was on when actual insertion happened even if genital genital rubbing was nude

-Unprotected giving and receipt of oral sex; not trivial but not too extensive either;

-Foreplay involving lip to lip kissing, breast sucking, and hand genital stimulation (her to me, me to her)

Reading your advice to others on this forum, I tested negative with 4^th Generation tests (HIV -1 antigen, and HIV-1 and HIV-2 antibodies) at both 42 days (post exposure) and 88 days (post exposure, 4 days more than 12 weeks and 2 days short of 90 days).

Requesting your expert opinion here:

1. Assuming she was infected with either HIV-1 or HIV-2 and the activities were extensive, what is the overall risk assessment of the exposure?

2. Even assuming she was infected with HIV-1 or HIV-2 (however high the risk at the time of exposure) and the exposure was high risk, can I take my test results to be 100% conclusive that I am not infected or that I did not get infected with either HIV-1 or HIV-2?

3. Do any of your answers to the above change knowing I am taking immune suppressor subcutaneous injections every fortnight for my condition? In other words, do my medication and conditions impact test validity for conclusively ruling out HIV-1 or HIV-2?

4. I am assuming I am covered (conclusively negative) from a HIV-2 perspective as well given 4^th Generation does not test HIV-2 antigen and given HIV-2 may be more prevalent in South India/Southeast Asia.

5. Did I need the 88-day test or would you have recommended it? Do you recommend any additional testing?

6. Am I able to resume regular unprotected sex with my regular girlfriend without any worry or risk? And, am I able to forget this incident I regret and move forward with life?

7. God forbid, however if you had been in my situation with my health condition/medication, what would you do?

8. What do I need to know going forward for similar such exposures were they to happen?

9. I have seen you mention in some threads that testing negative at appropriate times (>=6 weeks and sometimes 8-10 weeks) is fully conclusive and negative regardless of the risk . If I may please ask, doctors, why then do you in some threads ask people to outline their exposures?

10. Any other closing thoughts and feedback from you?

I am beginning my PhD in Mechanical Engineering soon and this incident stress has been very bogged down, anxious, and distracted. Thank you for your expert guidance and service to mankind. May God Bless you both.

H. Hunter Handsfield, MD

55 months ago

Welcome to the forum. Thank you for your confidence in our services.

Almost all your questions can be answered by addressing your test results. The statement in your 9th question shows you already know the important information, that the HIV antigen-antibody (AgAb, "4th generation") blood tests are among the most accurate diagnostic tests ever developed, for any medical condition. When done sufficiently long after the last possible exposure -- at least 6 weeks, the results are 100% conclusive and outweigh all other considerations. No matter how high the risk of HIV at the time of exposure, or whatever symptoms someone has (regardless of how typical they may seem for a new HIV infection, the test result is conclusive. Your test at 42 days was conclusive, and so was the second test at 88 days. (The old 90 day recommendation was for older tests no longer in use, i.e. first and second generation antibody tests.) Accordingly, it is 100% certain you do not have HIV. In addition, there are no medications or medical conditions that alter the reliability or timing of the AgAb tests -- including immunosuppressive conditions or drugs. (In fact, in theory the AgAb tests might become even more reliable if the immune system isn't functioning normally.)

Those comments answer all your questions, directly or indirectly, but to assure no misunderstanding: 1) Without unprotected vaginal or anal sex, the risk for HIV from this exposure was exceedingly low, probably zero. But as described above, the nature of the exposure is irrelevant in new of your test results. 2) Yes, 100% conclusive. 3) No change in this on account of your psoriasis treatment. 4) The AgAb tests are equally conclusive (beyond 6 weeks) for HIV2 as for HIV1. 5) The second test was unnecessary. 6) You can and should be continuing sex with your girlfriend; you are not infected with HIV and therefore cannot infect her. 7) At a personal level, I would do nothing more at this point; I probably would not have sought HIV testing at all, and certainly would not have tested beyond 6 weeks. 8) All you need to know is that you should use a condom if you have future sex outside your main relationship -- but even that is unnecessary unless there is vaginal or anal penetration. 9) See above. 10) I have no additional advice.

Thanks for your kind words about the forum. Best wishes in your studies -- I hope these comments help you get beyond the anxiety you are feeling about a sexual decision you apparently regret. Let me know if anything isn't clear.

HHH, MD

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55 months ago

I thank you for your expert opinion, Dr. Handsfield and thank you for the best wishes for my PhD.

A. There is nothing I can share about my exposure (bare meatus rubbing bare clitoris) or other questions (condom remained intact and did not break?, etc) that my mind may make up that would change any of scientific expert opinion you have provided to me on this exposure (I have not had an exposure post this exposure). Is this correct? Just asking to shut the brain from getting into an anxiety and doubt trap.

B. For my knowledge, does the presence of other STDs prevent the detection of or conclusivity window or accuracy of the 4th Gen test? I tested for negative for HIV and the other STDs as well.

C. The window period to conclusiveness that you have mentioned is independent of the level of risk. However high the risk, a negative test after the window period is 100% negative and indicates that despite a risky exposure, the individual did not catch HIV 1 or HIV 2. Is this correct?

D. I can discard and fully ignore the misinformation around perhaps delayed seroconversion and delayed antibodies production in an infected person with my health condition and immunesuppressor medications that could affect test conclusivity and reliability. Would this be appropriate?

E. I have to deal with my anxiety, regret and guilt about this exposure separately. But, from a HIV 1 or HIV 2 perspective, I have nothing to worry about and can rest assured that I am 100% negative. Am I correct?

I am glad I found this forum and I thank you once again for everything you do.

55 months ago

Dr. Handsfield: I was not able to edit the follow-up message I sent above and hence the message after my follow-up questions. Forgive me if I am unable to follow some of the English.

When you responded to Q1 below, you mean “irrelevant in view of your test results” not “new of your test results”. Is this correct?

In answer #4, by “The AgAb tests are equally conclusive (beyond 6 weeks) for HIV2 as for HIV1.”, you mean that the AgAb test is test equally conclusive beyond 6 weeks for both HIV 2 and HIV 1. Am I understanding you correctly?

In answer # 5, when you said “the second test was unnecessary”, I should understand that for the second part of the question that I had posed “Do you recommend additional testing?” – That your answer would “Definitely No More Testing is needed”. Is that a correct extrapolation?

Thank you.

H. Hunter Handsfield, MD

55 months ago

We don't mind clarifying questions, but you shouldn't need to repeat those already answered! Just asking again with different words doesn't change anything.

A. Irrelevant, since you weren't infected.

B. From my reply above: "...there are no medications or medical conditions that alter the reliability or timing of the AgAb tests."

C. Yes. Window period is independent of risk at the time of exposure.

D. Yes: Ignore what you think you learned about delayed seroconversion. It applies only to older (antibody-only) HIV tests. With the AgAb tests, there is no such thing as delayed seroconversion. Among millions of infected people with HIV and hundreds of millions of AgAb tests done, there has never been a scientifically documented case of delay in positive test results, except in one situation: when someone takes anti-HIV drugs as pre- or post-exposure prophylaxis, sometimes folks are infected anyway -- in them it takes longer for positive results. Obviously irrelevant to your situation.

E. Correct, nothing to worry about, 100% certain you don't have it. (Does it help to hear it a second time???)

Q1. Yes, view. Excuse the typo.

"In answer #4": Yes, you correctly understand.

"In answer #5": Again, this is obvious. You correctly understand. You did not need the 88 day test, and for sure do not need any further testing since that one.

You have one more follow-up comment/question coming. But my patience will wear really thin if there are any more questions asking me to repeat previous replies!

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55 months ago

Since this is my 3rd response and the thread will close after that, I just want to thank you, Dr. Handsfield, for taking the time out of your busy schedule to provide your expert opinions. I am sorry for coming close to wearing out your patience. I had not meant to. Thank you very much again.

H. Hunter Handsfield, MD

55 months ago

Thanks for the thanks. FYI, we never mind answering any reasonable question. But it's frustrating to answer the same question more than once. In any case, I'm glad to have helped. ---