[Question #7566] Sexual exposure guidance

3 months ago

Dear Doctors:  I have a situation for which I am seeing your opinion and guidance.

Episode:  Late fifties British male.  Happened in London with a Southeast Asian exotic club dancer (stripper) of unknown status who I also do not know well at all. Engaged in prolonged (3-4 hours on and off) unprotected naked frottage (bare unprotected genital to genital but no unprotected insertion), fingering, unprotected fellatio received, unprotected cunnilingus given, protected sex for 20-25 minutes with condom. Dancer was on her periods but it was not heavy. I believe, during sex the condom was on at all times, but I may be forgetting details whether it got torn or not or remained intact or not as I was drunk. I also engaged in sucking nipples and lots of lips kissing.

Test results: Exactly after 42 days (so exactly 42 times (i.e. multiplied by) 24 hours since last act with dancer completed, not more not less), I got 4th Gen AgAgb tested and results were Non-Reactive. I also tested Non-Reactive with 4th Gen AgAb exactly after 93 days (exactly 93 times 24 hours since last act with dancer).  I have not had an exposure since this episode with this performer. On the exactly “after 42 days test”, I also tested for other STDs and all were negative. I only tested for HIV on the “exactly after 93 days” test with 4th Gen and as mentioned earlier it was Non-Reactive.

I am in my late fifties and take medications, some of which are for my autoimmune condition that I have taken for several years.

I have the following questions for you from an HIV (HIV-1 and HIV-2 standpoint) standpoint.

Q1: What is your risk assessment for this exposure?

Q2: Can my test results be considered conclusively negative and that did not get infected with either HIV-1 or HIV-2?  Is the conclusiveness window also satisfied for HIV-2 as it is for HIV-1?  Am I totally fine and conclusively not infected and conclusively did not get infected?

Q3: Is the logic for “days since exposure” that I indicated above as my calculation correct?  (i.e. exactly 42 times 24 hours and exactly 93 times 24 hours --- since last act with dancer)?  How do you calculate the time period since exposure?

Q4: Did I test too soon with the ‘exactly after 42 days’ test?  Do I have to be worried about the fact that it was not “after 43 days or after 45 days”?  I have seen you mention “beyond 6 weeks” in your forum responses.  Do you mean “after >=42 days” or “after >=45 days” or  “after >=43 days”?  What if someone tested “after 41.5 days, i.e. “after 41 days and 12 hours”?  How does that affect the efficacy of the test?

Q5: Do I need additional tests to establish conclusiveness? Would you recommend additional testing?  Are the two tests thus far fully conclusive and enough?

Q6: I have seen many forum posters here test several times (sometimes over half a dozen). Is that necessary? Does the level and probability of conclusiveness increase with the number of AgAb tests?

Q7: Do my medications and medications for autoimmune impact anything that you have remarked?

Q8: Do your assessments hold even if the other individual with who I engaged with was infected with HIV-1 or HIV-2 (high-risk individual) and the exposure was high risk?  I am worried about the risks of delayed seroconversion and delated antibody production for HIV-2 or HIV-1 and if the tests totally rule out any and all such concerns.

Q9: Would you suggest (and can I) I put this episode behind me, not worry about it and not give it another thought and move forward with life?

Q10: Can I resume unprotected sex with my wife?  Heaven forbid but how would you react if you found yourself in my situation and exposure?

Thank you for taking the time to review and provide your guidance and opinion.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 months ago
Welcome to the forum. Thanks for your confidence in our services. The first two questions really cover all the others, directly or indirectly.

1) These events were very low risk for HIV (both types), but not quite zero risk. Based on my understanding of HIV epidemiology in London, the chance the stripper had HIV was very low, well under 1% maybe under 1 chance in a thousand. Even if she was infected, HIV is rarely transmitted without unprotected penile-vaginal (or -anal) insertion. Oral sex is near zero risk. However, condoms aren't perfect:  unrecognized failures happen. From an overall risk perspective, the risk was low enough that you really didn't need HIV testing, except for its reassurance value.

2) The AgAb (duo, 4th generation) HIV blood tests are among the most accurate diagnostic tests ever developed, for any medical condition. When done sufficiently long after the last possible exposure (6 weeks), the results overrule all other considerations, such as risk at the time of exposure. Even if you knew your partner had HIV and if you had had unprotected sex, the test result proves you weren't infected. There has never been a scientifically validated exception, except for persons taking anti-HIV drugs after exposure. Accordingly, the answer is yes:  your 42 day test was conclusive for both HIV1 and HIV2; the 93 day test wasn't necessary.

3,4) The data aren't nearly so precise -- there's no point in calculating test timing to the hour. A negative result any time on day 42 is equally valid as at any other time.

5) As all this implies, your current results are conclusive and no further testing is needed.

6) Indeed, many forum users have reported multiple tests beyond the necessary time limits. So what? In every instance, Dr. Hook or I have advised them that the tests beyond 4-12 weeks (depending on the specific tests they had) were unnecessary.

7) There are no known medications or medical conditions that affect the timing or reliability of the AgAb tests, except for anti-HIV drugs as noted above.

8) With the AgAb tests, "delayed seroconversion" is an urban myth. The level of risk, including the amount of virus to which one is exposed, makes no difference in test timing or reliability.

9,10) Well stated and you can safely resume unprotected sex with your wife; you could have done so after the 42 day test. If I had somehow been in your situation, I would not have felt a need for HIV testing at all and would never have stopped having sex at home. If the risk had been  higher and I got tested, I would have done so at 4 weeks (at which time I would have resumed sex with my wife) and again at 6 weeks.

Thanks for the thanks in advance. I hope these comments resolve your concerns. Let me know if anything isn't clear.

HHH, MD
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3 months ago
Dr. Handsfield:  Thank you for the enligtening response. 

For what tests do you suggest the 12 weeks and what tests are 4 weeks and where does AgAb fit in wrt to the test quality?  Both my tests were 4th Gen AgAb and blood drawn from a vein (in Quest Diagnostics outpost) and then the small cylinders of blood sent to a Quest Diagnostics lab for testing.  The test results were made available after a couple of days.   Are those the right 4th Gen AgAb tests that I got?

Also, at the risk of making you state the obvious, can you please confirm the following so I can move on?  I promise to not bother you any more.  I definitely do not want to be a repeat questioner of expertly stated opinons and scientifically stated facts.
Q11. That I am 100% negative for HIV-1 and HIV-2 
Q12. Both the 42 day test and 93 day test are definitely fully conclusively for both HIV-1 and HIV-2 and would catch both strains, despite medications (except the anti-HIV ones you cited below) and medical condition, for an infected individual
Q13. That I absolutely do not need any futher testing and can move forward with life forgetting this episode

Thank you for your invaluable service.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 months ago
I don't suggest any testing at 12 weeks. It's unnecessary, unless the only test available is an older (first or second generation) antibody test; or for the oral fluids test ((Oraquick).

All AgAb tests are equally valid, no matter what lab does them -- and are the "right" ones.

Q11, 12, 13:  Yes, all confirmed.
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3 months ago
Q14: The risk level (however) at the time of my exposure is irrelevant given my conclusive negative test results.   Am I correct?
Q15: For note in the future, as far as HIV (HIV-1 and HIV-2) are concerned, I should understand that, even with an infected individual, nude unprotected frottage (without penetration) and unprotected oral sex are practically risk free exposures and I must always use condom for anal and vaginal sex.  Is that a proper understanding with the all data points you know of?

Thank you, Dr. Handsfield.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 months ago
Q14:  Correct.
Q15:  Correct, with the stipulation that the interpretation of "practically" risk free oral sex is a relative one. There has never been a scientifically proved case of HIV transmission oral to penis, or by cunnilingus (in either direction) -- but that doesn't prove it cannot occur, just that the risk is very low.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful.
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