[Question #8368] Follow-up on Post-PEP testing question

45 months ago

Dear doctors,

Unfortunately, I'm back again with a follow-up question about the same exposure. After the conversation with Dr. Handsfield, I went back to my infectious disease doctor with regards to some of the facts we discussed here. I'll quickly recap my exposure:

- Broken condom during insertive vaginal sex with a 23-year old of unknown status, though she claims that she is "clean" and tested a month before the encounter

- Isentress + Truvada PEP regimen started at 30 hours post-exposure and taken as prescribed with no further exposures and full absention

- Testing at the end of PEP (28 days post-exposure) with AgAb = non-reactive, PCR RNA (40 copies sensitivity) = non-detected

- Testing 30 days from the last dose of meds (59 days post-exposure) with AgAb = non-reactive

Last time, Dr. Handsfield provided me with some reassurance. He stated that my chances of having HIV at no higher than 1 in 25 billion, that it is 0 for all practical purposes and that "There is no realistic chance you have HIV or will ever test positive." / "There is no chance at all that another test will be positive."

I tried discussion this with my doctor in the attempt to have another test in 6 weeks post-PEP, and the doctor "theoretically" agrees with the odds Dr. HHH listed but also says that there is no testing needed because in all practical means, I'm HIV negative and I should stop worrying. He referred me to a therapist and told me to work on cognitive psychology and move on.

I came back to the forum to ask:

1- Is me not getting tested further a risky call or should I trust my result and not bother with regards to that exposure?

2- Can you provide me with any literature that would back the need for another test at 6 weeks post PEP so I can show it to my doctor? I'm trying to avoid testing because it gives huge amounts of anxiety. Last time I tested, I was not able to eat or sleep for 36 hours until receiving results and I would like to avoid that situation again.

45 months ago

I do hope you don't find my questions repetitive. I just have been under a lot of stress after initially thinking my results were conclusive. I have not been able to properly sleep or eat or enjoy life ever since my last post on the forum and I am now worried that PEP tampered with my most recent results through masking the P24 protein and leading to a false negative on the test.

Edward W. Hook M.D.

45 months ago

Welcome back to the Forum although I'm sorry you felt the need. On this occasion I happened to pick up your question. I have reviewed your earlier interaction with Dr. Handsfield and agree with all he said. You certainly did not acquire HIV from the exposure you described. As Dr. Handsfield told you, there are few data on precisely how long after completion of PEP to follow someone. This is because PEP failures are so rare in persons who are adherent to the medications prescribed as you were. Our recommendation come from discussions with expert colleagues. In general, all agree that 4 or certainly 6 weeks are sufficient to determine the efficacy of PEP although all acknowledge that some experts may CHOOSE to err on the side of caution and test for longer periods. None that I am aware of have ever seen someone with a negative 4th generation test more than 4 weeks after completion of PEP who went on to show that they'd been infected. In answer to your specific questions:

1- Is me not getting tested further a risky call or should I trust my result and not bother with regards to that exposure?

I strongly advise you to trust your test results and move forward. To be honest, the risk from your initial exposure was so low that I probably would not have been willing to prescribe PEP for you. Were I you, I would not test further.

Follow-up testing is described in this medical journal article although, as both Dr. Handsfield and I have told you, recommendations are highly variable. https://www.bmj.com/content/363/bmj.k4928

Hope this will help you move forward. Be confident that you were not infected. EWH

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45 months ago

Dr. Hook,

Thank you very much for your very reassuring note. It means a lot to me in this very stressful and anxious time. Based on the advice I received from you, Dr. HHH, and my own doctor, I have decided to put the matter to rest and not pursue any further testing. I will, however, seek psychological help for my anxiety. Please, do let me know if I'm drawing the wrong conclusion from what you both have said. As follow-up questions, I have the following:

1- My doctor discharged me from the clinic. He said: "Given the low risk nature of exposure, the effectiveness of PEP, and the exceedingly sensitive testing you underwent, I can 100% say that you are conclusively HIV negative and that you need no further testing." Do you agree with him with regards to this statement?

2 - I had some symptoms show up that I wanted to inquire about. At about 9.5 weeks post-exposure, 5.5 weeks after PEP, I developed 1 tongue ulcer (occurred 2 days after I burned my tongue). This ulcer resolved itself in about 36 hours. I also had another ulcer show up around 11 weeks post-exposure (no reason this time), and also resolved itself within a day. My dentist says it is potentially due to stress. I have also seen some acne on my back. This is not uncharacteristic of me and I became aware of it a day or two before my last test results. It's like few red "dots", maybe 10 of them around middle right side of my back. It didn't seem like a rash but rather acne. Do any of these seem like ARS symptoms? I believe the answer is no but was worth checking

3 - I'm currently in an exclusive relationship with a woman I intend to marry within a couple of months. Am I good to go in terms of having unprotected relations with her without risk of infecting her? I think Dr. HHH said I could but I wanted to get the 100% go.

4- Could there be an instance where PEP suppresses P24 antigen in blood up to 8.5 weeks after exposure? My belief is that if antibodies won't show and if P24 is not there, you could expect to continue testing negative. I believe this would be my case, no?

Edward W. Hook M.D.

45 months ago

I agree with your plans to move forward. The repetitive nature of your follow up questions however serve to demonstrate the continuing presence of unwarranted anxiety. I encourage to seek professional counseling. Brief responses to your repetitive questions:

1. Yes, I agree. This is consistent with advice already provided by Dr. Handsfield and me.

2. The symptoms you describe are not symptoms the ARS.

3. There is no reason described in you posts to abstain from unprotected sex with your regular partner.

4. The situation you describe does not occur. Please believe your test results and move forward.

EWH

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45 months ago

Dear Dr. Hook/Handsfield,

I just wanted to update you on my most recent test results. I finally confronted my anxiety and went for another test. This time around it was a rapid combo AgAb test that gave me the results within 20 minutes. It came back non-reactive. this was at 15.5 weeks post-exposure and about 11 weeks from my last dose of PEP.

I take it that this test is 100% conclusive at this juncture and fully clears to move on with respect to that encounter? I was very delighted with this results and I feel finally able to move on completely and get back to enjoying my life fully, while making better life decisions sexually in the future!

Thank you for the all the help and assistance.

Edward W. Hook M.D.

45 months ago

Thanks for your follow up. It’s always good to hear when a client has confronted and overcome their anxiety over a misstep such as the one you reported. Your results are completely reliable. We wish you the best. EWH ---