[Question #841] Follow up to #803

52 months ago

Hi,

 

Dr. HHH gave me the green light (on #803) to ask some follow up questions. Anxiety still gets the best of me (despite (-) DUO after 27.6 days), so I'm opening a thread to address my lingering concern and also for educational on safe practices.

 

I remember Dr. Hook giving advice for retesting at 8 weeks for someone who was in a relationship with HIV+ woman. Given my repeated unprotected vag. exposures to a CSW without consistent condom use, are you still comfortable in saying that I need not retest after my (-) at 27.6 days? She repeatedly told me that she’s (-), but refused to show paper for privacy. How risky do exposures need to be before you consider a 4 week (-) result not yet conclusive?

 

As far as HIV is concerned, what practices would be considered safe sex? For example, would protected vaginal sex and unprotected oral sex with a (+) person be considered safe? Would they warrant testing? How about protected anal sex with a (+) person? I understand that condom provides 80% protection, it means protective anal sex still carries the risk of about 1/500 or 1/250? Aren’t these still more risky than even unprotected vag. sex?

 

I understand that you may be annoyed by my questions, but even after the last test (27.6 days), I’m still finding it hard to move on. I would test again, but I prefer not missing work for testing. So once again, I’m seeking reassurance (if you tell me to retest at later dates, that too I would do).

 

Thanks a lot, and I truly appreciate your services. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
52 months ago
Welcome back. But I'm not sure what you mean by "green light". My last comment in your other thread was "I would be surprised if there are any 'what if' scenarios you can think of that would change the opinions and advice you've already had. Any additional questions almost certainly will generate answers you already have had or can predict." And I was right.

The problem here is your obsessive anxiety. By definition, anxities and obsessions are rarely helped by simply hearing the facts once again. I expect you're going to continue to worry about this, regardless of what additional information I can provide.

1) You should not be searching for advice given to different persons in situations not analagous to yours. That Dr. Hook thought it would be reassuring for that person to have another test doesn't mean there was any chance it would be positive if a duo test at 4 weeks had been negative. Four weeks is always conclusive; there are no exceptions.

2) People rarely lie about HIV status when asked directly. Anyway, your CSW partner's HIV status is irrelevant. Even if you knew she were positive, your negative test result at 28 days proves you did not catch HIV. (And yes, once again, 27.6 days is the same!) 

3) If a bare penis (no condom) does not enter another person's vagina, rectum, or (rarely) mouth, then HIV is never transmitted. ALL other sexual exposures are safe with regard to HIV. Intact condoms can be considered 100% protective, not 80%. so that truly protected anal sex with an HIV positiive partner can be considered safe if the condom is properly used and doesn't break. But condoms do fail sometimes and can be misused. If you were to know a partner had HIV, of course you should avoid any insertive sex, even with condoms.

4) Your numerical calculations are wrong. Even without a condom, the average transmission risk in anal sex, from the anal to penile partner, has been estimated at 1 in 200. If you consider condoms 90% protective, the risk for any one exposure becomes 1 in 2,000. That's about the same as the estimate for unprotected vaginal sex. However, you also need to factor in the odds your partner has HIV, which for most CSWs is 1% or less; and for a CSW who says she is HIV negative, you can figure on 1 in a thousand, tops. So even with anal sex, you can reduce the risk accordingly.

5) We do not get "annoyed" by reasonable questions. But we can get annoyed with irrational nonsense, like your comment about having another test. You truly don't need one, but given the extreme level of anxiety you exhibit, it an additional negative test will help you move on, obviously it would be worth some minor inconvenience.

But you have 100% evidence you didn't catch HIV. The biological reasons for that, and the statistical analyses, really shouldn't matter.

Best regards--  HHH, MD

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52 months ago
Hi Doctor,

I sheepishly (foolishly) went for an INSTI rapid test at day 50, and obviously it was non-reactive (the councilor kept insisting that HIV remains a predominantly MSM/IDU issue, and non-endemic female sex workers are not even in hi-risk group, even ones without consistent condom uses).

He told me not to come back until 12 weeks, re-assured me that at 50 days, the rapid test is over 90% accurate (here, tests are covered by health care, and by retesting every 2 or 3 weeks, he claimed I'm wasting resources), and the Canadian HIV testing guideline put the rapid test at 95% sensitive at 34 days. He cannot, however, legally say that I am out of the woods yet, but told me that, in 18 years working in the clinic (literally the busiest STD-only clinic in Toronto), he has only seen maybe 3 or 4 heterosexual males testing positive (I actually doubt this; I would think heterosexual transmission would be FAR more common than this).

This reassurance, however, was gone as fast as it came once I realized that I have wasted my time due to the fact that rapid POC INSTI test at day 50 is not any more (or even less) conclusive than day 28 DUO. 

I concede now that my head is playing tricks on me. I am, to this date, still feeling all kinds of weird symptoms, even after receiving day 28 DUO and day 50 INSTI rapid results (night sweats, hot flashes [98.5-99.5], myalgia/arthralgia, weight loss, runny nose, persistent malaise, breath shortness, coughing, sneezing). The muscle and joint pains were not there before, and only started to occur in the fifth week, so it drove me a bit crazy for a while, until I found that extreme anxiety too can cause muscle and joint pains.

I realize at this point I will always link everything that 'feels' wrong in my body with HIV. I'm worried that, if I am somehow unlucky enough to have actual 100+ fever in the near future, I would run to the STD clinic for an HIV test rather than actually trying to treat the sickness. The problem is in my head, and I cannot fix this alone. While you are an HIV expert, I realize that I need to consult professional in mental issue to address this obsession over HIV I've somehow acquired.

This forum is probably the only place online that I can visit without triggering more anxiety (your blog-like post to 868 was probably the best written article on window period I've ever read), for which I truly thank you, Dr. Hook and Terry for providing expert's advice and opinion on STIs/HIV.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
52 months ago
Your test counselor is right in all respects, except that s/he underestimated the reliability of your 50 day INSTI test, which is closer to 99% or even 100% (despite offficial advice about 12 weeks). And it is true you already knew from your duo result that you weren't infected, so there was no point.

Thanks for your kind comment about thread #868. I hope you can now move on. If you cannot, I'm going to ask that you not seek more reassurance here. As I said above, just learning the facts and getting reassured is generally not enough when someone is as anxious and obsessed as you are. so it's a waste of time and energy on both your part and ours. The answer isn't in more facts and reassurance, but in understanding your own underlying mental health issues.

Good luck and best wishes.

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50 months ago
Thanks, doctor, this website has provided with an excellent source of information for us and a lot of worried folks like me out there.

I've been in a living hell this past few weeks, despite your repeated science-based reassurance on the inefficient transmission mechanism of HIV from female to make, HIV prevalence among non-endemic female sex workers, and also HIV test performances. You may call me insane (and I am insane), but I've been seriously overtested (I did a 10-test STD panel from stdcheck.com on the 70-day mark, and did pretty much weekly INSTI tests all the way until the 84-day mark), to the point where I became extremely anxious, thinking that I had been unnecessarily risking false positive results.

I believe that my source of (irrational) anxiety stems from the overly conservative 12-week window period, and their inflexibility in interpreting test performance (the only thing they mentioned to me was that the rapid test was 95 percent sensitive at 34 days, and 99.9 at 12 weeks, and that anything done less than 12 weeks post exposure would be too early). Of course, you and Dr. Hook knew better, and you already told me that I was clear ever since my DUO result came back negative after only 10-15 days after the last exposure (and all those panic and anxiety were completely for nothing).

So thanks again for all your help and all the good work you, Dr. Hook and Terry have done, and I hope to work out my (still existing) HIV anxiety with a mental therapist. 
50 months ago

While this is still fresh on my mind, I would like to ask several follow-up questions:

1. As I mentioned, I purchased the 10-test panel from stdcheck.com, and had blood and urine work on 70 days. The blood was withdrawn in a Toronto lab, and was then FedEX-ed directly to a Quest Diagnostics lab in VA. My question to you is, would this in any way degrade the sample, and, due to this, should I have any reason to doubt my results? The produced report looked legitimate, and matched the sample online for that VA QUEST lab.

2. This question is once again regarding the window period for HIV 4th generation test. You and Dr. Hook mentioned that the data are good on when p24 becomes detected. And you also mentioned that based on biology (on 868), everyone would have either detectable viral load or HIV antibody by the fourth week. But isn’t the DUO test searching for p24 instead of viral load? And isn't it the case that p24 would be detected roughly a week after the first viral onset (in fact, Darlene Taylor's paper placed a median detection by duo test about 7 days later)? I wonder if the 4 week-window refers to the combination of HIV RNA test + antibody test instead of p24 & antibody? I'm just trying to understand the biology here, & there is no better person to ask than the experts here.

Hopefully these would be the last set of questions I ever ask of you (at least about this exposure). And I would like to thank you once again for all the help, throughout all these difficult months.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
50 months ago
1. Specimen transport in this manner does not downgrade the performance of any test. And of course it is in all labs' interest to provide the most accurate results possible. Therefore, if there were such a risk, the receiving lab (Quest/VA) would have instructed the Toronto lab to not ship it.

2. p24 antigen is an excellent substitute for RNA/DNA testing (viral load). It doesn't measure the amount of virus in the blood, but a negative is evidence that an RNA/DNA test also would be negative. The 4 week window we refer to on this forum applies to both the duo test and the combination of RNA plus antibody.

Thanks for the thanks. I'm glad to have helped. That completes the two follow-up comments and replies with each question, so this thread is now closed. Best wishes, stay safe, and try to not worry so much! 



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