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HIV and the early test
Dear Drs,
First of all, great thanks to you for what you do. Exposure was 4 days ago with a CSW in London. Unprotected oral and protected vaginal, however the condom broke. We changed positions about a minute before and it was still intact, so the maximum unprotected period was less then a minute, although I think more likely just a few seconds at the very end when I ejaculated. The reason I think that is that when I withdrew and noticed the condom breakage, my penis was pretty close to if not completely dry and smelled of a condom and not of vaginal fluids. She went to the bathroom first, so it took me about a minute to go get cleaned up, first with warm water, then with purel (which I now realize from reading the forums wasn't a good idea). CSW seemed pretty distressed and told me it never happened to me, which I take as a good sign that she's most probably clean and is worried about me infecting her, not the other way around.
Now questions:
1. I'm scheduled for an early test next week (8 days after exposure). Here's the information on it: theearlytest.ucsd.edu/ - and here's a very recent article published from the study that this test is part of - http://www.annals.org/content/152/12/778.abstract Apparently, this test yields 99% accurate reports in one week after exposure. I wasn't able to find any discussion by either one of you regarding this test, so would like to hear your opinion on it, especially the risk of false positives. Just to be sure, I intend to follow up with 4 and 6 week ab tests, so this is more for anxiety relief.
2. Assuming the worst (understanding low odds of it), how much comfort can I take in the fact that my penis appeared completely dry and smelled of condom, as opposed to vaginal fluids?
3. Regarding purel, I've read conflicting opinions. In your opinion, did my uneducated act of putting it on my penis (including urethra) cause no effect one way or the other, or could it have a chance of exacerbating the issue?
First of all, great thanks to you for what you do. Exposure was 4 days ago with a CSW in London. Unprotected oral and protected vaginal, however the condom broke. We changed positions about a minute before and it was still intact, so the maximum unprotected period was less then a minute, although I think more likely just a few seconds at the very end when I ejaculated. The reason I think that is that when I withdrew and noticed the condom breakage, my penis was pretty close to if not completely dry and smelled of a condom and not of vaginal fluids. She went to the bathroom first, so it took me about a minute to go get cleaned up, first with warm water, then with purel (which I now realize from reading the forums wasn't a good idea). CSW seemed pretty distressed and told me it never happened to me, which I take as a good sign that she's most probably clean and is worried about me infecting her, not the other way around.
Now questions:
1. I'm scheduled for an early test next week (8 days after exposure). Here's the information on it: theearlytest.ucsd.edu/ - and here's a very recent article published from the study that this test is part of - http://www.annals.org/content/152/12/778.abstract Apparently, this test yields 99% accurate reports in one week after exposure. I wasn't able to find any discussion by either one of you regarding this test, so would like to hear your opinion on it, especially the risk of false positives. Just to be sure, I intend to follow up with 4 and 6 week ab tests, so this is more for anxiety relief.
2. Assuming the worst (understanding low odds of it), how much comfort can I take in the fact that my penis appeared completely dry and smelled of condom, as opposed to vaginal fluids?
3. Regarding purel, I've read conflicting opinions. In your opinion, did my uneducated act of putting it on my penis (including urethra) cause no effect one way or the other, or could it have a chance of exacerbating the issue?
MEDICAL PROFESSIONAL
If you present yourself as a potential study subject and they deem you are eligible, go for it. You can expect negative test results.
MEDICAL PROFESSIONAL
Welcome back to the HIV forum. The bottom line is that your risk of HIV is very low. From a risk assessment perspective, it could be argued that you don't need HIV testing at all -- and you certainly don't need DNA ("early") testing of the sort you are talking about. Here is why:
The UK Health Protection Agency (HPA) estimates that fewer than 1 in 1,000 London area CSWs have HIV -- and that risk may be even lower in CSWs who consistently use condoms, as your apparently does. Your partner's distress at the condom breakage is reassuring as well. It suggests she knows for sure she isn't infected and intends to stay that way. After all, from a statistical standpoint, CSWs are at higher risk for HIV from their clients than the othew way around. If despite this she were infected, the average transmission probability from a single episode of unprotected vaginal sex is estimated to be around 1 in 2,000. Together these factors suggest a maximu risk of 1 chance in 2 million you caught HIV.
To your specific questions:
1) The ability of nucleic acid amplification tests (NAAT) to detect early infection is not new information. San Diego research report you cite, which has had some media attention in the past few days, confirms previous research already published from North Carolina, Seattle, and elsewhere. Although it isn't clear from the abstract you cite, the full paper makes it clear that early NAAT testing is useful primarily, perhaps exclusively, in gay/bi men. Of the roughly 3,500 study subjects, all new infections detected only by NAAT were among the roughly 2,200 gay men. Among the 1,364 heterosexual male subjects (789) and women (575), only 6 were HIV positive and all of those were positive by antibody tests; there were no infections detected only by NAAT. These results are pretty much identical to those done a couple years ago in my own STD clinic in Seattle. In my clinic, we now do automatic routine NAAT testing among gay/bi men who have HIV tests, but not in anybody else. Certainly we would never spend the money to test someone with a 1 in 2 million risk of having a new HIV infection, even if the patient begged for it.
2) That factor suggests even lower risk of HIV than I estimated above.
3) I know of one research study, not very high quality, that suggested an elevated risk of HIV when men washed with soap and water after sex with HIV infected women. Several studies prove that the disinfectant nonoxynal-9, the active ingredient in many spermicides, definitely increases the risk of HIV in exposed sex workers. So the balance of data suggests increased risk from disinfectants. But it is difficult to know whether this applies to alcoholic disinfectants like Purel. All things considered, your risk was so low that this almost certainly made no difference one way or the other.
Bottom line: If you feel the need for HIV testing, have a standard antibody test at 6-8 weeks. I recommend against early testing with NAAT. If you can find a provider who will do it, most likely it will be quite expensive and I don't think it's worth it. (I doubt it will be available to you at any of the NHS GUM clinics.)
I hope this helps. Best wishes-- HHH, MD
The UK Health Protection Agency (HPA) estimates that fewer than 1 in 1,000 London area CSWs have HIV -- and that risk may be even lower in CSWs who consistently use condoms, as your apparently does. Your partner's distress at the condom breakage is reassuring as well. It suggests she knows for sure she isn't infected and intends to stay that way. After all, from a statistical standpoint, CSWs are at higher risk for HIV from their clients than the othew way around. If despite this she were infected, the average transmission probability from a single episode of unprotected vaginal sex is estimated to be around 1 in 2,000. Together these factors suggest a maximu risk of 1 chance in 2 million you caught HIV.
To your specific questions:
1) The ability of nucleic acid amplification tests (NAAT) to detect early infection is not new information. San Diego research report you cite, which has had some media attention in the past few days, confirms previous research already published from North Carolina, Seattle, and elsewhere. Although it isn't clear from the abstract you cite, the full paper makes it clear that early NAAT testing is useful primarily, perhaps exclusively, in gay/bi men. Of the roughly 3,500 study subjects, all new infections detected only by NAAT were among the roughly 2,200 gay men. Among the 1,364 heterosexual male subjects (789) and women (575), only 6 were HIV positive and all of those were positive by antibody tests; there were no infections detected only by NAAT. These results are pretty much identical to those done a couple years ago in my own STD clinic in Seattle. In my clinic, we now do automatic routine NAAT testing among gay/bi men who have HIV tests, but not in anybody else. Certainly we would never spend the money to test someone with a 1 in 2 million risk of having a new HIV infection, even if the patient begged for it.
2) That factor suggests even lower risk of HIV than I estimated above.
3) I know of one research study, not very high quality, that suggested an elevated risk of HIV when men washed with soap and water after sex with HIV infected women. Several studies prove that the disinfectant nonoxynal-9, the active ingredient in many spermicides, definitely increases the risk of HIV in exposed sex workers. So the balance of data suggests increased risk from disinfectants. But it is difficult to know whether this applies to alcoholic disinfectants like Purel. All things considered, your risk was so low that this almost certainly made no difference one way or the other.
Bottom line: If you feel the need for HIV testing, have a standard antibody test at 6-8 weeks. I recommend against early testing with NAAT. If you can find a provider who will do it, most likely it will be quite expensive and I don't think it's worth it. (I doubt it will be available to you at any of the NHS GUM clinics.)
I hope this helps. Best wishes-- HHH, MD
That's the thing, Dr. Handsfield (and no further response from you is expected, as promised) - they haven't really told me for sure they think it's BFP, choosing instead do the set of two tests again. It was actually I who suggested to the clinician that it's BFP based on my prior history, and while she thought it was likely the case, she wasn't completely sure, so I was just curious in your take.
Again, thank you very much for your input!!!
Again, thank you very much for your input!!!
MEDICAL PROFESSIONAL
If the positive test result was either an RPR or VDRL test, and if a confirmatory test (usually a TPPA, but other equivalent tests also are in common use), then it's definitely a biological false positive (BFP). By definition, BFP means you don't have syphilis and no sex partner is at risk.
But the question remains why you are asking here. The STD clinic's knowledge about these things is as good as mine or that of any other expert. Clarify the test results and their meaning with them, then accept their verdict.
That's all for this thread. Up to you if you decide to post a new question on the STD forum, but the reply won't be any different, so I suggest you save your money and not fill up a forum slot that someone else would be able to use. Only a limited number of questions are accepted each day.
But the question remains why you are asking here. The STD clinic's knowledge about these things is as good as mine or that of any other expert. Clarify the test results and their meaning with them, then accept their verdict.
That's all for this thread. Up to you if you decide to post a new question on the STD forum, but the reply won't be any different, so I suggest you save your money and not fill up a forum slot that someone else would be able to use. Only a limited number of questions are accepted each day.
And I promise no further follow-ups!
Dr. Handsfield, thanks for your response.
On the syphilis issue, it's not quite as you supposed (believe me that if it were, I would not even dream of wasting your time with it). I got a positive hit on a screening test that I did one week ago (9 day after exposure). They also did a confirmatory test that was negative.
Today they took another sample, same result from the quick screening assay (reactive 1-2, whatever that means. The confirmatory result won't be known for a week.
Now, I've had a very similar thing happen to me about three and a half years ago when there was a reactive screen result that didn't get confirmed, so I was just wondering if (assuming, as I suspect, that the confirmatory one done today will come back negative again) this is an indication that I'm chronically BFP for syphilis, if there is such a thing. This is especially puzzling, given that the screening tests that were done were done at 9 and 17 days post possible exposure, which, from what I understand, is too early for a positive test.
I'm not trying to overanalyze this, but I do have a romantic weekend planned in a couple of days, so I just want to make sure I'm comfortable that I'm not putting anyone at risk of anything.
Again, I realize that this is a bit off-topic, albeit stemming from the same incident, so I would be happy to repost on the STD board and make another donation to this great site.
On the syphilis issue, it's not quite as you supposed (believe me that if it were, I would not even dream of wasting your time with it). I got a positive hit on a screening test that I did one week ago (9 day after exposure). They also did a confirmatory test that was negative.
Today they took another sample, same result from the quick screening assay (reactive 1-2, whatever that means. The confirmatory result won't be known for a week.
Now, I've had a very similar thing happen to me about three and a half years ago when there was a reactive screen result that didn't get confirmed, so I was just wondering if (assuming, as I suspect, that the confirmatory one done today will come back negative again) this is an indication that I'm chronically BFP for syphilis, if there is such a thing. This is especially puzzling, given that the screening tests that were done were done at 9 and 17 days post possible exposure, which, from what I understand, is too early for a positive test.
I'm not trying to overanalyze this, but I do have a romantic weekend planned in a couple of days, so I just want to make sure I'm comfortable that I'm not putting anyone at risk of anything.
Again, I realize that this is a bit off-topic, albeit stemming from the same incident, so I would be happy to repost on the STD board and make another donation to this great site.
MEDICAL PROFESSIONAL
1) UCSD is among the top of all HIV/AIDS research institutions worldwide. I'm surenthey know much more about HIV and it's diagnosis than i do. However, I agree with what they told you. Follw their advice about additional antibody testing.
2) I agree exactly. Almost everybody has 1-2 nodes that can be felt imn the groin with careful examination.
3) If you have a positive syphilis blood test result that the STD clinic has diagnosed as false, I'm sure you can believe it. False pos syphilis results usually have no explained cause and carries no health risks. Don't worry about it.
That should end this thread and I se litle need for one on the STD forum. Take care.
2) I agree exactly. Almost everybody has 1-2 nodes that can be felt imn the groin with careful examination.
3) If you have a positive syphilis blood test result that the STD clinic has diagnosed as false, I'm sure you can believe it. False pos syphilis results usually have no explained cause and carries no health risks. Don't worry about it.
That should end this thread and I se litle need for one on the STD forum. Take care.
Dear Dr. Handsfield,
I have a couple of follow-up questions, if you don't mind.
1. I've been told by UCSD as well as the county STD clinic that the negative NAAT result at 9 days is as reliable as the 6-8 weeks negative AB result. Would you agree with that, or would you still advise getting an AB test at 6-8 weeks?
2. At an STD check-up the clinician said that one of the lymph nodes in groin area was slightly enlarged (that was the only one of those that she checked. From what I understand, a single node enlargement is not an indication of anything, and that it would take multiple node enlargements for there to be a concern. Is that correct?
3. I also have a question about syphilis (having to do with me being potentially false biological positive). May I ask it here, or do I need to start a new thread on the STD board?
Thank you!
I have a couple of follow-up questions, if you don't mind.
1. I've been told by UCSD as well as the county STD clinic that the negative NAAT result at 9 days is as reliable as the 6-8 weeks negative AB result. Would you agree with that, or would you still advise getting an AB test at 6-8 weeks?
2. At an STD check-up the clinician said that one of the lymph nodes in groin area was slightly enlarged (that was the only one of those that she checked. From what I understand, a single node enlargement is not an indication of anything, and that it would take multiple node enlargements for there to be a concern. Is that correct?
3. I also have a question about syphilis (having to do with me being potentially false biological positive). May I ask it here, or do I need to start a new thread on the STD board?
Thank you!
Dear Doctor, once again, cannot thank you enough for what you do!
Dear Dr. HHH. Just to clarify, I'm back in the States, and the test is part of a UCSD study, so it's free or virtually free ($15 I think) Thank you very much - you are a tremendous help to us, paranoid OCD types with sexual urges!
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