HIV - Prevention Expert Forum
Probabilities
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This forum is limited to prevention of HIV and to safe sex in general. All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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Probabilities

Hello, doctor.

I am a young gay male. As a member of an at-risk population, I keep myself well informed about HIV and other STDs. I have always practiced a safer-sex life style by ascertaining serologic status and always using condoms.

Recently, I was visited by a friend whom I have known for more than a decade.This is a person whom I trust not to lie to me where my health is concerned. We talked about our respective HIV statuses and infection risks and because of the unlikelihood of our seeing each other again for years to come, decided to forego the use of condoms in order to enjoy a rare intimacy. Before doing so, we both used the OraQuick oral mucosa HIV 1/2 test that is obtainable over the counter. Results: negative.

Over the course of his visit, he ejaculated inside me eight or nine times. I wasn't worried. The only risks were the possibilities that 1) he was in a window period and didn't know it or 2) the test result was a false negative.

About ten days after my last exposure, I came down with an illness that has me a little on edge. I have no runny nose or other cold-like symptoms. I just have exudative tonsillitis, swollen lymph nodes throughout the neck, fatigue, and a low-grade fever (99-100F) that has persisted for four days.

These symptoms match those of ARS and the timing is right. I went to my GP and had a rapid strep test performed. He noted that the exudate was "impressive" -- well, I'm glad someone was amused. Anyway, it's not strep. He did say that it could be mononucleosis based on its presentation. And I'm 26, so I guess mono isn't a completely ridiculous assumption even if my spleen wasn't enlarged. I'm not an expert.

Now, here's my question.

I'm still within the window period for HIV testing for this exposure -- it's been about two weeks. Nevertheless, I just took another OraQuick test and received a negative. If my symptoms WERE due to HIV, would I have formed enough antibodies for this test to show a positive?
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Welcome to the forum.  Thanks for your articulate and well-thought-out question.  And congratulations for a sober, analytical approach to HIV prevention.  It should continue to serve you well.

On a purely statistical basis, the chances your partner had HIV or that you have an acute HIV infection (acute retroviral syndrome, or ARS) are very low.  And in general, we advise pretty much ignoring symptoms as a clue to new HIV infections; so many other things (strep throat and mononucleosis among them) cause the same symptoms as ARS.  Your symptoms are partly consistent with ARS, but not entirely typical:  the fever usually is higher (101 or more); most people would also have a skin rash; and the lymph node enlargements would be in other locations aside from the neck, e.g. armpits, groin, etc.

Having said that, I believe it would be wise for you to be tested -- without waiting -- for HIV.  Two weeks is much to soon to put any stock in your most recent oral fluids test.  If your GP implied you couldn't accurately be tested this soon for HIV, he or she was wrong or you misunderstood.  In the situation you describe, an infectious diseases or genitourinary medicine expert, or any physician highly experienced in HIV medicine, would recommend a PCR test for HIV RNA/DNA, which is highly accurate (although not quite 100%) at 2 weeks.

Another approach would be to contact your partner and determine -- if you didn't ask before -- what sort of sexual partnerships he experienced in the 3 months before your contact with him.  If no other unprotected partnerships in that time, it would be strong evidence he could not have been in a window period.  And if he has had other unprotected exposures, you could explain your situation and ask him to be re-tested.

A final comment about the oral fluids HIV antibody test, which applies to both the version performed by health providers and that intended for home self testing:  this test is not a good one when someone is concerned about very recent infection.  Evolving research shows it becomes positive less rapidly than the blood tests for HIV antibody.  In general, I recommend oral fluids testing only in people who have not been at risk for 3 months or more.

I imagine these comments will be a bit alarming; it isn't fun to learn that your worst fears have a possibility of coming true.  But I stress that I doubt you have ARS -- more likely a slightly more severe than usual viral pharyngitis, or perhaps mono.  But better safe than sorry -- and also wise to be tested sooner, without having to go through a few 2-4 weeks of wonder and worry before a reliable antibody test can be done.

I hope these comments have been helpful.  Let me know if anything isn't clear.

Best wishes--  HHH, MD
7 Comments
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Avatar_m_tn
I've contacted my friend as you suggested. Sorry for not doing so beforehand. I didn't want to bring the matter up again unless I thought it necessary.

In any case, before he took the HIV test during his visit here he had received a previous negative result on an OraQuick oral fluids test on February 11. He has had no unprotected anal contacts since that time -- only protected sex.

As for myself, my only other risks in the testing window time frame are from providing oral sex to two other men.

Given this additional information, should I still seek out an infectious disease specialist? My insurance allows me to do this without a problem, but I wouldn't know how to get an appointment in a timely manner. I'm in the SF Bay Area, so surely there are plenty of knowledgeable providers around here.
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Avatar_m_tn
Addendum: the low grade fever is still present on day five (99.5 upon waking), but other symptoms have begun to subside in severity. My tonsils and cervical lymph nodes are still noticeably enlarged, but throat pain has subsided and there is markedly less exudate present on my tonsils. No signs of a rash anywhere that I can see.
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Avatar_m_tn
Still *profoundly* tired, though. Guh. Whether it's mono, acute HIV, or a bad viral infection -- it sucks.
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239123_tn?1267651214
I suggest you return to your GP for further evaluation and/or ask him or her for a referral to an ID specialist.  Let me know the outcome when you have done that -- but until then it seems senseless to speculate and I won't have any further comments.
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Avatar_m_tn
Actually, as it happens I just got back from an appoint with an accredited HIV specialist. He's a gay doctor who does family practice, and he really knows his stuff. Before returning to medical practice, he worked for Gilead for ten years and worked on the development of Truvada. He got me in on the same day I called, read your comments, and ordered a PCR with a genotype expression that I'll get back in a couple of days. He thinks it's unlikely that the test will come back positive, but in the event that it does, we'll already have resistance information on hand and can start treatment right away. I'm impressed!

Thanks for the help, doctor. Just wanted to let you know that I'm in good hands. Take care!
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239123_tn?1267651214
Thanks for the follow-up.  I'm glad your HIV doc is in agreement with my advice; I'm sure he knows more about all this and probably has managed many more patients with early HIV infections than I have.  I continue to remain confident your PCR test will be negative -- good luck and fingers crossed for you!
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