Fresh finger cut exposure - I'm an idiot i know

Hi Doc,

Around six days ago I got very very drunk, although this in no way excuses what I did. To cut a long story short I ended up having a threesome with two Tanzanian CSW. I’m aware HIV prevalence is very high in Tanzania, however in my drunken state I never asked either of their status. I’ve since read that HIV prevalence among CSW in Tanzania is upwards of 60%!!

Luckily all sex both vaginal and oral with both ladies was protected. However my concerns arose the following day when I noticed a fairly deep cut around 1 cm long on my middle finger about 1cm above the nail. I remembered I had cut this on a glass literally only an hour or two before the sexual act. The finger bled at the time for a while. What worries me is that I’m fairly certain I was fingering these women with the cut finger for a while and also one of them was sucking on it during intercourse.

What are the risks via this route of transmission, i.e. saliva and vaginal secretions into a fresh cut?

I’m presently worried sick and don’t think I can wait the full three months of the window period to get tested. Unfortunately I currently live in the middle east which makes testing very difficult as any positive test will see me thrown out of the country. I’m therefore considering flying to Thailand for testing around the 4-6 week mark.

Would a negative PCR test combined with a negative duo antigen P24/antibody test at this time (4-6 weeks) be definitive or not?

Also what % of people that seroconvert have ARS symptoms?

Thanks for your help. You provide a great service.

[H. Hunter Handsfield, M.D.]

There are no data to directly answer your question.  With a fairly deep gash, I would be more concerned.  (Presumably your cut was superficial enough that you didn't feel the need to go get stitches, for example.)  And even within an hour, wounds start to "seal off" through the blood clotting process, and it is likely that not many HIV-susceptible cells were exposed.  Still, your statistics about Tanzanian CSWs probably are correct -- although perhaps not that high among those who are more likely to serve western clients. (You don't say whether the events took place in Tanzania, or with Tanzanian women visiting your middle eastern country.  If the latter, the chance they were infected probably was quite low.)

Still, the actual risk probably was no higher than 1 chance in 100 and likely much lower than that.  (One in 100 is about the risk when a health care worker sustains a deep cut or stab with HIV contaminated sharp instruments.)  In other words, even the highest risk scenarios, the actually transmission rate is pretty low on a case by case basis, so the odds are strongly in your favor.  But you would have qualifed for post-exposure prophylaxis (PEP), i.e. immediate treatment with antiretroviral drugs.  But PEP has to be given within 72 hours to be effective.

A negative duo antibody/p24 test at 4-6 weeks will be virtually 100% assurance, without the PCR test.  If that's also negative, so much the better.

Probably somewhere around 80-90% of newly infected people develop symptoms.  Sometimes they are mild, however.  But if you have no hint of fever, sore throat, etc over the next 2-3 weeks, that will be reassuring.

In the meantime, try to relax.  As I said, the odds are strongly in your favor.

Best wishes--  HHH, MD

[idiot7]

Hi Doc,

Thanks for the reply.

You say "A negative duo antibody/p24 test at 4-6 weeks will be virtually 100% assurance, without the PCR test". Would an antibody/p24 test and PCR test at say 5 weeks be 100% conclusive than?

I'm aware the PCR tests have a high incidence of false positives but really i just want to know how and when i can get conclusive testing done asap (bearing in mind i will only have time to take one set of tests in Thailand), rather than waiting for the three month window period with antibody tests?

Also from your experience does a fever always occur during ARS and do these symtoms (symptoms) ever occur beyond the four week exposure mark?

Thanks again

[idiot7]

Sorry forgot to ask, do PCR tests check for both HIV 1&2 and their sub-types.

Thanks

[H. Hunter Handsfield, M.D.]

I'm not sure about PCR testing for HIV-2.  But I wouldn't worry about it.  A negative duo test at 5 weeks will be 100% reassuring; even 3-4 weeks.  That's the whole idea of dual testing for antigen and antibiody:  it is almost impossible to have a new HIV infection without one of those being positive by 4 weeks.

[idiot7]

Thanks you've been a great help

[Rks213]

Dr. ,
I'm a little confused by your response.  You have repeated said that hand to genital contact is zero risk even if there are cuts on the hands.  This is basically a story of someone fingering with a cut that has stopped bleeding.  So, why would he have been a candidate for PEP?  It seems a little confusing that torn cuticles, hangnails, etc would pose no risk and a 1 cm cut could be as a high as 1:100 for transmission.  

[H. Hunter Handsfield, M.D.]

I pretty much knew someone would split that hair when I was writing my response.

Do not automatically transpose situations described in one question to others.  This situation was different than any previously posted on this forum, including the potentially higher likelihood the questioner's partners were infected, the freshness of the cut, and possibly the extent of the wound. (In fairness, I should have said "may" instead of "would" have qualified for PEP.)

[idiot7]

Hey Doc,

Sorry to bother you again but wanted to follow up on some symptoms which i'm having which are obviously worrying me. I know symptoms are never a good indicator of HIV infection, however you mentioned that "if you have no hint of fever, sore throat, etc over the next 2-3 weeks, that will be reassuring".

Well guess what right after our last conversation (7 days post exposure) i got a sore throat, no fever or other symptoms. Basically it was just  a swollen like feeling in my throat which has lasted around 7-8 days and has now subsided. It wasn't particularly painful just irritating.

I would like to ask from your experience should i expect any further symptoms or would they all come on at once as antibodies shall now begin to develop?

Also is it pssible i could have got any other STD's or infections from my exposure that i should get tested for?

Thanks again

[H. Hunter Handsfield, M.D.]

Sore throat alone is not common with primary HIV, and of course we're in the time of year when garden variety colds are most common.  That is a far more likely explanation.

No non-HIV STDs are likely.  You don't need testing.

[idiot7]

Hi again,

I got tested in Mumbai at 48 days post exposure. In the meantime i'd experienced various symptoms, i.e. at 4 weeks post exposure i had a heavy cold for ten days, also i currently have a macupapular rash over my back which has been there for the past two weeks and won't go away. The rash has been particularly worrying me as it's very unusual and i'm not sure what else it could be.

HOWEVER all test results:
  -  HIV-DUO (serum) by CMIA (IVth Generation test)
  -  HIV-p24 antigen detection,serum  by ELFA
  -  HIV-Proviral DNA, blood by PCR

Came back not detected or negative. I'm guessing from your previous responses you'll tell me not to worry about my current symptoms, which i can't help and that i'm in the clear. Would you reccomend further testing, i.e. at 3 months exposure? or for HIV-2? or is it time to move on despite the rash?

Thanks again

[H. Hunter Handsfield, M.D.]

The tests prove your symptoms cannot possibly be due to HIV.  You don't have it.  The only way to know the true cause of your rash and other symptoms is to see a health professional.  But put HIV out of your mind.

That's the last comment on this forum.  

[sam121]

Dear Dr....

In this case you have told that idiot7 could have qualified for PEP with open cut, and chances are 1/100. I have gone through many others thread simillar to this experience , where people have fingered vagina with some sorts of cut on their fingers. In allmost all of them you and Dr Hook has said that this is almost a no risk activity and hiv test is not even warranted. I consider idiot7 had the same experience only difference being he had in Tanzania. But in other threads you have said it will still be very very low  to no risk  if the fingered person is positive.

Your Answer will be greatly appreciated

[bigmistake99]

A related discussion, Big Mistake in Bucharest I dont know what to do was started.