high risk exposure? ARS sx?

[concernednurse]

ok, i'm a 23 y/o/M straight, non-drug, no std's, please assess my exposure. 3-25-07 i went out to a strip club/brothel in Mexicali, Mexico(border city)not a premiscious guy, nor visits stripclubs,heavily etoh and had vaginal intercourse unprotected for 15-20 min. did not ejaculate. got home, finished self off,uncircumsized went to bed, next day noticed small abrasion to shaft most likley from masterbating healed in about 5 days. freaked out about desicion made,covered self with ABX,but did not check for std'd.70hrs went on combivir for 4 weeks.through out had nausea,diarrhea probably dude to meds. through out following weeks have had severe anxiety(cant stop thinkning about dying from AIDS and having HIV,) intermitant fevers (feeling hot) when checked from normal 98.5 to 99.7., fatigue, general body aches, had sore throat, lost about 7 #'s, neck pain. have checked HIV antibodies, initial neg, 2 weeks negative, 4 weeks negative, 6 weeks negative,47 day neg,53 day negative (being may 16th). May 17th till now 20th, have burning sesation to neck (like sun burn) face, chest, and arms. feels like i'm burning up, can't sleep and noticed skin rash to face, torso, arms, now legs,feels hott( when i touch it it blanches and this is abnormal for me).please assess my risks. 1) is this HIGH RISK? what is HIGH RISK? 2) does PEP delay seroconverion and void my 53 day negative? 3)does this sound like seroconversion to you? 4)are chances still 1-2,000 or more of a chance since she is a CSW?

[H. Hunter Handsfield, M.D.]

The additional information does't change my opinion or my advice.  If you have symptoms that concern you, stop trying to figure it out online and see a health care provider, preferably the one who prescribed your PEP.

As I said, "high risk" is just words.  Compared to a monogamous married guy having sex only with his wife, sex with a CSW is high risk.  Compared with anonymous unprotected anal sex with an unknown partner in public restroom, it is extremely low risk.

I won't have any further comments.

[concernednurse]

ok i take it back, one more Q. like i said, i continue to have this rash to my torso, mainly upper back, chest and neck,  it appears like a vauge maculopapular rash,....its red and have delayed blanching wich is really abnormal for me, i'm like mocha colored, ( latin ) and its freaking me out, continue having that burning sensation and i know its not sun induced. burns, feels itchy time to time to various parts of body. continue having a temp up to 99.8 oral, i had a 100.1 R as well. nausea hasn't stoped since march. sore throat, kinda red, neck feels tight, and upper back, bad headaches. BLAH! its scary cause this all started like a couple days ago, and landed @ the 3 week mark from last PEP dose. really scarred, if unprotected CSW sex isn't that bad then what is??? please one last response, promise not to bug anymore. thanks doc. sincerly.  

[concernednurse]

ok, thanks alot, i know i was explained all the risks, i thought in my opinion, that i was healthy enough to risk taking PEP for chances of not getting HIV. i guess its that damn label. (HIV+) at the time, anxious and overreacting i thought liver or multiorgan failure was better. ha! i know i know. so having intercourse with a CSW isn't high enough risk? what is? i'm not trying to be a smarty pants but i'm just curious. would it have to be a unprotected with a CSW in Africa that uses IV drugs, looks all emaciated  and stuff?? its just scary on this end you know doc. so last combivir dose was april 25th i believe. your saying anywhere from this coming tuesday the 22nd to june 5th would be suffice? june 16 is the 12 week mark...scary. also, do you know any examples of delayed conversion due to PEP? when you say "PEP dalays conversion in theory"......do you mean.....like...."you can get HIV from oral sex"....in theory? so chances are pretty slim ehh? my mind has been playing gnarley tricks on me...this anxiety and paranoia is horrible. this is my last post. thanx doc HHH.
Hunter,..i always liked that name. like hunter thompson. Doc, if i'm negative @ 12 weeks i'm naming my first son after you!!!! Hunter...sounds good. thanks again.

[H. Hunter Handsfield, M.D.]

There was very low HIV risk from the exposure you describe.  The odds are strong your strip club partner doesn't have HIV, and if she did, the chance you caught it after a single exposure were less than 1 in 1,000.  Whoever prescribed PEP with combivir (or anything else) was irresponsible, in my opinion; your risk of HIV was not high enough.  (I could be wrong in that, if there is evidence of particularly high rates of HIV in commercial sex workers in Mexicali, which I don't know.)  In any case, the negative test results at 7.5 weeks (53 days) is strong evidence you didn't catch HIV.  However, in theory PEP might delay seroconversion, so for increased assurance you should be tested one last time about 4-6 weeks after your last dose of Combivir.

1) 'High risk' is just words.  There are no definitive definitions.  Your overall risk was extremely low from the events you describe.  2) See above.  It doesn't void the result, but you might want to have another test.  3) No, you describe nothing that suggests ARS symptoms or seroconversion.  4) One in 2,000 is the risk for transmission from a definitely infected partner.  Whether that partner was a CSW or not changes the likelihood she has HIV, but not the 1/2,000 risk if she is infected.

The main result of your unnecessary PEP was to delay the time until you know you weren't infected, since you require delayed testing to know for sure.  Other users should take note of your mistake.

Bottom line:  You really have no worries, but probably should be tested one more time as suggested above.  Good luck--

HHH, MD