HIV and Friend

[Heather34]

hi dr. handsfield,

I just have a quick question, but I haven't been able to sleep this week and have been sweating at night for periods.

About 3 weeks ago, I was helping my friend who is homosexual sand his back deck.  He badly scratched the skin on the back of his hand with a course metal brush (sanding brush) and it bled (maybe 10 or 15 drops).  He didn't realize he had done it until I had already used the same brush and scratched my hand with the brush (the scratch bled as well).

I probably scratched myself about 5 minutes after he did, so his blood was on the brush for about 5 minutes before I created my bleeding scratch.

I have had the following symptoms (Rash upper chest, looks like 9 raised and flat pimples, Fever of 97.7-99.5 (Depending on the time of day, and NIGHT SWEATS (just my head and neck) for 3 nights).  

To this point I have not had any glands, sore throat, aches type problems that I can see.

I am not prejuduce against Gay Men (As many of my close friends are gay), but I have heard it is a high risk group for HIV which is why I am concerned.

Did I have any risk for HIV whatsoever? I am concerned about my boyfriend of 7 years.  Do I need to test for HIV before I have sex with him again?  Are my symptoms = to HIV?

Please help as I am distrought

[Willl]

I just read some of the aidsmeds.com site and they do give very good advice. I had wrongly assumed because I initially saw it was not an MD moderated forum. It is very low to nonexistant chance. The guy probably didn't even have anything.

[monkeyflower]

I'm completely confused and confounded by most of these cautious responses. Is this *seriously* a risk? If it were me, HIV infection wouldn't have even crossed my mind... I'd think the risks from what she describes would be minimal at best, along the lines of normal, everyday contact anyone would have.

[Heather34]

Thank you, Willl, and I very much appreciate your attention to this matter and to be honest you have freaked me out a bit more.  But I know you are only trying to help.

I do take Andy Valez and Jonathan Kinev's advice very seriously (at aidmeds.com) because Andy is considered one of the top experts in the field and Jonathan has done countless hours of epidomoligy research in the field.  It frankly is the only thing I am holding on to to keep my sanity.

But Of course I will take your advice and get tested at 6 and 13 weeks just to be sure.  Also, the 2 sites you sent me to that says the virus becomes in active within 1 minute of being outside the host is very encouraging though.

Dr. Hansfield, do you concur with Willl to get tested at 6 weeks?  Given Willl's new info, do you think there is a 'strong' chance I could have been infected?

[H. Hunter Handsfield, M.D.]

The bottom line is that the risk of HIV transmission via environmental contamination and inadvertant skin injury, at least outside health care settings, is extremely low.  The biological explanation is secondary, it seems to me.

HHH, MD

[Willl]

Though I think it would be pertinent for the average family doctor evaluating a patient's risk level (and whether PEP is appropriate) to understand the most important factor of transmission in the rare case, whether it is time outside the host or potential inoculum to which one was exposed.
I am done.

[Willl]

I forgot to mention one thing. I am afraid that the low estimates of healthcare transmission figured in those who took PEP. Years before the current 3 and 4 drug combinations, I believe many exposed workers at least took AZT (I know Dr. Bob did back in 1991).

[Willl]

I don't think he was saying that the virologist didn't know, just that the risk is so low it is not being currently studied.

The CDC statement I referenced is clear to me, that once blood has dried the virus is inactivated. But the new information contradicts this, that HIV can survive (remains infectious) in dried blood for several hours! I have kind of been suspicious about HIV and time to inactivation, as you see the following CDC documents on PEP never mention a consideration being given to time that an infectious fluid is outside the body to exposure, only the amount of fluid one is exposed to.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm

I don't know why they would state that drying of blood completely inactivates all the virus if this is not true.
Here is an Austrian MD site, where the advice given is very similar to what Dr. H gives on this forum. However, one of their main arguments is that HIV DOES NOT remain infectious more than 1 minute outside the body in small quantities of blood.

http://www.virushotline.at/

But I agree that most of the situations such as you were involved in DO NOT lead to infection, or people would be showing up with it all the time as carpenters, mechanics, anyone using there hands and being injured on the job. The explanation of inoculum size has been given by the virologist and Dr. H.

You can see some of the descriptions in the following regarding healthcare workers that have been exposed:
http://www.hpa.org.uk/infections/topics_az/bbv/pdf/intl_HIV_tables_2005.pdf

This is an extremely educational discussion, great forum!

[Heather34]

So what you are saying is that the Virologist doesn't really know a specific answer because he has not studied it enough, because of the low risk of environmental transmission.

I just went on Aidsmeds.com and the strongest experts there (Andy Velez and Jonathan Kinev) have said that no one has ever gotten infected in a situation like mine described do to the fact that once blood (or other infected fluids) leaves the body, they become uninfectious within less than a minute or 2 and that the only healthcare settings that would require PEP testing would be a needle stick (due to the fact that the blood is not in the environment yet and still inside the needle) and blood from an infected patient getting directly into a mucous membrane or a fresh cut or sore.  When they say directly, they mean within less than a minute (like a blood splash in the eye, sore, cut, etc.) coming directly out of a patient and into a membrane or sore (i.e. a patient's vein getting cut and blood splashing directly into these openings, without time to sit).

Of course it is important to note that they are not MD's, but rather experts in transmission mostly from research and epidemiology studies.  In other words, not how the virus THEORETICALLY could be transmitted, but how it HAS ACTUALLY BEEN SHOWN to be transmitted.

I agree with you willl that the definition you describe seems very difficult to understand and isn't very concrete from the CDC.  However, it would seem that their definition would 'back up' the aidsmeds.com assertions and the CDC has always been more conservative than others for all infections.

What are your thoughts Dr. Hansfield?  Do you concur with aidsmeds.com?  Does your friend the virologist?  Should have I still done PEP?

[HHH,MD]

Here is what I asked Dr. Douglas Richman, an old friend and world-renowned HIV virologist and director of the UC San Diego Center for AIDS Research:  "To what extent can the low rate of transmission from environmental exposure to HIV contaminated secretions, and for some sharps injuries, be attributed simply to low inoculum versus nonviability of the virus? HIV is inactivated by drying. How rapidly? Does it apply equally to HIV in blood or secretions as to "free" HIV? Looked at another way, is there a difference in risk of percutaneous transmission from a contaminated needle or scalpel blade immediately, a minute later, 5 minutes later, or after an hour or a day?  Or is it all exceedingly low simply because of low inoculum size?"

He responded that inoculum size almost certainly is the main explanation, and that HIV can survive for at least a few hours in dried or drying biological materials, like blood.  [Dr. Richman didn't say it, but I would surmise it depends a lot on other environmental conditions, such as temperature and humidity.]  Basically, serum proteins and other components stabilize the virus membrane, and the virus is inactivated by drying much more rapidly when not in biological fluids.  However, he acknowledges that he is unfamiliar with the possibility of more recent research on the topic.  He agrees with me that there hasn't been much incentive to study this issue in recent years; the transmission risk is so low that understanding the biological explanation isn't a high priority.

HHH, MD

[H. Hunter Handsfield, M.D.]

I'm always willing and eager to learn. I'll look into it and get back to you.

HHH, MD

[Willl]

Thanks for getting the information!

Do you feel that the CDC's statement that drying of infected blood inactivating virtually all HIV is a little misleading, as I do?
http://www.cdc.gov/hiv/pubs/facts/transmission.htm

[Willl]

I know this is a question that is dependent on lots of variables (viral load, quantity of blood, temperature change, pH, other bacterial contact) and the studies on HIV outside the body have been done in lab settings. But I have found several places of seemingly competent sources that say HIV does not survive past 1 minute outside the body (oxygen exposure)in small amounts of blood in natural settings. Here is one, I can get a couple of others:
"HIV becomes uninfectious in less than a minute outside the body."

http://www.i-base.info/htb/v6/htb6-8/coinfection.html

Dr. H, I know you have said you are not a virologist, but surely you know someone with all your experience and work with the CDC who could confirm or give an educated guess on HIV infectious time outside the body in a situation such as the original poster has presented.

[H. Hunter Handsfield, M.D.]

A lot has been said on the STD forum about drying of secretions and HIV transmission.  HIV doesn't survive drying, but it isn't clear how rapidly that happens.  The low risk of transmission from most medical sharps injuries and other non-sexual blood contact may have more to do with the dose of virus than with drying.

I don't want to overly frighten Heather34, but if she were a health professional, if the brush were a medical instrument, and if her friend were a patient known to be HIV infected, she would qualify for post-exposure prophylaxis.

(Don't panic, Heather.  You still don't know that you were scraped by exactly the same bristles that your friend was, nor do you know that he was HIV infected.)

HHH, MD

[Willl]

After 5 minutes, blood on brush bristles would have dried (completely eliminating the virus)or else enough of the virus would have been inactivated after this long that an infection would not occur.

[genedog]

hi heather at least get tested for hep c i got the virus 11 years ago from a coworker in a bad industerial accenident,

[H. Hunter Handsfield, M.D.]

Even if he has HIV, the chance you were infected remains very low.  Among health care providers who are stuck with HIV-contaminated sharp instruments, about 1 in 400 gets infected.  Your risk is no higher than that, probably lower.

My advice still applies.  Personal or not, almost certainly your friend will not be offended if you ask in a sensitive, caring manner.  Trust me on this.  If he is infected, he probably knows it and cares about protecting his friends.  And if he isn't, he has thought about HIV and its effect on his life; it's probably an important part of his life.  Most gay men are more than happy to have sensitive, informed conversations with their straight friends.  It might even cement your friendship; it's sort of like the only African American in an office, in whom race never comes up.  And if is offended he is no friend and you're best rid of him.

I'll be interested in the comments of any gay men who read this.

HHH, MD

[Heather34]

I am sure that the brush was not used on the deck in between his slash and mine.  He stopped because of the cut, went to the bathroom and I scratched my self right afterwards (5 minutes).  He said he got a few drops of blood on the brush and told me I shouldn't have used it.  My scratches bled as well.  It took about 15 minutes to stop both of our scratches from bleeding.

1. No risk for HIV?  Can I have sex with my boyfriend?

2. HEPB OR HEPC?

Now I am terrified that I could have gotten something based upon your response.  I really don't want to ask my friend, because I don't want to offend him (i work with him, that is where I met him) and it is a personal question.

[H. Hunter Handsfield, M.D.]

The risk is low, but you don't provide quite enough information for me to be sure.  If the brush was used on the deck after your friend scraped himself, it is difficult to imagine there would be enough residual virus to infect you.  Also, it sounds like your scrape was pretty minor.  But if the brush wasn't used between his injury and yours, and if your scrape was inflected by the same bristles that injured your friend, there might be a small risk of a blood-borne infection like HIV or hepatitis B or C.  Have you mentioned this to your friend?  If he really is a friend, I'm sure he would understand if you told him what happened (if he doesn't know), described your concern, and asked whether he has any of those infections.  If the answer is yes, it might be reasonable for you to be tested in a few weeks.  Even so, I would expect your result to be negative.

Your symptoms don't particularly suggest HIV.  You don't have any fever, if 99.7 is your maximum temperature.  (Everybody's temperature flucuates, up to around 99.5-99.7 degrees.  98.6 is the average, not the maximum normal temperature.)

There is no need for you to worry about your boyfriend at this point.  But talk to your gay friend as a likely reassuring step.

I hope this helps.  Best wishes-- HHH, MD