HIV from Bloody Oral During Acute HBV

[ithinkimstuck]

Hi Doctors,

Thank you for this forum and for your help. I know that the common wisdom is that oral is not a risk for HIV, but I have a situation, which I think may pose an HIV through oral worst case scenario. I got some advice on the Health Forums, for which I'm very grateful, but wanted to ask you about my particular set of circumstances.

I've copied my original question below.

On Friday, May 17th, I received unprotected oral from someone whom I believe to be a higher risk for HIV (African American, CSW from a very rough part of town - not an escort). I mention this without bias. My understanding is that statistically it matters. I understand that the general consensus is that oral carries no risk of HIV but there are a couple items which I think might make things different in my particular case. I'm not implying that my situation is special or unique. I just think I screwed up big time.

1.) Though I did not bleed (I checked for scratches and cuts), I am uncircumcised.
2.) She did bleed some. There were visible streaks of blood on the head of my penis. Not copious amounts, but enough to see without strain.
3.) On Sunday, May 19th, I was diagnosed by an ER doc, and subsequently by a specialist with Acute HBV. Didn't know I had it. I noticed my urine was very dark that Sunday and went in to get checked. I'm right in the middle of hopefully clearing the infection.

I'd like to know, based on these factors and my partner's characteristics, how elevated is my risk of having contracted HIV.

[H. Hunter Handsfield, M.D.]

Yes, your negative HIV test is definitive in relation to the exposure at which you aquired HBV.

That will end this thread.  It's time to move on.

[ithinkimstuck]

Thanks for clearing that up Doctor.

OK, so that I'm clear...

Since I took the HIV oral swab test on a date that is likely 12-18 weeks after the exposure event in which I initially contracted HBV, can I consider the test conclusive for that exposure, conclusively meaning no co-infection?

This is my last question. I'm just rewording one of the previous questions from when I got confused.

[H. Hunter Handsfield, M.D.]

Sorry, I didn't remember the original context and didn't re-read the original question.  To clarify, there are several tests for HBV infection and the "window period" varies depending on the specific tests done.  Most people with new HBV would have a positive antigen test (HBsAg) within 6-8 weeks.  The antibody tests (HBsAb, HBcAb) become positive in the 6-12 week time frame.  It would be quite rare for it to take 5 months for positive test results, but that's the outside time limit when you acquired your HBV infection; more likely it was 6-12 weeks before onset of symptoms.

[ithinkimstuck]

Hi Doctor,

I'm sorry to bother you again... I did contract HBV. I mentioned this in my original question. I was unaware of it, but had already contracted it when the event on May 17th occurred. I was diagnosed on May 19th when I began presenting symptoms and went to the ER.

In your initial response on May 25th, you mention the incubation period for HBV. Did I misunderstand the nature of the comment?

I'm a bit confused now.

[H. Hunter Handsfield, M.D.]

With a negative oral fluids HIV test at 6 weeks, you also can be very confident you did not catch HIV.   Since you were at little or no risk for either HIV or HBV, you can take your current results as definitive.  (The lower the risk, the more reliable the results of negative tests, even if done a little earlier than recommended.)

Your quote about "the usual incubation period of hepatitis B" did not come from me; usually it is a lot less than the figures you state.  The negative 6 week result is highly reliable.

That will end this thread.  There is no need to post any further test results.  You can definitly expect any and all future tests to remain negative.

[ithinkimstuck]

Hi Doctor,

I've been waiting out the window period of my last potential exposure (the oral on May 17th) and plan to get a blood test in the next couple weeks. This time has been very stressful but I've been using it to try to learn to manage my anxieties, and hopefully develop better decision-making skills and impulse control.

As I mention above, I haven't had a blood test yet. In the interim, I have however had an OraQuick In Home HIV Test. This is the oral fluid swab test. I administered it myself at the 6 week mark. I very carefully followed the instructions in the package, waited the 20 minutes for the results, and received a non-reactive. The control line showed up very clearly while the test line did not; not even faintly.

I understand that this result is in no way conclusive for the May 17th event. I've also read that the rapid oral swab tests are less accurate in detecting early infections. I took the test, not for closure, but hoping that it would be non-reactive and give me somewhat of a picture--albeit limited--of my status. Obviously, the result also helped relieve some anxiety that had been building.

I have two questions:

1.) You mention in your first response that "The usual incubation period of hepatitis B is 2-3 months, sometimes as long as 5 months, so it seems likely you had a substantial blood or sexual exposure in that time frame." Based on the shortest possible incubation period from your response (2 months), how accurate would you believe the test I took to be at 14 weeks after a "substantial blood or sexual exposure"?

2. At 6 weeks, is there anything I can glean from the non-reactive result of the test, in regards to the May 17th event? Is there a level of accuracy we can assign at that time frame or was it completely worthless regarding that event?

I apologize for the long post. Doctor, thank you again for your time. I will not consume any more of it until I have had a blood test.

[ithinkimstuck]

Thanks again doctor. I'll return in 4-6 weeks to post my results. Until then, please take care.

[H. Hunter Handsfield, M.D.]

By the way, the CDC's STD/HIV phone hotline is run by contract to the lowest bidder.  The phone rep probably was not actually with CDC, but probably a low-paid, minimally educated person who was following a script.  CDC's hotline is pretty good for some things, but not for more sophisticated medical issues.

[H. Hunter Handsfield, M.D.]

1) Correct.

2) There are no medical conditions known to interfere with HIV antibody test reliability, with the theoretical (but unproved) possibility of advanced life-threatening conditions like overwhelming sepsis, terminal cancer, etc.  There is no known effect from other acute viral infections like hepatitis B.

3) PCR testing can give reassuring results in the time frame you suggest, but you still would need an antibody test after 4 weeks, so PCR doesn't actually reduce the time to a definitive answer.  And it's quite expensive and probably not covered in this situation by most health insurance policies. For these reasons, it's generally reserved for much higher risk situations than yours.  But it's something you could discuss with your doctor.  Peraonally, I certainly wouldn't do it if somehow I were in your shoes.

Thanks for the thanks.  Take care.

[ithinkimstuck]

Thank you doctor for such a detailed response to my question. I'm very grateful for your time and expertise.

You're correct, the specialist that confirmed my HBV diagnosis had me tested for HIV (1/2). The results came back negative.

If you don't mind doctor, I have 3 follow-up questions:

1.) As I read your response, I understand that you're saying, that the fact that I was in the middle of an a Acute HBV infection does not raise the risk of acquiring HIV during the oral episode on May 17th. Is that correct?

2.) Would the fact that my immune system is currently fighting an Acute HBV infection, potentially delay seroconversion for HIV? Does the immune system work in a first-come, first-served basis?

3.) I spoke to the a phone rep from the CDC and they told me that there was a test that I could take for earlier detection. I believe it's PCR-RNA and it's valid starting 9-11 days after the event. Can I take that test? Is it worth it?

This will be my last post for a while. I don't expect to bother you again until 4-6 weeks. I'll come back to post my results. Hopefully negative.

Thanks again doctor.

[H. Hunter Handsfield, M.D.]

Welcome to the foru.  Thanks for your question.

You are correct that an African American sex worker, is statistically more likely than most persons to have HIV.  However, it depends somewhat on geography as well; if you're in Washington DC or any number of other eastern urban areas, the odds would be a lot higher than in, say, Denver, San Francisco, or Phoenix.  And even in the highest risk settings, most such women in fact don't have HIV.

As you already know, and as commented by Teak in the community forum, oral sex has rarely if ever transmitted HIV in the oral to penile direction.  While blood contact during such an exposure in theory might raise the transmission risk, oral lesions that bleed aren't all that rare (dental problems and many other possibilities) -- so there must have been millions or billions of fellatio events with HIV infected partners that also involved blood exposure, but still no clearly documented cases of oral to genital transmission.  So that aspect doesn't significantly elevate your risk.

To my knowledge, there are no data to suggest that acute HBV infections raise the risk of HIV infection if exposed -- and I don't see it as biologically likely.  So your recent diagnosis also doesn't alter my perspective.

Of course the other issue, which you don't address, is the source of your HBV infection.  In itself, that's a major red flag signalling HIV risk -- not because of susceptibility (as just discussed), but all behaviors and exposure events that transmit HBV also are high risk for HIV.  The usual incubation period of hepatitis B is 2-3 months, sometimes as long as 5 months, so it seems likely you had a substantial blood or sexual exposure in that time frame.  On that basis, it wouldn't be all that surprising if you were found to have HIV.

That said, most doctors would automatically test any patient with new HBV infection.  If that was done and negative, you can dismiss it.  As for your recent oral sex exposure, I really don't see a high priority for HIV testing -- but if you would like the additional reassurance of an expected negative result, you can be reliably tested any time more than 4-6 weeks after the exposure, depending on which test (or comination of tests) are done.

I'll be happy to comment further if you would like to post either a current or future HIV test result.  In the meantime, I hope this has been helpful.

Best wishes-- HHH, MD