Contradictory Information about HIV testing

[nervouspartner]

Dear Dr.

My partner had an encounter with another man in June, and last month tested + for syphilis after developing an anal fissure (otherwise, no symptoms). A Stat-Pack rapid HIV test at 16 weeks after exposure was Negative for us both.  Other STI tests: mine all  came back negative. Besides his syphilis, he tested positive for HSV 1.  We both also are dealing with recent outbreaks of HPV (we've had this before so it's hard to attribute it to his June exposure). In the last month, my partner got three rounds of penicillin shots. I was given one round of penicillin shots just in case.

1. We did stat-pack antibody test 16 weeks, and now 20 weeks after exposure.  Different HIV counselors say the results are conclusive given it's over the 3 month window. Yet, infectious disease doctor insists on 6 months.  This contradiction is brutal for our anxiety. In your professional opinion, can we celebrate at this point that we don't have HIV and can we move on with our lives and try to rebuild our relationship? Or is there any reason to still think there may be chance for a positive result?  

2. Would syphilis somehow delay someone's positive result beyond the 3 month window?

3.  As related specifically to the syphilis, now post-penicillin shots, what's the protocol to make sure the treatment has worked?  The infectious disease doctor says to get tested in six months. The primary care physician says it should be sooner to know if treatment has been effective.  Again, the contradiction is driving us crazy.  How much do we have to wait after the penicillin shot to know we are in the clear with respect to the syphilis?

4. Is there any way to know if the HSV-diagnosis is connected to this most recent exposure, or can it be something my partner has had for years?  He's never had any symptoms.

Thanks for your time Dr. I know it's valuable, so I hoped to get as much information in my question and avoid too much back and forth.

[Edward W Hook, MD]

My first step would be to contact the dermatologist and ask hin/her if this is herpes zoster (i.e. shingles, the chicken pos virus) or some other sort of herpes virus.  If they say shingles (herpes zoster) I would not test further or worry.  

Herpes cultures can be done on intact skin.  A biospy would not be done and unless this is shingles, should have been done.

Swolen glands are typical of any local inflammation.  

It is not conceivable that you got HSV through kissing and it spread to your forehead.

I continue to recommend against a blood test.

These are all questions that your doctor should have already answered.

EWH

[nervouspartner]

Thank you Dr.

My dermatologist didn't specify what kind of herpes it was. The sore is already darkened and hard so I'm assuming a culture isn't possible.

If I were to get a blood test for HSV-1 and 2 and it came back negative, would I then be able to conclude that what I had was shingles and not HSV-1?  If so, can I get tested right away or wait?  

Lastly, are swollen glands (mainly on my face by my ear/sideburn) typical of shingles and/or HSV?

Would it be conceivable that HSV was transmitted through kissing and resulted in herpes in my forehead instead of labial?

Thanks a million for your help doctor. This will be my last question and I can't thank you enough for your help and for this site. The last few months have been a lot to bear for me. Here's to a healthy and happy 2014.

[Edward W Hook, MD]

No, that is my answer.  What your doctor has said does not make sense to me.  A biopsy is not needed to diagnose herpes, it is diagnosed with a PCR or culture test.  EWH

[nervouspartner]

Dr.

I think the last part of your message got cut off.

[Edward W Hook, MD]

Sorry for the delay.  In transit.  Briefly, I have no explanation for the diagnosis of herpes on your forehead.  Are you sure that he is not thinking herpes zoster (a recurrence of the chicken pox virus)?  Her did not need to do a biopsy, he could have done a PCR or culture.  This just does add up.  It him
No you need another opinion.  EWH

[nervouspartner]

Not sure if you've read my questions from yesterday....??? I know you're busy, but just wanted t make sure I wasn't lost....

[nervouspartner]

Dear Dr:
A new development since out recent convo, in which I mentioned that in our battery of tests my partner had tested positive for HSV-1 while I tested negative. That was in late October.  Yet today, I visited my dermatologist for a burning rash on my forehead which he believes is herpes and opted to treat as such (he didn't want to biopsy my forehead). I began a 7 day round of Valtrex and Doryx today. I now also have some jaw discomfort and pain (parotid glands?) I am baffled that I would have herpes after testing negative not so long ago. I don't know if my partner has recently gotten it, or whether he's had it for years (no big outbreaks that he remembers...just little mouth ulcers every so often). Nonetheless, we've been together 10 years, and until now I hadn't had anything. The only intimate contact we've had is kissing, but i haven't developed any cold sores ... only the rash on my forehead.  So my questions are:
1. Is there any explanation for herpes on my head and not my mouth? Is kissing the culprit? I didn't have any cuts in my forehead, so how did the virus get there?
2. If this is herpes, would another blood test reveal this at this point, or would I need to wait?
3. Given the sores on my forehead and my parotid discomfort (under my chin and by my ears), might this be anything else - another issue i can bring to the attention of my primary care doc?

Thanks, and I appreciate your thoughts on this.

[Edward W Hook, MD]

Thaks again for this clarifcation.  In that case, the earliest I would test would be a 3 months (12 weeks) after the first injection of penicillin.  If it has changed  great.  If not, I would then wait until six months to repeat the blood test.  EWH

[nervouspartner]

Just to be clear, It's been 20 weeks since the exposure. But it has only been a month since the syphilis diagnosis and a little over a week since his final penicillin shot.  When would it be appropriate to test to see if the treatment has worked?

[Edward W Hook, MD]

1.  I see no need for further HIV testing. the 20 week result, like the 16 week result before it is definitive.

2.  The VDRL and RPR are not interchangeable.  Both are good tests and your partner can be followed by either- it is his doctor's preference.


As far as the response to therapy, these tests are rather strongly positive and thus I anticipate they will decrease (perhaps not to zero) following therapy.  Since it has been 20 weeks since the diagnosis of syphilis, I think it would be fine to test nor.  If the test had decreased 4-fold (i.e. the VDRL is now 1:32 or the RPR is now 1:8) this would represent a good response to therapy.  EWH

[nervouspartner]

Dear Dr. Hook,

Thanks for your comments. They are very much appreciated.  

1. So, given that my partner again tested negative today for HIV (20 week period), you deem no other test is necessary?

2. As far as the syphilis, he had two tests done within days of each other in mid October, and both BEFORE any penicillin shots. The VDRL test was 1:128 and the RPR test was 1:64.  So which one should we go on?  and should he wait 6 months before getting retested (like infectious disease doc says), or should he get tested sooner (like primary care doc says)?  I guess my question is more about how to tell treatment has been successful and can have peace of mind that the syphilis is behind us.  My partner was given the three rounds of penicillin because the Dr. could not determine the stage of his disease. Apart from the anal fissure which had his doc suggest a syphilis test, he had no obvious symptoms (no penis sore, no rash on hands, etc)

[Edward W Hook, MD]

Welcome to our Forum.  I'll be pleased to comment.  In the U.S. today syphilis and HIV are closely linked and persons who acquire syphilis represent a group who are greatly increased risk for HIV.  From what you tell me however, your partner was fortunate and although he acquired syphilis, he did not acquire HIV.  I think his doctor is being overly conservative in suggesting that a 6 month antibody test is needed.  Results of his HIV antibody test at 16 weeks provide conclusive evidence that he did not get HIV.  

In answer to your specific questions:
1.  I agree with the counselors, the 16 week results are definitive.

2.  There are no data to suggest that the presence of syphilis delays development of antibodies to HIV.

3.  Blood tests tend to change slowly following syphilis treatment, presuming your partner's initial blood test was positive.  How positive was it?  The higher the blood test the more rapidly the tests improve but the standard times for testing depend on how long the infection was present.  In 20% of patients the tests do not change even though treatment has been successful.  I will comment further once I know the numerical value of your partner's syphilis test result.

4.  It is more likely than not that your partner has had his HSV for a long time although on occasion the two infections can be acquired at the same time.

I hope these comments are helpful. EWH