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RNA Testing
I had a sexual encounter with another male of unknown HIV status about 2 weeks ago involving unprotected oral sex and protected anal sex. My partner ejaculated on my face and some of his semen entered my mouth. At the time of the event, I had two aphthous ulcers; one on my lip and the other on the back of my throat. I am aware that my relative risk of HIV exposure is low and didn't really give it much consideration until yesterday when my cervical and axillary lymph nodes became sore and inflamed.
I have scheduled myself for STD screening this week at the local health department. Fortunately, the facility I am being tested at offers RNA testing for HIV in addition to the standard ELISA and Western Blot. I know that the ELISA would be inconclusive after 2 weeks, but (1) would the sensitivity of the RNA test be high enough after 2 weeks to sufficiently rule out HIV after my "potential" exposure and (2) if the RNA test was negative, would you see any reason to perform further HIV testing (2 - 3 months post exposure).
Thank you for your time...
I have scheduled myself for STD screening this week at the local health department. Fortunately, the facility I am being tested at offers RNA testing for HIV in addition to the standard ELISA and Western Blot. I know that the ELISA would be inconclusive after 2 weeks, but (1) would the sensitivity of the RNA test be high enough after 2 weeks to sufficiently rule out HIV after my "potential" exposure and (2) if the RNA test was negative, would you see any reason to perform further HIV testing (2 - 3 months post exposure).
Thank you for your time...
MEDICAL PROFESSIONAL
First, congratulations on your pursuit of mostly safe sex. Using a condom for the anal exposure was very important. The oral exposure carried little or no risk, with or without getting semen in the mouth.
Actually, I don't recommend RNA testing in this sort of circumstance. The chance of catching HIV, even if your partner was infected, is too low. The mouth is not highly susceptible to HIV. Performing oral sex on an HIV infected partner, the estimated average HIV transmission risk is around 1 in 10,000 -- equivalent to giving oral sex to infected persons once daily for 27 years. Whether or not there is ejaculation in the mouth probably doesn't make much difference one way or the other. And the RNA tests do have a slight chance of false positive results. In other words, if the result were positive, it wouldn't be reliable -- and think what you would experience for the next several days while waiting for confirmatory tests to show you didn't have HIV after all.
That said, probably around 90-95% newly infected people would have positive RNA results by 2 weeks, and your result probably would be negative. This has not been carefully researched, so that's just my estimate. In other words, for 100% certainty you weren't infected, an antibody test would still be required at 6-8 weeks after exposure. (With HIV antibody tests currently in standard use, 3 months is old news; you really don't need to wait that long for reliably negative results, especially for a low risk exposure like this one.)
For these reasons, I suggest you wait for 6-8 weeks and just have an antibody test. In the meantime, don't be worried. You can expect a negative result.
My final advice is that you go all the way with safe sex, not half way. I'm not referring to the oral component -- that was pretty safe. I'm referring to the fact that your partner's HIV status is unknown to you. Please start to routinely discuss HIV status with your partners before having any sex at all, and avoid contact -- or at least be even more compulsive about condoms for anal sex --- for men who are positive, don't know, or seem evasive about it. After all, condoms do fail sometimes, and not infrequently are forgotten in the heat of the moment. In the long run, "do ask, do tell" is just as important a safe sex strategy for gay men as consistent condom use for anal sex. (Perhaps you do this now -- in which case, apology for the lecture. But I take the opportunity to say this every chance I get!)
Regards-- HHH, MD
Actually, I don't recommend RNA testing in this sort of circumstance. The chance of catching HIV, even if your partner was infected, is too low. The mouth is not highly susceptible to HIV. Performing oral sex on an HIV infected partner, the estimated average HIV transmission risk is around 1 in 10,000 -- equivalent to giving oral sex to infected persons once daily for 27 years. Whether or not there is ejaculation in the mouth probably doesn't make much difference one way or the other. And the RNA tests do have a slight chance of false positive results. In other words, if the result were positive, it wouldn't be reliable -- and think what you would experience for the next several days while waiting for confirmatory tests to show you didn't have HIV after all.
That said, probably around 90-95% newly infected people would have positive RNA results by 2 weeks, and your result probably would be negative. This has not been carefully researched, so that's just my estimate. In other words, for 100% certainty you weren't infected, an antibody test would still be required at 6-8 weeks after exposure. (With HIV antibody tests currently in standard use, 3 months is old news; you really don't need to wait that long for reliably negative results, especially for a low risk exposure like this one.)
For these reasons, I suggest you wait for 6-8 weeks and just have an antibody test. In the meantime, don't be worried. You can expect a negative result.
My final advice is that you go all the way with safe sex, not half way. I'm not referring to the oral component -- that was pretty safe. I'm referring to the fact that your partner's HIV status is unknown to you. Please start to routinely discuss HIV status with your partners before having any sex at all, and avoid contact -- or at least be even more compulsive about condoms for anal sex --- for men who are positive, don't know, or seem evasive about it. After all, condoms do fail sometimes, and not infrequently are forgotten in the heat of the moment. In the long run, "do ask, do tell" is just as important a safe sex strategy for gay men as consistent condom use for anal sex. (Perhaps you do this now -- in which case, apology for the lecture. But I take the opportunity to say this every chance I get!)
Regards-- HHH, MD
MEDICAL PROFESSIONAL
To my knowledge this is the first time anyone has commented on this forum on the approach to HIV testing taken by North Carolina's public health clinics. This is a good opportunity for me to comment on it, and then bookmark this thread in case of future questions about it. Thank you for the opportunity -- but it makes for a longer response than you might have expected.
This is called pooled HIV RNA testing. Batches of several patients' specimens (I forget whether it's 10, 20, or some higher number) are mixed and a single RNA test is done on the pooled batch. If negative, everyone in the pool is known to be negative. If positive, the individual specimens are tested to identify the infected person. The idea is to pick up those few people in the window period, when HIV is in the blood but antibody -- detected by standard blood tests -- has not yet developed.
Pooled HIV RNA testing was developed and investigated by superb scientists, close colleagues of Dr. Hook and myself. Pooled testing works efficiently -- i.e. saves money and allows earlier HIV detection in sufficient numbers of persons to make it practical -- only when the prevalence of positive persons in the population is at a certain minimal level. It is impractical and more costly when the percent positive is either too low or too high. NC happens to have just the "right" numbers to make it feasible to do it for all patients tested at public health clinics. At the Seattle-King County STD clinic, we routinely do pooled HIV RNA testing for gay men, but for no other group.
NC's data show that false negative HIV RNA testing is rare. However, some experts continue to worry that RNA testing may miss a few people with early HIV infections. The standard advice is that following significant HIV exposures, people with negative RNA tests during the window period should still have standard HIV antibody testing around 6-8 weeks after the last exposure. This is an area that needs more research. I'm not implying the advice you received is wrong. In any case, with protected anal exposure (and unprotected oral) your particular exposure was sufficiently low risk that from a risk assessment perspective, you really didn't need testing at all. Combining the low risk you were infected plus the negative RNA test, your doctor's advice is definitely valid: you don't need additional testing on account of this exposure.
Thanks for the thanks about the forum and our advice. Take care.
This is called pooled HIV RNA testing. Batches of several patients' specimens (I forget whether it's 10, 20, or some higher number) are mixed and a single RNA test is done on the pooled batch. If negative, everyone in the pool is known to be negative. If positive, the individual specimens are tested to identify the infected person. The idea is to pick up those few people in the window period, when HIV is in the blood but antibody -- detected by standard blood tests -- has not yet developed.
Pooled HIV RNA testing was developed and investigated by superb scientists, close colleagues of Dr. Hook and myself. Pooled testing works efficiently -- i.e. saves money and allows earlier HIV detection in sufficient numbers of persons to make it practical -- only when the prevalence of positive persons in the population is at a certain minimal level. It is impractical and more costly when the percent positive is either too low or too high. NC happens to have just the "right" numbers to make it feasible to do it for all patients tested at public health clinics. At the Seattle-King County STD clinic, we routinely do pooled HIV RNA testing for gay men, but for no other group.
NC's data show that false negative HIV RNA testing is rare. However, some experts continue to worry that RNA testing may miss a few people with early HIV infections. The standard advice is that following significant HIV exposures, people with negative RNA tests during the window period should still have standard HIV antibody testing around 6-8 weeks after the last exposure. This is an area that needs more research. I'm not implying the advice you received is wrong. In any case, with protected anal exposure (and unprotected oral) your particular exposure was sufficiently low risk that from a risk assessment perspective, you really didn't need testing at all. Combining the low risk you were infected plus the negative RNA test, your doctor's advice is definitely valid: you don't need additional testing on account of this exposure.
Thanks for the thanks about the forum and our advice. Take care.
Just to follow-up, all of my STD screens were negative; North Carolina performs RNA testing with every HIV test (it isn't something you request or ask for) and both the ELISA and RNA test results were negative.
In keeping with your advice, I attempted to make an appointment to have a 6 week rapid oral HIV test done for next week, but I was told by the clinician (who was a doctor) that this was unnecessary since my RNA test was negative.
Do you agree?
On a final note, I just wanted to say that my anxiety about this entire experience resulted from a sore throat and lymphadenopathy 2 - 3 weeks after "exposure" (during the dreaded ARS window). I personally feel that all indications have and will continue to point to a negative result. Sooo...I guess its true after all: "symptoms" really aren't reliable indicators of infection. Yes, you've typed this over and over until I'm sure your fingers are raw and bleeding, but I just wanted to take a moment to say: You were right. (Someone had to say it...)
Thanks for your advice and counsel. You are providing a wonderful service...
In keeping with your advice, I attempted to make an appointment to have a 6 week rapid oral HIV test done for next week, but I was told by the clinician (who was a doctor) that this was unnecessary since my RNA test was negative.
Do you agree?
On a final note, I just wanted to say that my anxiety about this entire experience resulted from a sore throat and lymphadenopathy 2 - 3 weeks after "exposure" (during the dreaded ARS window). I personally feel that all indications have and will continue to point to a negative result. Sooo...I guess its true after all: "symptoms" really aren't reliable indicators of infection. Yes, you've typed this over and over until I'm sure your fingers are raw and bleeding, but I just wanted to take a moment to say: You were right. (Someone had to say it...)
Thanks for your advice and counsel. You are providing a wonderful service...
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