Fear of the False Positive

[Concerned__]

Dear Dr.,
I know the topic of fears from extraordinarily low risk HIV exposures has been run into the ground on this and other sites.  I'm certain that most of the extreme anxieties over HIV from receiving unprotected oral is the result of irrational paranoia and/or a guilt response.  Unfortunately I find myself in this situation and the easy answer of getting the "peace of mind" testing is causing me even more stress.

A few days ago a masseuse suprised me by turning the manual stimulation into oral.  It took a several seconds for me to register what was going on and respond to stop it.  I know most say the risk is neglible and according to the CDC link posted earlier by Dr. H, the risk would be about 1 in 20,000 when exposed to an HIV+ person.  The country where this took place has an HIV rate of significantly less than that in the US, but countering her behavior it might be reasonable to assume a full 1% chance of her being positive.  So my effective risk would be about 1 in 2 million.  Perhaps too small for most to worry about but my wife will be nursing for several months to come and I can not accept any possibility that I could ever be the source of harm to my wife and child.  I'm a very poor at managing such worries and have been losing sleep over this possibility.  

So the obvious answer is get tested as soon as possible.  But in reading it seems the NAT tests have high false positive rates and are not recommended for diagnostic testing (still not sure about the reasons for this beyond cost and false positive risk).  I don't want any risk of false positive as I couldn't deal with that (so I suppose rapid response tests are out).  It seems that the most recommended tests is the ELISA confirmed by Western Blot.  But for that I would need to wait about 6 weeks and repeat at 3 and 6 months?   But those also have a 1 in 250K false positive rate (so false positive is 10 times more likely than my actual exposure). Is there anything that is more accurate and available earlier?  Cost is not a particular concern.  What do you recommend for me?  Perhaps a p24 and antibody combo test?  I can't find info about false positives for this test.  Perhaps this duo test at 28 days?

Also, regarding testing locations, I can't go to my primary because of common acquaintances and I'm not sure I would be comfortable in a free clinic environment.  Also, I don't want to patronize organizations that use fear-based marketing for selling testing.  Any suggestions?

[Teak]

No incident HIV infections among MSM who practice exclusively oral sex.
Int Conf AIDS 2004 Jul 11-16; 15:(abstract no. WePpC2072)??Balls JE, Evans JL, Dilley J, Osmond D, Shiboski S, Shiboski C, Klausner J, McFarland W, Greenspan D, Page-Shafer K?University of California, San Francisco, San Francisco, United States

Oral transmission of HIV, reality or fiction? An update
J Campo1, MA Perea1, J del Romero2, J Cano1, V Hernando2, A Bascones1
Oral Diseases (2006) 12, 219–228

AIDS: Volume 16(17) 22 November 2002 pp 2350-2352
Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men

Page-Shafer, Kimberlya,b; Shiboski, Caroline Hb; Osmond, Dennis Hc; Dilley, Jamesd; McFarland, Willie; Shiboski, Steve Cc; Klausner, Jeffrey De; Balls, Joycea; Greenspan, Deborahb; Greenspan
Page-Shafer K, Veugelers PJ, Moss AR, Strathdee S, Kaldor JM, van Griensven GJ. Sexual risk behavior and risk factors for HIV-1 seroconversion in homosexual men participating in the Tricontinental Seroconverter Study, 1982-1994 [published erratum appears in Am J Epidemiol 1997 15 Dec; 146(12):1076]. Am J Epidemiol 1997, 146:531-542.

Studies which show the fallacy of relying on anecdotal evidence as opposed to carefully controlled study insofar as HIV transmission risk is concerned:

Jenicek M. "Clinical Case Reporting" in Evidence-Based Medicine. Oxford: Butterworth–Heinemann; 1999:117
Saltzman SP, Stoddard AM, McCusker J, Moon MW, Mayer KH. Reliability of self-reported sexual behavior risk factors for HIV infection in homosexual men. Public Health Rep. 1987 102(6):692–697.Nov–Dec;

Catania JA, Gibson DR, Chitwood DD, Coates TJ. Methodological problems in AIDS behavioral research: influences on measurement error and participation bias in studies of sexual behavior. Psychol Bull. 1990 Nov;108(3):339–362.

There is no debate (among experts) about the HIV risks associated with oral sex. The risk is so low that almost nobody who cares for HIV infected patients has ever had a patient believed to have been infected that way. Among experts, it's a semantic issue about using terms like "no risk" and "very low risk". There is no difference between my or Dr. Hook's use of "low risk" and other experts' "no risk".
DR. HANSFIELD

"And oral sex is basically safe sex -- completely safe with respect to HIV and although not zero risk for other STDs, the chance of infection is far lower than for unprotected vaginal or anal sex. Please educate yourself about the real risks. If you stick with oral sex and condom-protected vaginal or anal sex, you have no HIV worries and very little worry about other STDs. " DR HANSFIELD

"I am sure you can find lots of people who belive that HIV is transmitted by oral sex, but you will not find scientific data to support this unrealistic concern..." DR HOOK

"HIV is not spread by touching, masturbation, oral sex or condom protected sex."- DR. HOOK

in the public HIV Prevention forum of MedHelp, TEAK and the other moderators maintain that oral sex in all forms is a zero risk activity. Would you agree with this assessment?
I TOTALLY AGREE / DR GARCIA

"The observation on thousands and thousands of observations is that HIV is not spread by oral sex (of any sort)." DR HOOK

[diver58]

As you said yourself, your risk is too small to consider. Whatever numbers you read on the net, one out of 10,000 or 1 out of 20,000, reality on the ground is, no confirmed reported case of HIV transmission through oral sex alone. You and I can not be the first one to change the history of HIV/AIDS spread over 3 decades.

In your situation, testing is not required, however if you think that nothing else can reassure you, other than your own test report, you may go for it. It is too early for an antibody test and in any case it would come negative so you will not be satisfied again. You may go for a PCR RNA which is effective after 4 weeks. Though this is not the recommended way to check your status, I am suggesting only to level your worries down.

However, if you believe in my sincere and honest advice, a test is not at all required in your case.You were never at a risk.

[diver58]

By the time, I was writing your reply, Teak has given you a very comprehensive (as usual from him) reply to your post. Hope now you should be feeling better.

[scratch81]

Good articles teak

[Concerned__]

Thank you for the kind responses.  It really does help to hear this info.  

But if I did want to get the peace of mind test, is there any option that is basically free of any chance of false positive?

[ricky_id]

If the test gets into positive, you'll be referred to a confirmative test called Western Blot. Its result will say whether the previous test result was false or true positive.

But oral sex is no HIV risk, no matter what.

[Concerned__]

Various information sources still indicate that there is a chance of false positive with ELISA and WB.  I would not be able to deal with that at all.  Is there any test or option with no chance of false positive.  If not then what can be done to reduce that chance to an absolute minimum?  Private lab over non-profit? Rapid result vs non-rapids?

Sorry if I've looking for an answer that doesn't exist, but I'm quite sincere in my questions and just trying to put this anxiety behind me.

[ricky_id]

Not with Western Blot.

[NickOne7]

You NEVER had a risk from oral sex, of course there is a chance of a false positive result

Sounds like you are seeking more stress than it is worth

You did not get HIV from oral sex