Could I have Primary HIV?

[greyhairedprof]

Dear Dr,

I am a healthy 40 y/o male. Recently (20 days back) when out of town in Las vegas, I had unprotected oral sex and  vaginal  sex with condoms with 3 escorts on 3 sucessive days. The sessions were prolonged and with 2 of the escorts, the unprotected oral sex last a total of atleast 20-30 mins with breaks inbetween till  I ejaculated in their mouths. All were upper end escorts

  All STD tests done over the last several years including for HSV-1 and HSV-2 have been negative ( not that that might be relevant to my question). Including HIV 1 month back

About 3 days back, almost 18 days since my last encounter, I have developed a high fever (103 deg F) with chills and myalgia and exudates on my Rt. tonsil. Oddly, not much of sore throat. Fever does not come down with either Motrin or tylenol, and only when I combine 50mg of relafen with 500mg of Tylenol, my fever goes down from 103 to 100
I did see my Family Doc 2 days back who is a family friend too (I did not tell him about the sexual encounters). Rapid strep was negative in office. Throat cultures are pending. When he wiped the exudates, it bled, he said that it was unusual for strep throat to do that.
WBC -11k, CRP-2.9, Mild elev liver enzymes

I was started on Avelox 400mg daily ( because of high Zithromax resistance in community and I am allergic to PCN). After 2 days, still it has made no difference in the severity of my fever or chills

Even though I know my risk for HIV is extremely low from unprotected oral sex (0.5 per 10,000 acts as per CDC), I am wondering if this is not an acute primary HIV infection.

Should I get a PCR test for HIV? Because, if positive, atleast I might benefit from Antiretroviral treatment?

What are your thoughts reagrding this? If it was a bacterial infection, should I not be atleast 20% better?

Thanks!

[H. Hunter Handsfield, M.D.]

Thanks for the follow-up; I'm glad to hear the happy outcome, but not surprised, of course.  A bit surprised about mono, though, which is uncommon at age 40.  But the monospot test is reliable, so that settles it.

Take care.  

[greyhairedprof]

Ok, Dr! Statistics win again.

I consulted with an ID who practices exclusively in HIV. He recommended against any testing as he informed me that my risk was Zero(practically). Further more he provided me the following points:

Argument against my clinical picture being primary HIV:

No rash after 3 days
He informed me that HIV usually causes non exudative pharyngitis and not exudative tonsillitis.
No ulcers on mouth or genitals
Fever had resolved by the time I saw him
No Lymphadenopathy.

He informed me that I had Mono mostlikely because:

Elevated liver enzymes
Exudative tonsillitis with Negative Strep culture.

He ordered a Monospot test and it came back positive.

So alls well that ends well. I was relived. Thanks for your input

[greyhairedprof]

Thanks Dr, for the detailed reply. I will try to consult with a ID expert tomorrow or early next week. I will post back with an update. My fever has somewhat gone down since the last post, so maybe the antibiotics have kicked in.

Actually I was not worried about HIV till this brutal episode of ilness that I have. Anyways, thanks, maybe next week with updates.

[H. Hunter Handsfield, M.D.]

Welcome to the forum and thanks for your question.  I'll try to help.

Your analysis of the low risk nature of the exposures is correct.  Not only did you use condoms for the significantly risky parts (vaginal sex), but the overall frequency of HIV is believed to be low in commercial sex workers in most areas of the US, probably lower still in "high end" escorts, and (to my knowledge) thought to be rare in Las Vegas.

Your symptoms are consistent with any number of infections.  Acute HIV is among them, but it remains statistically very unlikely given the exposures.  Most such illnesses are viral, especially when the strep test is negative, so non-response to antibiotics doesn't mean anything one way or the other.  Infectious mononucleosis would be a consideration except for its rarity at your age; mostly it's a disease of children and teens.  Primary oral herpes may be a consideration, but usually is associated with mouth ulcers as well as tonsillitis/pharyngitis, and the timing is a bit late; onset of primary herpes can occur as late as 3 weeks, but usually it's 3-10 days.

Having said all that, I believe it would be reasonable for you to be evaluated for HIV.  It isn't necessarily that early treatment would make a difference (this is controversial), only that in today's world it's simply common sense to be sure.  Given the exposure history, I expect the results to be negative.

It would not be appropriate for me to recommend specific HIV test(s).  They might well include PCR, but a far better approach is for you to tell your doctor about the sexual exposure and your concern for HIV.  Friendship notwithstanding, I'm sure he will treat your information with confidence.  You might start out with a personal conversation to say you're worried about HIV, and ask frankly whether he is comfortable evaluating you and discussing the risks in view of your relationship, or might prefer to refer you to someone else, such as an infectious diseases specialist.  But if you can't get past the friendship issue (which is understandable), then you'll need to find another physician.  I recommend you do so promptly -- not because I'm especially worried about HIV, only to get a prompt answer that will get you past your fears about it.

Try to relax while you work this out; the odds really are strongly in your favor.  Please return with a follow-up comment after you have been professionally evaluated.

Regards--  HHH, MD