[Question #803] Repeated Exposure to CSW

64 months ago

Hi Doctor(s),


I am an uncircumcised male age 31, living in Canada. I have (foolishly) had several unprotected (vaginal) encounters with a CSW (ethnic Thai, but based on her stories, she became a CSW in Canada) over the past several months (last one being May 4 2016).


I believed I contracted Molluscum on my shaft, but for a while, I thought it was pimples and continued the unsafe practice with her. I came to my senses around early May, decided to get tested on May 13 (rapid POC antibody), and it was negative. I was relieved for a while (as this indeed ruled out the majority of our encounters except for April 7, April 21, April 26 and May 4; and also the Molluscum, since the Moluscum bumps had been around since last year, I'm currently under freezing treatment), but on Monday May 16, I started feeling what I thought was an ARS symptom.


I would feel hot flashes from time and time, where my face and my neck felt burnt, and started taking my temperatures excessively (it would hover between 98.5 to 99 under my arm). To this day (May 26), I'm still feeling the flashes around my neck and face from time to time, and this causes a great anxiety in me. Sometimes, I would read about ARS on the Internet, and I can feel that the flashes would get worse.


I went to the doctor on May 19 (15 days after latest exposure), got tested for a battery of things and HIV once again. The doctor took oral temperature, and it was 99F, decided it was not a fever.


Just yesterday (May 25) I got back my test results (thyroid, diabetes, etc), and it was normal except for the fact that I was slightly anemic (slightly lower Hemoglobin count, which was concerning me since it is uncommon for a 31 year old male to have anemia).


I also got my blood test for HIV1/2 Ag/Ab Combo Screen (this was done, as mentioned, on May 19, 15 days after the last exposure), it came back non-reactive for both HIV antibody and p24 antigen.


HIV hotline told me that this test meant nothing after only 15 days, and it would only be conclusive after 12 weeks. But I keep hearing from medhelp that 4 weeks after exposure of HIV Ag/Ab Combo would be definitive?


Are these symptoms suggestive of ARS (happening 2-4 weeks after exposures, 99-99.5 body temperature, hot flashes during day and night (but not hot enough to get to 100F), night sweats on May 24, weight loss? I know symptoms are mostly meaningless, but I heard that the absense of 101+ fever would rule this out as ARS?


My questions now are as follows:

1. Given my symptoms, how likely are these to be ARS (mild anemia on a man, hot flashes (99-99.5 F), sweaty palms, one episode of night sweats)?

2. In general, how much exactly am I at risk? I am uncircumcised, I have molluscum bumps (about 6 or 7 of them), and it was unprotected vaginal sex. She repeatedly told me that she is tested regularly, and that she is negative, but I'm not sure how much I can trust her. I asked her repeatedly to show me some documentation, but she refused because it contained her real name/info. This got me very worried as if she's hiding something. I'm still in touch with her to this day (by text messages), sharing my anxiety, but she insisted that she tested negative for HIV and is tested regularly.

3. At 15 days after potential exposure, how likely is it that I would have tested positive if I was infected? 

4. How sure are we with the p-24 Ag/Ab Combo screen at 4 week mark? Can it be possible that the p24 antigen would have receded but serroconversion has not yet happened?

5. What should I do now? I will get tested at June 1, which is day 28 (if I can convince my doctor to administer me the same test; everybody here seems to think that you need the 3 month window to be conclusive, despite the availability of the Ag/Ab combo screening), but should I take the test here to be conclusive?


The past several weeks have been some of the worst period of my life, and my anxiety has been getting the best of me from time to time.


I hope your answers can help me relax, or at least help me put things into perspective as to how much of a risk I have been exposed to.


Thank you very much for your help.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
64 months ago
Welcome to the forum. Thanks for your question.

For future reference, and for other potential users who may read this, you bypassed the intended 1500 character limit (about 300 words), probably by writing your question in another program then pasting it into the question window. At about 4,000 characters, your question is almost triple the usual limit. The normal response is to delete such questions without reply, but I guess you caught me in a good mood!

First, the chance a partner like this has HIV is probably under one chance in a thousand. And when a woman has HIV, the average transmission risk is once for every 2,000 episodes of unprotected vaginal sex. These figures put your chance of infection at under 1 in half a million. Further, people rarely lie when asked directly about HIV status, so your partner's claim she gets tested frequently and is HIV negative probably is valid. (I agree with her that you have no right to ask for written documentation. That's her business.) (That takes care of question 2.)

Second, your HIV hotline advisor doesn't understand the nuances of HIV testing. At 15 days, around 80-90% of newly infected people would have positive Ag/Ab combo test results. Your negative results at 15 days were highly reassuring, even if not conclusive. He also is wrong about waiting 3 months for conclusive results. Despite official advice by some agencies, the Ag/Ab tests indeed are conclusive at 4 weeks. (Question 3 done.)

Third, your symptoms cannot possibly be due to HIV/ARS. You can't have symptoms due to HIV with negative test results. It doesn't happen, or so rarely that it can be ignored. (There's question 1.)

To your other questions:

4) No, it is not possible for HIV antigen to have "receded" but antibody not be present. It is the antibody that clears antigen from the blood; in other words, the Ag component cannot become negative until Ab is present. That's why the combo test is so reliable:  once Ag clears, the Ab test must be positive, and the test then remains positive for life.

5) What to do now? First, relax. There is simply no realistic chance you have HIV. Second, go ahead with your plan for another test at 4 weeks -- not because I think there is any chance it will be positive, but because the negative result probably will be more reassuring than my judgment based on scientific principles, probabilities, etc. But say mellow while you await the test. It will be negative.

As for your symptoms and anemia, it's hard to comment. The tests prove they aren't due to HIV. You don't say the test results, i.e. how anemic you are. In any case, continue to follow your doctor's advice about further evaluation.

Final advice:  I hope you informed your partner of your molluscum contagiosum. If not, do so now; it is your obligation to tell her about any potentially communicable STDs you may have. Statistically, it is likely she has been infected previously and is immune to a new infection. But you don't have the right to take that risk and must inform her.

I hope this has helped. Best wishes--   HHH, MD

64 months ago
Thank you very much, doctor, for your response. It is highly reassuring. I apologizing for going over the limit, as I was typing my first post at work.

I understand that I will have 2 chances for follow up, so I'm going to use this one to make sure that my exposure was repeated (4/7,4/21/4/26 and 5/4 within the past six weeks of May 19) and many more times before that), unprotected, and it was with the same CSW.

Will these facts (ethnic Thai CSW, repeated exposure) change your opinion at all on whether to test after the 4 week mark?

I just double checked my anemia hemoglobin count, it's 133 g/L (normal is defined as 135 to 175 g/L). Is this concerning?

And can you clarify on this:

"You can't have symptoms due to HIV with negative test results."

Even if the negative test results were still within the window period? And would you consider 99-99.5 body temperature an ARS-like fever (I understand that mine is probably not due to HIV, this is just a general question)?

And yes, she is well aware of my molluscum (I told her right after diagnosis), and I probably got them from her anyway (since I have never had unprotected sex with anybody else).

And finally, for now, would you be able to share where you got the 80-90 percent figure for day 15 accuracy?

Thank you very much once again for your help, Dr. Handsfield, and I hope to use the second follow up post to update you on the result (probably in 2 weeks).
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
64 months ago
You're overthinking this.

"Will these facts (ethnic Thai CSW, repeated exposure) change your opinion....?" No. I saw and considered them all in my reply.

99-99.5 is never a fever. Like many people, you misunderstand normal body temperature. 98.6 isn't the top limit of normal, but the human average. Everybody's temperature varies during the day, up to about 99.5. You don't have fever at all, and certainly if you had ARS you would have definite fever (usually 101 or higher).

Symptoms cannot be present without HIV antigen or antibody being present in the blood. If your symptoms were due to HIV, your test would have been positive. You can't interpret "window period" and symptoms separately; they are intimately linked with one another. 

You really aren't anemic. You're at the low end of the normal range. No concern at all. But recheck with your doctor if you remain concerned or have questions about it. (In any case, anemia is not a sign of HIV/ARS.)

80-90% for the test at 15 days is based on the biological principles of the test and the natural course of HIV infection. Antigen-only (or RNA tests) pick up 80-90% of infections by 10-15 days.

Feel free to post your final test result if you like. But I can tell you my response now:  "Congratulations. Of course no surprise at the negative result. You can go forward without worry."

Best wishes in the meantime.
64 months ago

Tested at 27.6 days  (5/4 night to 6/1 morning).


HIV 1/2 Ag/Ab Combo Screen: Non-Reactive
HIV Final Interpretation: No HIV p24 antigen and no HIV1/HIV2 antibodies detected

1. It's 27.6 days instead of 28 days, does it matter? Is it conclusive (given hi-risk repeated exposures with hi-risk CSW, would you suggest retesting)? 
2. Based on the results above, is this the same combo test with 4 wk window? Do I have reason to suspect the reliability of this test compared to the one in US (I am in Toronto)?
3. Why is there contention over the window period for duo test? Not talking about legality, but even some experts (i.e. Dr.Frascino) refused to say that combo test is conclusive after 4 wks. And of course, all here keep saying 13 wks conclusive (though they acknowledge POC test 95% after 5 wks).
4. Online resources mention ARS may happen even 6 wks after. If I have 100+ fever, sore thrt, and rash before 6 wks, would it be concerning that I should get retested?
5. Tested for gon, chla (5/13),  HBV, HCV (6/1), all (-) except for HBV Ab (14.24 mlU/ml). Anything missing? Should I redo HCV later? Syphilis, HSV (will purchase HSV question soon)?
6. I've several more questions, limit won't let me.  Is it acceptable to purchase new  question just for information purposes?

Thank you very much once again for you, Dr.Hook,Terry for the excellent services. I just wish that everybody here can be brought up to date to understand more the nuances of newer HIV testing.
64 months ago
I forgot to ask one question which is nagging my mind (let me know if this should be in follow up, and I'd gladly purchase it).

Should I be worried about HIV-2 infection? I heard that p24 was produced only by HIV1, and that fourth generation Elisa Test won't be able to.pick up HIV2 antigen. Wouldn't that mean that there is a chance HIV2 infection has not yet developed antibodies after 4 weeks?

Thanks, and again, if this should go for follow up, then I'd gladly purchase one.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
64 months ago
1) No difference between 27 and 28 days.
2) The combo tests are the same in all industrialzed countries (and probably world wide).
3) Some experts interpret the available data differently than others, and some choose to follow official advice (e.g. CDC) regardless of the science of testing. There will never be 100% concordance on things like this.
4) I can't imagine any scientifically reliable resources that would say ARS can occur as late as 6 weeks. In any case, test results are far more reliable than symptoms in judging whether someone has HIV or ARS.
5) You don't need any more tests of any kind and shouldn't have had some that were already done. For example, HCV detinitely was no risk:  the only docuemtned sexual transmission scenario for HCV is between MSM who have traumatic (bloody) rectal sexual exposures with one another. The heterosexual partners of people with HCV have no higher risk of infection than anyone else with no risks.
6) You could ask another question if you like, but I would be surprised if there are any "what if" scenarios you can think of that would change the opinions and advice you've already had. Any additional questions almost certainly will generate answers you already have had or can predict.

HIV2 is extraordinarily rare in North America (or Asia, if considering your partner's origin). And in any case, the antibody portion of the combo test detects HISV2.

That concludes this thread. Take care, and do your best to move on without worry.