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Complicated case (amended)
Sep 8, 2006

Dear Dr. Bob

I am a hetero sexual male 33. I am also married but strayed a couple of times in the last 3 months. My last exposure was 7 weeks ago, me giving anal sex to a girl without protection, who said she had been tested and was negative, I am still in touch with her. I was inside her for about 5 mins or more before coming to my senses, withdrawing and washing. She also had her period during that time. I dont know whether any blood had got onto my penis from our encounter. Before this I had sex with a girl (student) when the condom broke, but I carried on unaware. This girl had also tested and was negative on ELISA/qualitative PCR after 12 weeks after our exposure. Anyway the GP I saw straight after my last exposure (48hrs) possibly misinterpreted my exposure risk and offered a basic PEP regime (duovir) and I went on it just to be on the safe side. My baseline ELISA was negative.

Another Dr. (a dermatologist) recommended a PCR RT Quantitative test, 2 weeks after which surprisingly came as positive with 25,000 copies. This is where my nightmare started. I had also given a second sample of blood (4 days after) to the same lab. After receiving the result still in a state of shock, I went to a different lab to have the same test done about 6 days after the first sample was given. Based on the first unconfirmed result, having a high viral count I was also put on ARVs by the same Dr.

The lab that did the initial PCR, (I deduced later) found that the results of the first blood sample and the second sample were not matching and requested me to give a third sample 7 days after the first sample was given. Both of the two subsequent tests were not detectable i.e. negative. The lab, to make sure, also did a rapid immunocomb test and western blot test. It then said the first test was false, and admitted to their mistake but couldn't explain adequately where the mistake had occurred, most likely in the handling of the sample or interpretation. The PCR RT test at the second lab was also negative.

I was pretty distraught and saw an expert in the field of HIV. He recommended a DNA Proviral Qualitative test. I also got this done (3 weeks after the exposure) at the lab that had made the original mistake, this was also negative. I confirmed this with the pathologist there who had taken a personal interest in my case.

This Dr was very encouraged but said that I should continue with the ARVs until 6 weeks post exposure, and stop after ELISA test is negative. This was because he did not want to lose the efficacy of the ARVs just in case I had the virus.

6 weeks after my exposure, my HIV 1,2 p24 test came negative. I also sent a sample for another PCR DNA qualitative test which also was negative, the lab again had run PCR RT, Immucomb rapid and western blot test as backups, as a favour to me, all negative.

I now have stopped ARVs, I still suffer from anxiety, also fear that with no ARVs or PEP, I am now seroconverting, suffering from mouth ulcers and sore throat. I don't have fever or rashes, but do get stiff neck and upper body muscle pains, I have these symptoms for 5 days.

My question is there a chance that I am now seroconverting because I am no longer on PEP or ARVs. Could they have interfered with my 6 weeks extensive test results and other negative tests after the first false positive. Did the lab really make a mistake, or were they right the first time. Logic dictates that they did make a mistake and they admitted it, because how can results be so different just within 4 days. I had been on 2 weeks of PEP at that time, maybe that interfered with the results of the second, third, 4th, 5th 6th PCRs both qualitative and quantitative. Also the Western blot, ELISA and Rapid Immunocomb. Sorry if I sound like the most tested person on the face of this earth.

My GP and the Pathologist, who is quite renowned in her field says I have nothing to worry about. Do you agree.

Your response will be greatly appreciated and thank you for all your good work.

Response from Dr. Frascino

Hello,

There were several errors in judgment in this "complicated case" (which really shouldn't have been complicated at all!).

These errors in judgment include:

1. Your having unprotected sex.

2. The dermatologist recommending a PCR. First off, PCRs aren't recommended for routine screening, due to the possibility of false-positive tests. (I guess you learned this fact firsthand from your experience!) Second, ordering a viral load test while you were on antiretrovirals (PEP) to diagnose a potential HIV infection makes no sense whatsoever. (The antivirals could suppress HIV replication to undetectable levels, thereby giving a "false negative.")

3. Being placed on ARVs because of a spurious test result.

4. Continuing ARVs for six weeks when there was really no reason to do so.

My assessment of your situation is simple:

1. You had an HIV risk, unprotected sex, for which you should have gotten a single HIV-antibody test at the three-month mark to ascertain if you had contracted the virus.

2. Your initial PCR was a false-positive, once again demonstrating why I don't recommend them for routine screening.

3. I do not believe you are seroconverting, but I do believe you are suffering from anxiety, a condition for which I suggest you seek treatment. Because you remain so worried, I would suggest you get a single HIV-antibody test at the three-month mark. The odds remain astronomically in your favor that you did not contract HIV.

Your nightmare has several take-home lessons:

1. Unprotected sex isn't worth the risk.

2. HIV specialists should be consulted, if PEP is started, to assess the risk, optimize the therapy, manage complications and interpret follow-up tests.

3. PCR testing is not recommended for routine HIV screening.

4. Never vote Republican. (OK, I just threw that one in for good measure.)

Good luck. Fortunately for you, your complicated case will have a happy ending when all is said and done.

Dr. Bob



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