Help for my client
Jun 29, 2011
Hi Dr. Bob, I am a consultant and have a client who worries that a sexual interaction with a suspect individual last summer left her HIV positive. She has taken three HIV tests, one after the 3 month window from time of exposure, one after six months, and one after nine months. All tests were negative. Since sometime after her sexual contact, however, she started experiencing a variety of unexplained physical symptoms, including continued oral thrush and a bad taste in her mouth, and a January illness that included low-grade fever, joint and muscle pain and weakness, and stabbing pain near her genital region. Following blood work, her doctor diagnosed her with Herpes, but she does not accept the diagnosis--partly because she had no external genital wounds during her illness--and more so, because she believes still that she had HIV. She has asked me to contact you to ask: 1) What is your opinion regarding her symptoms? 2) Why do you believe some clinicians still recommend testing for HIV after one year from exposure, though no one--including the CDC, with whom I spoke--has seemingly documented a case of HIV that tested negative after six months yet manifested later? 3) Can someone have HIV without subconversion/antibodies forming after nine months from exposure? 4) Are the three, six, and nine month windows indeed measured from time of sexual contact/exposure, or sometime after, such as when she first experienced symptoms? 5) Could the continued thrush just be from stress? and, 6) Should she take another test now--at the 12 months time?
I have already found these answers for her, and she has been to a more than a dozen doctors, nurse practitioners, expert consultants, and a dentist, but she trusts your opinion and also is reticent to accept she is being hypochondriacal. (I am convinced she is not malingering or Munchhausen's, however--I am a former psychotherapist--because she is receiving little in secondary gains and truly, truly wants to be HIV negative; she lives daily in deep-seated depression because she believes she is dying. She also believes that if she has HIV, she will get AIDS pretty much immediately and die soon, despite all medical advancements in treating HIV and AIDS). She does, however, have a history of OCD, which has reportedly included past symptoms of fears of death, of contracting HIV, and of her daughter dying unless she performed certain rituals). It is clear to me that she is performing rituals now (hours spent checking Internet blogs and chat rooms, ruminating about her symptoms, and visiting and speaking to doctors and HIV specialists, to quell the anxiety of her obsession (that she has HIV, despite negative results after the nine-month window). I told her I would ask you her questions, and I will let her know I have included some background. She has refused urgings from me of going to a licensed psychotherapist or another consultant. She also will not take a prescribed antidepressant from one of her doctors but has started St. John's Wort about six weeks ago. This seems to be helping with her depression but not anxiety and ruminations.
So, after all this rambling--and I know that you cannot diagnosis over the Internet--I am wondering if you may answer her questions, and also render an opinion regarding what may be going on overall, and where you think she may go from here? Apologies that this is so long, but your input is greatly appreciated. Thank you.
Response from Dr. Frascino
1. Your client's symptoms are not consistent with or worrisome for HIV acute retroviral syndrome (ARS) or HIV disease.
2. There are a number of different testing guidelines still floating around. Some haven't been updated in many years and may have originally been based on early generations (versions) of the testing assays, which are not as sensitive and specific as today's third- and fourth-generation tests. Some doctors (and clinics) may be so concerned about possibly missing a true HIV-positive test that they err on the very conservative side regarding the duration of the "window period" (period between HIV infection and the development of detectable levels of specific anti-IV antibodies).
4. From the date of contact/exposure.
5. Unlikely. She may also not have clinically relevant oral thrush.
6. No. HIV is not her problem. No way. No how. No addition HIV testing is medically warranted.
You have listed a number of psychiatric/psychological conditions for your client: "OCD, deep seated depression, anxiety, ritualistic behaviors, etc." Her negative HIV tests out to nine months are definitive and conclusive. It is clear that she has psychiatric illness that most likely would benefit form appropriate evaluation and management.
HIV paranoia is not uncommon. We have a chapter in the archives of this forum entitled "I'm Positive I'm Positive." It's filled with testimonials very much like that of your client. Refusing to believe overwhelming and irrefutable evidence (and the advice of a dozen doctors/ healthcare professionals) demonstrates the depth of her psychopathology. Irrational obsession with HIV (or any disease) can be a sign of depression, obsessive-compulsive disorder or hypochondria.
I would suggest you continue to be very direct with her, advising that she needs to see a psychiatrist and that her fears are completely irrational and totally unwarranted. Discourage further testing, doctor shopping and visits to Dr. Google. Encourage her to review the "I'm Positive I'm Positive" chapter in the archives, and point out that none of those individuals turned out to be HIV-positive.
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