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Are there possibilities of disease transmission if I had penile bleeding during unprotected sex with a sex worker having 51 copies of HIV in RNA PCR test?

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The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.

Medically reviewed by

iCliniq medical review team

Published At September 16, 2022
Reviewed AtOctober 11, 2023

Patient's Query

Hello doctor,

I had unprotected sex with a sex worker three weeks before. I had both oral and vaginal sex. During oral sex, she gave me a small cut on the foreskin, which I did not realize. However, it bled heavily from my penis after I finished vaginal sex.

I started antiretroviral medications within two days. I am taking it regularly but not maintaining a specific time. Earlier I was taking it in the morning and now taking it before sleep.

I have got HIV tested for the sex worker, which showed 51 copies of HIV in RNA PCR test antibody and antigen report negative. After two weeks, I did my PCR test which showed the target was not detected.

  1. What is the possibility of transmission to me? As my HIV-1 RNA report is negative. So that means I did not get the virus through the cut?
  2. At 51 copies/ml, can the sex worker still transmit HIV because there was a cut on my penis foreskin and it bled during sex?
  3. The antibody test and antigen reports of the sex worker are negative. So how can she have low HIV copies in the PCR report? If she is recently infected, she should have a lot of copies in her blood, right?
  4. Or was this girl on HIV medication earlier, and due to this, her viral load was low?
  5. I took a liver function test, where my SGOT and SGPT levels were increased. So should I add some medications?

I have attached all the reports. Please inspect them and suggest to me your opinion, doctor.

Hello,

Welcome to icliniq.com.

I read your query and can understand your concern.

Let me know if you were wearing a condom during vaginal sex because HIV (human immunodeficiency virus) transmission is possible if you do not use a condom during vaginal sex. There is no or little risk of HIV transmission through oral sex. Sexual activities that do not involve contact with body fluids (semen, vaginal fluid, or blood) carry no risk of HIV transmission.

  1. The sex worker may have had an HIV infection but a low viral load. But if oral sex was the only way of exposure, it is doubtful that the disease would get transmitted to you.
  2. A 51 copies/ml viral load comes within the range of an undetectable viral load of 40 to 75 copies/ml. This could be caused by ongoing anti-HIV therapy. However, this could also be the result of an old HIV infection. At this viral load considering other tests negative, she may be less likely to transmit to you even if you have been exposed vaginally (without condoms).
  3. Elevated liver enzymes called AST (aspartate transaminase) and ALT (alanine transaminase) are common in HIV-infected patients taking antiretroviral medications and can indicate liver damage. However, it can also be caused by hepatitis B or C transmitted coinfection. Therefore, I suggest you get tested for these diseases as well.
  4. Do not stop the post-exposure prophylaxis medicine before getting these lab reports. However, consult the physician, discuss with them and start taking medications with their consent.

Thank you and take care.

Patient's Query

Hello doctor,

Thank you for the reply.

I want to make my queries clear.

I had oral and vaginal sex without a condom.

  1. I have attached the sex worker's reports of HIV antibodies, western blot, and viral RNA. All are negative except viral RNA. How is it possible?
  2. She was tested for viral load after 12 days of exposure, and I had a cut on my penis. Is there a possibility of infection transmission?

In addition, I have also attached my viral RNA and LFT (liver function test) after starting post-exposure prophylaxis medication.

Kindly help.

Hello,

Welcome back to icliniq.com.

I read your query and can understand your concern.

I have seen the reports (attachments removed to protect the patient's identity).

  1. There would be every likelihood of transmission of HIV infection to you if she was infected. But the chance of transmission is low or negligible since she has a viral load in the undetectable range and if she is already on post-exposure prophylaxis.
  2. Viral load directly measures HIV RNA (ribonucleic acid) levels, whereas other tests are indirect. However, the clinical scenario is more likely to have a positive antibody test but an undetectable HIV-1 RNA level in case of HIV infection. Hence, HIV antibody tests are employed for screening purposes, and positive HIV RNA levels are considered.
  3. Lack of antibody response to HIV-1 is rare due to a defect in HIV-1-specific immunity rather than infection with the attenuated virus. Since she has negative antibody tests and a nearly undetectable HIV-1 RNA level, it is possible that she also does not have HIV infection. It is also likely that she has been constantly on anti-HIV medications.
  4. You did the right thing in starting PEP (post-exposure prophylaxis) within 72 hours. The optimal duration for PEP is around four weeks. It is recommended to periodically screen antibody-antigen and NAT (nucleic acid testing) or if you develop signs and symptoms suggestive of HIV even after completion of PEP.
  5. Both HIV infection and anti-HIV drugs can cause raised liver function parameters. However, your laboratory tests do not currently warrant stoppage or dose reduction unless you have signs and symptoms of jaundice, increased indirect bilirubin, and other LFT (liver function test) parameters, and since the duration of therapy is about four weeks.
  6. However, to rule out the other possible concomitant causes of raised liver function test elevation, I suggest you undertake blood tests for hepatitis B and C.
  7. In general, oral sex is known to have less than a 0.1 % chance of sexual transmission of HIV. The possibility of transmission to you due to oral sex is relatively low, considering the issues mentioned above.

I hope this helps.

Thank you and take care.

Patient's Query

Hello doctor,

Thank you for your reply.

1. I finished the Trioday PEP seven months back but for last week I am having leg muscle pain and joint pain which is not going. Also, I had a fever 2 to 3 times in the last seven days. I have other tests done like COVID, Malaria, and Dengue and all are negative. Does it mean that I am getting early HIV symptoms?

2. I have done the 4th generation test and HIV 1 RNA PCR test after 4.5 weeks of exposure and immediately after finishing PEP, and both are negative. How much am I safe?

3. Can continued joint pain and muscle pain be because of stress also?

Hello,

Welcome back to icliniq.com.

I read your query and can understand your concern.

1. PEP (post-exposure prophylaxis) medicines do cause adverse events. There is a low risk of gastrointestinal adverse effects with Tenofovir plus Lamivudine, such as nausea, abdominal bloating, and vomiting, along with headaches. Low risk of neuropsychiatric effects with Dolutegravir may also exist. The most frequent first adverse events are gastrointestinal disorders (22 %), followed by general symptoms (9 %), hypersensitivity reactions (1.6 %), and CNS (central nervous system) symptoms (1.3 %).

Lopinavir or Ritonavir has greater potential for drug-drug interactions and adverse effects than other medicines such as Raltegravir, Dolutegravir, and Darunavir- Ritonavir with little added efficacy benefit expected.

Hence it depends on which drugs are being administered to you, the adverse events may slightly differ. Muscular pain and joint pains are rare adverse events but do happen.

2. Fourth generation HIV (human immunodeficiency virus) test negativity shows the likely efficacy of PEP therapy. However, it is ideal to check continued viral negativity with a test, after 3 months of the last dose of PEP.

3. Muscle and joint pain may happen due to multiple other causes such as stress and is lesser likely with PEP therapy.

I hope this helps.

Thank you.

Patient's Query

Hello doctor,

Thank you for the reply.

My muscle pain is not going for the last 10 days. In the morning it is less and by evening it becomes more, so I have to take a muscle relaxant to sleep. Is it a symptom of early HIV? I also feel weak to do my daily job along with stress and anxiety. I have done an HIV-1 RNA-PCR test again after 9 days of finishing PEP which again shows negative.

Hello,

Welcome to icliniq.com.

I read your query and can understand your concern.

As stated earlier, it is ideal to check continued viral negativity with a test, after 3 months of the last dose of PEP (post-exposure prophylaxis). It would be preferable to check up with a rheumatologist for joint pain-related issues. The symptoms are quite generic and not related to HIV (human immunodeficiency virus) specifically, also there is negative clinical evidence to deduce the likely possibility of HIV.

At this time, please do not take any muscle relaxants without consulting rheumatologists or orthopedic experts.

I hope this helps.

Thank you.

Same symptoms don't mean you have the same problem. Consult a doctor now!

Dr. Shubadeep Debabrata Sinha
Dr. Shubadeep Debabrata Sinha

Infectious Diseases

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