Better never than Late

Posted on May 16, 2012 by drtan

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Hi Forum and welcome to our new blog.

I have decided to take a slightly different approach with this. I will write up interesting HIV/STD cases that I have seen and I think we can all learn from. Names will be withheld and certain details that are non-material to the main points of the case will be changed. This is really to protect the anonymity of the person involved. Otherwise, these stories will be based on actual cases that I have seen and treated.

Let’s get started with our first case which I like to call ‘Better never than Late’

It was a usual busy and hot Tuesday afternoon. There were 10 patients trying to squeeze into my small waiting room that really only has space to seat 5 (7 if you squeeze). Nobody wanted to wait outside and suffer the blistering Singapore heat. So faced with the perennial question ‘squeeze and stay cool or don’t squeeze and sweat buckets’ most people decided to squeeze.

It was then when I was trying to clear my patients as quickly as I could that in walked Mr. X. Mr. X is a 32 year old man from China. He has been working in Singapore for the past 2 years and held a regional high flying job in the Advertising sector. He spends most of his time zipping from city to city.

Mr. X is also a man who has sex with other men (MSM being the technical medical term although various other nomenclature has been used eg homosexual, gay etc). Being a really smart chap, he has figured out a fool proof method, or so he thought, of having safe yet unprotected sex. He would purchase HIV home test kits over the internet and use them on his sexual partners. Once they tested negative for HIV, he would go ahead and have unprotected sex with complete peace of mind.

When Mr. X saw me, he looked extremely pale and worried. 5 days ago, he was in Bangkok for business. He met a nice young Thai gentleman whom he wanted to have sex with. He did his usual routine of testing his partner before sex. He did the test and after 5 minutes, took a quick glance at the strip and was satisfied that it was negative. He then proceeded to have unprotected sex with his new partner. Unfortunately, this was when everything went wrong. After they were done, Mr. X was reaching for the HIV test strip to throw it away when he saw 2 red lines staring back at him. His partner was HIV positive.

Mr. X was understandably extremely worried. He told me how he spent the last 5 days going through every detail of that night over and over again in his head. How long he penetrate his partner? How long did he get penetrated? Were there cuts? Was there blood? Was there ejaculation? Did he have ulcers? Did he brush his teeth before that or after? Was the test accurate? Did he actually see 2 lines? How long did he wait? Was it too long? After 5 sleepless nights he finally relented and was thus sitting before me in my office. He was surfing the web and came across this treatment called PEP. I had to break the news to him that there is no proof that PEP works after 72 hours post exposure. I explained to him that the only option available to him now was to wait and get himself tested for HIV after 1 month. Although obviously disappointed, Mr. X nodded and left.

The next time I saw him was 3 weeks later. He very honestly told me that after our last discussion he saw another doctor who prescribed him the PEP. The first week of the treatment he suffered some nausea and diarrhea but was otherwise well. But for the last few days, he had been having a fever of more than 38°C everyday despite taking Panadols. He was very scared and wanted an anonymous HIV test.

I conducted a rapid HIV test for him using finger prick whole blood on the Determine HIV ½ rapid test strip. The control line was nice and red, unfortunately, there was a faint red line in the patient window. This indicated the presence of HIV antibodies in his blood and a presumptive diagnosis of HIV infection. I explained and results to him and told him that his blood will be sent for confirmation on the Western Blot. I added that the Western Blot might take up to 2 weeks for results and will still remain anonymous.

I received Mr. X’s Western Blot results 2 weeks later. It was ‘Indeterminate’. That is the lab’s way of saying ‘maybe he has HIV but we are not sure. Do the test again.’ By the time Mr. X saw me again it was 3 weeks later and a total of 6 weeks since his exposure. He was very calm but looked very dejected. He told me that he went back to the doctor who prescribed him the PEP after he completed his course of medicines. The doctor conducted a HIV test for him and that test was also reactive. Since the doctor he saw was not mandated to conduct anonymous HIV tests, his results were notified to the Ministry. His employment pass had been terminated and he had 2 weeks to leaveSingapore. I gave him whatever information I could find about seeking HIV treatment in China and wished him all the best

That was the last time I ever saw Mr. X.

Learning points:

1. There is no substitute for safe sex. Even if your partner just had a negative HIV test, he/she could be in the window period.

2. There is no good scientific evidence for PEP to be effective after 72 hours. Even if started within 72 hours, PEP is at best 90% effective.

3. Different countries have different laws when it comes to HIV. Educate yourself on the laws of the country in which you reside.