Citation Nr: 21003141 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 15-44 645 DATE: January 19, 2021 REMANDED Entitlement to service connection for human immunodeficiency virus (HIV) is remanded. REASONS FOR REMAND The Veteran had active duty military service from September 1983 to April 1987 and from October 1987 to December 1993. This matter was previously before the Board in July 2019, when it was reopened and remanded for additional development. The Board finds that the development requested was not completed and that additional development remains to be done before this matter may be properly adjudicated. Entitlement to service connection for HIV In the prior July 2019 Board remand, the Agency of Original Jurisdiction (AOJ) was instructed to obtain records from the Social Security Administration pertaining to the Veteran’s claims and benefits through that agency. The Board notes that the appropriate requests were made, and records were received. However, upon further review, the Board notes that the records received were related to benefits for the Veteran’s son and were likely identified by Social Security because the benefits were payable based on the Veteran’s wage earner status, rather than on his son’s. As such, the Veteran’s Social Security number was associated with those records, but they did not pertain to the Veteran’s disability and were not relevant to the current claim. The Board has removed the records from the claims file as being inappropriate and potentially violating privacy statutes. An attempt to obtain relevant records from Social Security should be made on remand and, if such records no longer exist, the Veteran should be duly notified. The Board notes that a VA examination and opinion were also requested as part of the Board’s previous remand and that an opinion was obtained in January 2020. However, upon review, it is not adequate for adjudicative purposes as it leaves specific concerns unaddressed, including the Veteran’s hearing testimony that he was only engaged in high-risk sexual activity during service. The Board finds that an expert medical opinion from an immunologist is necessary on remand to address specific questions raised by the history provided by the Veteran. The matters are REMANDED for the following action: 1. Submit an additional request to the appropriate federal records custodian for any relevant Social Security records pertaining to the Veteran’s disability and medical history. Instruct the records custodian that records pertaining to the Veteran’s children, even those with the Veteran’s Social Security number as relevant wage earner, should be protected in accordance with federal law and should not be provided in response to this request. In the event that it is determined that relevant records no longer exist, please notify the Veteran in accordance with the requirements of 38 C.F.R. § 3.159(e). 2. Obtain an expert medical opinion from an immunologist with experience treating human immunodeficiency virus regarding the Veteran’s claim of service connection. The expert should review the entirety of the record, with special attention to Veteran’s statements and those of his friends and family regarding his medical and sexual history. During his hearing, he indicated that he engaged in high risk sexual activity only during service. The expert should provide an opinion as to whether it is at least as likely as not (probability 50 percent or greater) that the Veteran’s HIV was contracted in service. In furnishing this opinion, the medical expert must specifically address the following: the dormancy period between exposure to HIV through unprotected sexual contact between males and a positive HIV test result; the likelihood of detecting HIV through a blood test within the first 30 days following unprotected sexual contact with an individual diagnosed with HIV; the sensitivity and accuracy rates of HIV testing used by the U.S. military in 1991 and 1992; and, the significance, if any, of the Veteran’s gastrointestinal symptoms in service and their similarity to his current gastrointestinal manifestations of HIV. The medical expert is instructed to accept the statements of the Veteran and his family and friends regarding his sexual history as accurate unless a clear basis can be stated for finding otherwise. In rendering an opinion, the medical expert is asked to cite to specific relevant evidence in the record and to provide clear citations for any medical treatises or research which informs the opinions rendered. The expert should provide an explanation or rationale for all opinions rendered. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Cheryl E. Handy The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.