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Ever retracted a WOO HOO? UK HIV advisor (3 MONTHS VERSUS 6 MONTHS)

May 2, 2009

Doctor Bob,

I have noticed a bit of an anomaly in the window period advice you give different people. The way I read some of your recent answers is that a 12 week test is 'no way, no how' conclusive if you're not aware that your sleeping partner has HIV. But if he/she does have HIV you always write 'the CDC recommends a follow up at 6 months'. So what of those people who write to you unaware of their partner's status and are given a WOO HOO, then maybe find out a day later that they did in fact have HIV? Is the WOO HOO retracted? Is there any reason you would give them the absolute all clear if you thought that there was any way seroconversion could take up to six months? After all, you have advised in the past that we must all assume our partners are HIV postive, yet your responses don't assume this unless you are told by the questioner that their partner has HIV. As British HIV trust telephone advisors, myself and my colleagues continually field calls from worried people asking about the 'American 6 months window period' which they read about on the net, and immediately freak out about. We are trained to reply that 3 months is absolutely conclusive irrespective of whether the partner is confirmed to be HIV positive; provided a recent generation of test was taken. This is backed up by the observation that in over 12 years of the application of the 3 month rule in the UK and Europe, not once has it been shown to have failed. You have been asked about the 3 month rule in the UK before and replied: 'The CDC is a branch of the U.S. Government. Look at who we currently have at the helm. Do I need to say more? No, I thought not.

BRAVO to the UK HIV guidelines folks for their clear and concise statement. I wholeheartedly agree!

Yet your advice of a 6 month follow up does not 'wholeheartedly agree' with how we are trained to advise callers at all!

Ps apart from the occasional 6 month recommedations you give, which I suspect may be for CYA reasons, I think you do an absolutely fantastic job, and I have learned so much from reading your advice.

Response from Dr. Frascino

Hi British HIV Trust Telephone Advisors,

I receive a number of questions on a nearly continual basis asking for an absolute black-and-white answer to this perennially confusing and often anxiety-provoking question. Unfortunately, like many things in the field of medicine (as in life) the truth has a grayish tinge. I certainly do not fault your guidelines or the consistent message you give to your British callers and I stand by previous statements about those guidelines. Just as I will stand by my statements concerning the eight-week cutoff guideline established in parts of Australia. (See below.) Have you received letters from the former penal colony (Oz) asking why you stick to three months while their data suggest eight weeks is definitive?? How are you going to reply to them when they do begin questioning you (if they haven't already)? I suppose you could state "that's what we are taught". Or you might quote a set of British guidelines that states three months is definitive. But that doesn't really answer the question, right?

Returning to your question I should point out your callers are primarily British citizens and you add the qualifying statement that three months is definitive "provided a recent generation of (the) test was taken." Your response is also going to one person and not the entire cyber universe. Approximately 1.5 million folks read my comments every month. Some of them may not have access to the latest generation of HIV tests. Many of them and presumably at least some of your callers may not know if the test they took was a "recent generation." Would a second generation test in Africa qualify?

It's also important to point out the immune system is not a calendar or a stopwatch. It doesn't tell time or count days. Immune integrity and the robustness of a specific immune response vary considerably from person to person for a whole host of reasons. Add to that variability in viral strains and you may begin to understand the black-and-white model is too inflexible to cover all contingencies when dealing with a worldwide audience.

The potential problem with setting a strict timeframe for a definitive result is that you might miss an infection in someone who takes a bit longer to seroconvert due to some type of extenuating circumstance not immediately identifiable in a format such as a question submitted over the Internet. The consequences of missing a true infection can, of course, be catastrophic. The consequences of someone getting an additional (perhaps unwarranted) test at six months are inconvenience and additional cost. The reason I stipulate that the CDC recommends an additional follow-up test at the six-month mark for individuals who have had a significant exposure to someone confirmed to be HIV positive is that it is exactly what their current guidelines recommend. However, for the extremely common worried-well questioner ("grandma farted in her Barcalounger, could I catch AIDS?") certainly a test at three months is more than sufficient. Testing these folks out to six months is a waste of resources. Many of them, of course, don't need any testing but until they see their negative results they are absolute basket cases. Similarly all the folks who have a paper cut and touched a stripper while cheating on their wife or jacked off a closeted gay Republican in an airport restroom on their way to Bible class demand some type of closure that their minimal to nonexistent exposure isn't going to kill them (often their guilt is the real problem). And although my comments may appear at first glance to be contradictory, in essence they are not. I give my personal opinion based on facts established in large epidemiological studies and also include the CDC's current stance on special circumstances where the potential risk is theoretically somewhat higher (confirmed significant exposure). This six-month recommendation also applies to occupational exposures in healthcare settings.

The important thing to remember here is that because the actual amount of virus circulating in the blood is relatively small, we are not measuring it directly but rather indirectly by assaying for anti-HIV antibodies. These are the immune system's response to being invaded by HIV. It's a more complex concept than most questioners (or even HIV counselors) realize. It would be much easier for me to ascertain the true level of risk and validity of a test result if I had the patient in my office where I could ask questions and see exactly what test assay was performed. Unfortunately that is not the case. Consequently I choose my words carefully and attempt to give the wisest answer to an individual that also won't be misinterpreted by the millions of worried eyeballs scanning for information to apply to their own unique situation.

I hope that helps settle the confusion. Maybe not. But that's my story and I'm sticking to it (at last for now).

Take good care mates and keep up the great work across the pond.


Dr. Bob

Swine flu and HIV-infected People
Circumcision at age 37

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