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WHO guidelines/ WBC count/ OI's
#213855 - 11/05/06 03:24 PM
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Questions:
1. Does anyone know what is WHO window period guidelines?
2. Do WBC count drop during primary infections - say like 10 days - 2 weeks post infection. By WBC count drop, does it mean total leucocyte count or only lymphocytes count. This I am asking because manyplaces white blood cells are referred to as Total leucocytes count. TLC includes, lymphocytes, neutrophils, monocytes and couple more.
3. How soon can OI's like thrush realistically start after infection. Some say it happens in late stages whereas other says it can happen pretty early in the infection as well. And, how does thrush really feel. Is it white vcoated tongue with irritation in throat as if something is stuck or is it somewhat different...
Thanks....
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Let's cut to the chase. You're worried about your status. OK. Only one answer. Test.
Symptoms or lack thereof don't mean a thing when you are trying to figure out if you are or are not infected.
Just get the test. Until then. Sorry, but you will just have to sweat it out. That's a good thing. Gives you time to figure out what behavior got you here in the first place, and what you plan to do about it.
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Let's cut to the chase. You're worried about your status. OK. Only one answer. Test.
[Reply] Completely agree
Symptoms or lack thereof don't mean a thing when you are trying to figure out if you are or are not infected.
[Reply] Completely agree
Just get the test. Until then. Sorry, but you will just have to sweat it out. That's a good thing. Gives you time to figure out what behavior got you here in the first place, and what you plan to do about it.
[Reply] How long to keep on testing after 3 months. With whatever, you have stated above as your answer completely defeats the purpose of my question. Here is my reasoning:
i. I really wante to know what is the window period set by WHO as i didn't get any write up on that.
ii. When person is infected initially, the lymphocytes & monocytes count may drop down. Due to this fact, PCR's may not be able to detect the infection as they look for virus in lymphocytes and monocytes. So, in a way I just wanted to cross check if this new information I found from Dr. Hodginly's reply is agreed upon or not about PCR's looking for infection in lymphocytes.
14 days post my exposure my lymphocytes were low but my neutrophils were way high and this caused by TLC to be very high so I just wanted to know if someone has been through some similar situation. As some information about WBC, TLC, lymphocytes and neutrophils would have been good if someone was willing to share.
iii. OI's - I asked about OI's because yes, I happen to be a worried well and well past most commonly stated window period for testing but still have something wrong going on.
iv. Please - I am asking relevant questions and do not reply back asking me to get mental healthcare help...
Note: Please show some patience rather than throwing ever ready answers like get tested and go for mental help. Anyone can say that...Let's discuss constructively..
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Window period from WHO states that normally the time between infection and positive ELISA is 14-21 days. They also state that some have taken longer than six months albeit about 10 years ago. There's your window period. Once again left vague because of all the variables such as patient testimony, outdated tests in the early and mid nineties, etc.
I personally would not worry about your lymphocyte count unless you have less than 10 copies per milliliter which is so close to impossible I really wouldn't consider it. even if you are a worried well. The only thing that would cause a false negative DNA PCR would be lab technician error, performed with home brewed assays without all primers or if you tested during the eclipse phase where the virus replicates in neigboring lymph nodes before spilling out into the blood stream. The eclipse phase lasts no longer than 3-4 weeks and on average is ~10 days. If you tested with the DNA PCR before 4 weeks, then I would not consider that definitive, the sensitivity is anywhere from 30% to 90% during that time. This very well could be the low lymphocyte count during ARS which you mentioned coupled with the problem of the eclipse period.
As far as OI's, I'm sure you realize that on average it takes more than a few years to suffer from them. ---unless you can not produce antibodies and consequently would have you in the hospital right now a few days from death.
If you are worried about tests not picking up your infection with PCR's and antibody tests after the window period due to recombinant strains and new subtypes than you really do need to seek the assistance of a mental health therapist.
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So, from what you are saying, will it be wise to conclude that any DNA PCR done post 1 month, should be definitive and would have taken care of the eclipse period ( which for wat you have mentioned and if I understand clearly do not extend beyond 1 month post infection date).
Does antibody production gets delayed when the lymphocyte count has gone down. See, the catch here is that lymphocyte count can go down in presence of other bacterial STD's which cause neutrophils to rise. Also, when the virus is replicating in neighboring lymph nodes (eclipse period), am I correct to assume that no antibody formation will take place till the time virus gets spilled into the blood stream.
It seems that for DNA PCR to work perfectly, the CBC should be in good shape otherwise the results can be flawed. However, I reallyhope that statement is incorrect and please correct me if I am wrong.
So, in order to conclusively shorten the window period, will it be OK to have a HIV A/B test couple with DNA PCR at 6 weeks assuming it would well take care fo the eclipse period.
Also, I have seen some very good information imparte by you on this website. Is it ok for me to ask you what was your risk and how long did you test for it.
Thanks for a good knowledgable answer......Trust me...it is appericiated
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If the DNA PCR is conducted by an experienced laboratory --not clinical post one month, it is definitive, conclusive, etc and the eclipse period is not a factor. Antibody production WILL NOT be delayed due to low lymphocyte count. The best way to assure you would be that the majority of individuals who actually get infected with HIV are co-infected with other bacterial and viral infections, such as herpes, chlamydia, etc. and they will still test positive within ~six weeks.
Antibody formation begins as soon as the individual is infected. Once the virus invades neigboring lymph nodes, cells immediately begin to produce proteins or antibodies and after the eclipse period, both spill into the blood stream.
Theorhetically what you propose could happen but doesn't or at least hasn't been documented. The DNA PCR IS the most sensitive NAT there is, and if performed at the right time (>one month), by the right commercial kit and experienced laboratory should absolutely detect the virus.
Most experts would agree with your statement about shortening the window period with the testing outline you described. Some won't. It is hard to back away from the most conservative guidelines when dealing with HIV.
As for my risk, none. I am a microbiology dork attending medical school. I also serve as a mental health therapist in the ARMY.
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That means the proteins and antibodies spill into the the blood stream after the eclipse period. If this would really be the case then how could DUO(4th gen ELISA - P24 + 3rd gen Antibody test) could be considered conclusive at 28 days. The eclipse period will also defer detection of P24 antigen in the blood stream (say in case the virus is replicating in neighboring lymph nodes). With that possibility both DNA PCR and P24 antigen really can not be taken for sure as early markers of an infection. Performance wise, they would be able to detect the infection almost at the same time when the 2 tests are compared to each other with none of them holding edge over the other.
This brings another interesting topic upfront. Is the short window period especially set for people who are involved in receptive anal sex because that would be the only way where the virus directly enters the blood stream enabling early detection & readily available antibodies in blood. That can possibly mean that detection timeline may differ(delayed) for straight men where the eclipse period may come more in picture as a result of virus invading the lymph nodes in groin.
Also, I wanted to confirm another thing about WBC and lymphocytes. After talking to some of my doctors, they told me that in case of HIV infection the WBC(total leuocyte count) should go down and not high. It may involve lymphopenia. But, lymphopenia can be induced as a result of any bacterial infection as the infection causes neutrophilia. So, I feel that in case of primary HIV infection WBC(which is also referred to total leucocytes count) goes down and not up where both neutrophils as well as lymphocytes go down.
I would like to add that this discussion be considered as a healhy discussion whereby I am not trying to prove anyone wrong but just trying to clarify some misunderstanding/misconception I ( as well as other people) might be having towards how a human body responds to the most dreaded infection. I understand I may be wrong in my assumptions but please give me the beneffit of doubt for at least trying to logically reason the logistics of HIV and its detection upon entering human body. I am not an arguer and just looking for facts which are difficult to find.
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I was never under the impression that a 4 week duo could be considered conclusive, especially when the sensitivity of the P24 antigen is only 80%. The eclipse period differs for everybody. Some inidividuals will test positive as short as 72 hours with NAT assays. It's the variable immune response of individuals, aggressiveness of strain, etc.
/With that possibility both DNA PCR and P24 antigen really can not be taken for sure as early markers of an infection/
Exactly right, they can help prove infection, but not rule it out. Only an antibody test at three months can do that.
/Is the short window period especially set for people who are involved in receptive anal sex because that would be the only way where the virus directly enters the blood stream enabling early detection & readily available antibodies in blood/
No. An infection is an infection. Surely if inoculation takes place directly in the blood stream, one can conclude an antibody response will be quicker, but not perfectly so. All this really does niot matter, as three months is more than ample time to for the infection to take place and the immune system to respond.
If you have an HIV antibody test at 3 months post exposure, then whatever is causing your symptoms is not HIV. If for some reason, you feel you can't produce antibodies to the virus, then get a DNA PCR at six weeks and 4 months. If you feel that you have a recombinant strain or a new type, then get a T cell subset completed. If you feel that the virus is "hiding" in your system than you need mental help.
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So, with the above discussion, and upon reading millions of responses (some by experts and others by freelancers), can we conclude that window period does not necessarily have to be 12-13 weeks (it can be shorter and also bigger) and can exceed even in people not known to be having any immuno compromising ailment, cancer or chemotherapy. There are a lot of lose ends about HIV and the answers regarding window period are veriable.
However, it is difficult to comprehend that experts on medhelp do term 8 weeks testing as solid and some stupid forum users also misinforming people that 4-6 weeks is good enough. Also, certain countries in Europe have 8 weeks window period. With the variability in individual immune system response to HIV infection, can 8 weeks (or say 6 weeks as a matter of fact in massachusettes) be considered conclusive. Wouldn't you be advising policy makers for those countries and states to get mental help or is mental help only warranted for people wanting to test beyond 3 months(Pls don't hate me for writng this previous comment - meant for a laugh).
Also, as far as PCR goes, I am going to agree that it does not rule out the infection. At the same time, I also know many experts calling a 4th gen test at 28 days or 6 week conclusive. I personally feel that a DNA PCR has more sensitivity as compared to P24 antigen test so rather than a 6 week 4th gen test, it will be good to have a 6 week antibody and DNA PCR test and rest easy. An illustration - want to see if you believe it....
-----------------------------------------
Question:
Hello,
I just want to ask how reliable is a HIV PCR test taken 6 weeks after possible exposure? So, how big is the chance for false positive result (I guess quite big, because of this it is not widely used) and how big is chance for false negative?
Many thanks for short and accurate answer.
Answer provided by:
Marty Markowitz, M. D.
Clinical Director
Staff Investigator, Aaron Diamond AIDS Research Center
Associate Professor, Rockefeller University
PCR tests at 6 weeks...
The use of PCR alone for diagnostics beyond the acute infection timepoint is not recommended nor approved by the FDA.
However the use of antibody and antigen testing (PCR) can be useful...
A negative Ab(antibody) test and a negative PCR at 6 weeks is conclusively NEG.
A positve Ab test and a positive RNA PCR at 6 weeks is conclusively POS.
A neg Ab test and a high positive RNA is diagnostic of acute infection...however, this is usually within weeks of infection...not 6 weeks post infection.
False postive RNA PCR results do occur (less than 1%) ...as a rule the amount of RNA reported in these is less than 2000 copies/ml.
If an antibody test is negative...the HIV RNA should be very high...if the RNA is low and this is a true positive the Ab test should be positive (this is a "maturing infection")
Finally, the false negative rate is VERY low...however some infected people are not viremic...but they always have a positive serology.
------------------------------------------
Do you think it will be ok to assume that performance of DNA PCR and RNA PCR will be the same(or almost same) at 6 weeks post exposure. I understand that RNA PCR hold early advantage but at 6 week to 8 weeks, their performance would almost be comparable.
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The facts are the facts, and people interpret them differently.
Fact: With today's 3rd generation ELISA antibody test, at least 97% test positive at six weeks post exposure-some will say it's higher.
That's considered conclusive for many individuals with certain risks.
At three months, greater than 99% will test positive after an exposure. That' s pretty conclusive for the VAST majority of exposures.
At six months, greater than 99% will test positive and so on and so on.
There will always be exceptions to every rule in medicine.
The window period is extended for conclusiveness in certain situations. NO one can tell you that there is no chance you are infected with something.--Would you if you were in their place. Sure, it's easy to say "unlikely" or "essentially," but it's a lot tougher to say "absolute certainty" or "NO WAY." No one would like that coming back to bite them. There will always be "loose ends" when dealing with something carrying the stigma of HIV.
As far as DNA PCR, if you are infected with HIV, the assay will pick it up >99 percent of the time at one month post exposure. I have also seen studies giving this test 100% sensitivity when taking it at 2 months.( a lot better than a P24). It's impressive when a group of researchers and scientist's give a test of any kind 100% sensitivity and have the balls to publish it.
When it comes down to it, you will have to come to the ultimate conclusion to if you are truly infected or not. You have all the information in front of you, and hopefully you will make that decision sooner than later.
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mpo131
To an extent, I am getting a feeling that you are also agreeing that infection can be detected earlier in receptive gay sex
as compared to hetero - vaginal sex. I understand what you are aying about the eclipse period but I would really want to know
if any research has been done with respect to the eclipse period and how long it can continue for(max). Because,
with whatever we have discussed in this thread above it realy seems the window period may very well be dependent on
the eclipse period keeping aside other immunological disorders. Keepig the receptive anal sex(gay sex) in mind, GMHC
may be right in calling 3 months test conclusive because the main criteria for that organization is to focus on gay folks.
But, due to the fact that this is not only a gay disease and is also spread through vaginal sex, window period may differ.
So, with the discussion above, this is what stands out:
Window period can be shorter in case of - blood transfusion
- needle stick injuries
- receptive anal sex
(This is ue to the fact that this way virus gets dect access to the blood stream which gets rid of the eclipse period)
and a little longer in case the sex act involves penis and vagina as virus can replicate in neighboring lymph nodes before
spilling to the regular blood stream for detection.
You might be wanting to call me a freak but let me know if you think these assumptions may hold good amount of truth.
You being a med student, I hope you can help clarify this and thanks for bringing forward some interesting facts.
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mpo131
To an extent, I am getting a feeling that you are also agreeing that infection can be detected earlier in receptive gay sex
as compared to hetero - vaginal sex. I understand what you are aying about the eclipse period but I would really want to know
if any research has been done with respect to the eclipse period and how long it can continue for(max). Because,
with whatever we have discussed in this thread above it realy seems the window period may very well be dependent on
the eclipse period keeping aside other immunological disorders. Keepig the receptive anal sex(gay sex) in mind, GMHC
may be right in calling 3 months test conclusive because the main criteria for that organization is to focus on gay folks.
But, due to the fact that this is not only a gay disease and is also spread through vaginal sex, window period may differ.
So, with the discussion above, this is what stands out:
Window period can be shorter in case of - blood transfusion
- needle stick injuries
- receptive anal sex
(This is due to the fact that this way virus gets direct access to the blood stream which gets rid of the eclipse period)
and a little longer in case the sex act involves penis and vagina as virus can replicate in neighboring lymph nodes before
spilling to the regular blood stream for detection.
You might be wanting to call me a freak but let me know if you think these assumptions may hold good amount of truth.
You being a med student, I hope you can help clarify this and thanks for bringing forward some interesting facts
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I disagree with your conclusion about shorter window periods for anal sex. If anything, the window period should be longer due to the increased chance of infection having occurred.
An old study, and you can find it on the web, illustrated the length of the window period and if a person is actually infectious to others during it. Keep in mind that study was done over 10 years ago. It concluded the length of the eclipse period was 22 days and that antibody detection averaged around 40 days. This hasn't been reproduced to my knowledge. Recent studies conclude the length of the eclipse period is ~11 days. You can conclude that the eclipse period is a important factor when considering the window period. Theorhetically the eclipse period could go on for months, but this has not been documented and most experts will tell you that a month is ample time to be sure the eclipse period has elapsed.
Anal sex does not always result in the virus being exposed directly to the blood stream. Mucous membranes, which are present in both the vagina and anus, have extensive layers of dendritic cells that envelop the virus and lead to infection. (more so in the anus and I believe the cervix).
The window period takes into consideration the chance infection occurred. If the chances are high, then a provider would suggest testing longer, not shorter.
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