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Jedi Master

Some interesting questions and answers.
      #5699 - 06/15/00 03:45 AM

Ive gathered this information from

Here there are some interesting questions and answers given.

Three or six months? A follow-up question on the window period.
Answered ny Nicolas Sheon, HIV InSite Prevention Editor
I had received oral sex from a woman and was concerned about hiv. I didn't notice any open sores on my penis or cuts. The other thing I was confused about is the window period for hiv to show up. I had a Elisa test done at 3 months, it was negative. The GMHC (gay mens health crisis) in NYC say 3 months is long enough. But the CDC says no way, 6 months. So the GMHC sent to me a 2 page paper that was sent to the NY state Dept. of health. Itsaid two astounding things. 1) The Elisa test is more sensitive then it used to me and pick up hiv antibodies earlier.
For example, most antibodies show up within 4-6 weeks. And it goes on to say that if a person tests negative at 3 months then no further tests are needed. Anyway, in your web site, you counsel to your clients 3 months. Why is that? You go on to say that 3 months is conservative, why is that? You also acknowledged that other organizations still say 6 months. I'm sorry but I think this is wrong for the public. If a person here and there show up positive after 3 months then I beleive the window should be possibly 5 or 6 months. Again why would your HIV help desk tell people 3 months?? Do you really think that 3 months is anything but conservative. One final question, do you agree with the NYS dept. of health? That at 3 months, virtually all will have detectable antibodies? And why do others not change their policy. Thank You very much for your response.
I am sorry about any inconsistencies in my web postings regarding the length of the window period. The reason for this is that my own understanding of this issue is still evolving as I learn more about the data on this issue. I have revised the web posting for the question several times to reflect my current understanding. If I have to choose between being inconsistent versus being dogmatic, I'd rather be inconsistent.
There are several problems I've had in answering this question to people's satisfaction, including my own.
1. In analyzing the probability of HIV transmission, it is not a good idea to make blanket statements such as everyone should test "x" months after possible exposure. I am guilty of this myself in saying that 3 months is conservative. There are simply too many factors involved and each situation needs to be analyzed on a case-by-case basis. I have since changed my mind about my three month statement, and have changed the text of the answer. More about this below.
Because there are so many factors, if I were speaking to someone face to face about whether they should retest and when, I would ask them a lot of questions about the particular incident that has put them at risk. Based on that, I would recommend a window period. If there was very little risk in the first place, then the chances of the person being infected are very small and the chance of having a long window period on top of that makes this so improbable that I would recommend a three month window period. If there was more risk, then I would recommend a longer window period.
Therefore in your case, from what you describe, being sucked by a woman and you had no sores on your penis, there is simply no risk, so I would not only agree with the GMHC, I would even say you did not need to be tested at all. I would, however, understand if you wanted to test anyway to help ease your anxieties, as long as you realize that there is no clinical basis for testing. If I was your counselor, which I am not, I would also try to see if there was anything about this particular woman that is causing you to worry.
In my experience working with clients, I realize that very little of testing is really about risk of transmission per se. For many people, not necessarily you, the test is a cleansing ritual, a modern form of the confessional in which people seek reassurance, guidance, and a sort of serological "absolution" for their transgressions. I try to explain this to clients who may be exaggerating their risk from a clinical standpoint, but have a lot of anxiety about AIDS nonetheless. I think hotlines focus too much on clinical issues such as transmission and too little on the relational and emotional context of AIDS related anxieties
2. There is important data on the window period that has not yet been published. Since it hasn't been published, I have to rely on the words of experts. I spoke to two researchers, Michael Busch and Glenn Satten about a cohort of 50 health care workers who had occupational infections. They described the results to me and I included these in my latest version of the window period question. This study has a very small sample and it's hard to compare occupational to sexual exposure since the mode of transmission is very different.
These researchers had some pretty scary things to say about the window period for two of the 50 people. While 48 people took an average of 46 days, for two it took longer than six months, They speculate that HIV can "hide" in lymph tissue near the point of entry, so that the infection is sort of latent in rare cases. A needle stick into a finger is very different than sexual exposure along a mucous membrane, so I don't know how relevant this is to exposure through sexual contact. However, they suggest that to be absolutely sure, a health care worker should get tested one year after exposure just to be sure. This information has caused me to think that, depending on the risk involved in a particular situation, the window period may be up to one year. Because longer window periods appear to be so rare, a three month test is very close in accuracy to a six month test. So for most people who have sexual risk, a three month window period is still adequate. The costs and benefits of waiting longer than threee months before testing or retesting at six months have to be weighed on an individual, case-by-case basis.
3. As a counselor who has counseled thousands of clients (in an actual clinic setting, not on the web), I've seen many people agonize over what I think is a very minor or non-existent risk. These clients are dealing with ethical or moral ambivalence over their behavior by projecting their anxieties onto HIV risk. As a result of this projection, I've seen many people develop a dependence on testing that can become compulsive. For example some people are never satisfied with a negative result even after years of testing. Confusion about the length of the window period feeds this anxiety and I hate to think that, in my attempt to help people, I may have added to the confusion myself.
Because there is some uncertainty about the window period, it is best to be cautious and recommend a fairly long window period. This may be why the CDC is holding to its guns at six months. The New York State Department of Health may be advocating three month window periods for reasons other than what is known scientifically about the length of the window period (which isn't much). For example, getting people tested and into services as soon as possible may be preferable than having everyone wait until six months after exposure. In places where there is a large incidence of HIV, it makes sense to promote more frequent testing. In areas with a lower incidences of HIV infection, there may be too little money to promote testing when the likelihood of finding a positive result is so small. So even policy and public health concerns can influence who says what about the length window period.
The need to be cautious about the length of the window period has to be balanced against the knowledge that this will prolong people's uncertainty and cause them to experience a sort of serological "limbo status." I want to be cautious, yet I don't want people to get tested unnecessarily or to add to their anxieties. If you tell someone to test at three months when you know they have little risk and they will probably want to test at six months anyway, then you will have caused someone to test twice without relieving their anxiety until the second test. This may sound paternalistic, but my motivation in telling people this is based on my experience as a counselor and seeing the suffering of people in the window period. These experiences necessarily influence my interpretation of the scarce scientific data on this issue.
Finally, the improvement in ELISA tests occured around 1989.

Why can't you test for HIV using a Complete Blood Count?
Answered by Nicolas Sheon, PhD, HIV InSite Prevention Editor
Question 1
You say that the only test for HIV is to test for antibodies. So many people are asking about other blood tests that they have recently received, and if they could detect an HIV infection. I find it hard to believe that there is no substitute for testing for HIV, when a blood differential and a Complete Blood Count test for all of the versions of white and red blood cells, including T cells. Could you please fill me in on why you insist on getting the HIV antibody test instead of a regular extensive line of blood tests? Please answer as soon as possible, as I am very curious as to why. Very anxious and stressed out, too.
Thank you for your time and anticipated cooperation.
Question 2
I had two EIA tests, one at 6 months after a possible exposure, and another at 2.5 years. I read so much about all these other tests -- P24, DNA PCR, etc. Wouldn't I have had detectable antibodies by the second test? What if I am one of those people that don't develop antibodies -- wouldn't I be showing symptoms if I were? Please clear this up for me. I want to put it behind me and move forward with my life. Thank you for taking the time to answer.
Tests that count white blood cells in blood plasma are not useful for detecting HIV infection because there are many reasons other than HIV/AIDS for people to have abnormal blood cell counts. Some people can have very low CD4 cell counts and not have AIDS. Conversely, there are people with HIV infection who have normal blood cell counts. Therefore, the only way to tell who has HIV is to test to see if their immune system has reacted to HIV by producing specific HIV antibodies. HIV antibodies are usually produced within 1-3 months after infection. The most common antibody test is the ELISA test using blood samples, however there are ELISA tests for oral and urine samples as well. Positive ELISA tests must be confirmed with another type of antibody test, the Western Blot. There are other tests to detect HIV infection, (PCR and P24 antigen), but these tests have a very limited application in diagnosing suspected acute HIV infection in the absence of antibodies in the first weeks after infection. PCR tests are primarily used to measure viral burden in people with confirmed HIV infection, i.e. people who have tested positive for HIV antibody using the ELISA test.

Is a 6 month test necessary in my situation?
Answered by Nicolas Sheon, HIV InSite Prevention Editor
Hi! I am really confused and hope that you can clarify this. I took an Elisa test 3 mos after a possible exposure - non reactive. My doctor gave me a PCR viral load test at 4 mos, also undetectable. She said no more testing was needed. Someone else said that my viral load could be undetectable at 4 months even without medication and that I should take another Elisa at 6 months. I really don't want to take any more tests if not necessary. Is a 6 month test needed in this situation? Thanks for your help.
Whether a six month test is necessary depends primarily on how risky the "possible exposure" was. If you had unprotected, receptive sex with someone who is HIV positive, then you probably should. But since you have tested for antibodies (the ELISA) and for the virus itself (the PCR), I think you have covered your bases.
About 50% of people will test positive with the ELISA after only one month. At three months you can be about 85-90% sure. At six months, about 95-99%. As you can see the difference between three months and six months is very small. So if your risk of exposure was not that great to begin with, another test is, in my opinion, redundant.

Would an ELISA and a PCR test at three months be sufficient?
Answered by Nicolas Sheon, HIV InSite Prevention Editor
I am about to get tested three months after a possible, though I admit unlikely, exposure. My question is, if the standard ELISA test is negative at three months, would a PCR viral load test at the same time eliminate the need for another ELISA at six months?
The ELISA test is still the gold standard for ruling out HIV infection. While the window period makes it nervewracking, other tests are not designed to rule out HIV, and thus may have a higher false positive rate.
According to Dr. Josh Bamberger of the San Francisco PEP Feasibility Study:
A 3rd generation anitbody (ELISA) test should be as sensitive and specific as a viral load test three months after exposure. I would not recommend a viral load test in this setting as it does not improve accuracy and the 5-10% false positive rate is unacceptable.
Since the exposure is already, as you point out, "unlikely," the chances of infection are extremely remote. If we further divide that tiny chance into the tiny chance that you still do not have antibodies three months after infection, we have a number that is very close to zero.
I hope this helps to put it into perspective for you.

I have tested negative at ten months after exposure. How can I be sure I'm really negative?
Answered by Nicolas Sheon, PhD, HIV InSite Prevention Editor
I have tested negative at ten months after exposure. I heard that if someone's immune system is good, it may take longer time to contract HIV. So now I can't be sure whether I am really HIV negative or I am still in seroconversion. I know six months is a gold standard, but there should be some exceptions out there, right? I am really afraid I am part of them. I can't become happy anymore since I had the thought that I may be potentially infected. Please, please help me clear my doubts!!! Do I need more tests? Or can this ten month blood test be definitive?
Thank you for your time and answers very much!!!
These feelings of "I can never be sure" and "I must be the rare one-in-a-million case of seronegative HIV carriers" are unfortunately pretty common. We all have these feelings to some degree. For some people, this certainty that they are HIV positive despite many tests indicating otherwise can become an obsession.
In terms of the clinical picture, you are HIV negative. If you had been infected ten months ago, your immune system would show signs, in the form of antibodies to the virus. Please let me know where you heard that a good immune system means longer time to "contract" HIV. You may be confusing the time it takes to develop antibodies after infection (this is the testing window period of six months) with the time it takes to develop AIDS once you have been infected (this is the natural history of HIV infection which takes on average ten years). If your immune system is in good condition then it will respond more quickly to HIV rather than more slowly. Developing HIV antibodies is part of the initial response to HIV and happens within the first few months. The time it takes to develop AIDS depends on a number of factors including the fitness of the virus and the host's immune system. In terms of the testing window period, remember that the average time for people to develop antibodies is actually one month, not six months, and certainly not ten months. The six month time frame is used to be absolutely certain.
But this clinical certainty about your status doesn't necessarily mean that you are emotionally ready to move on. Whatever happened ten months ago may still be bothering you on both a conscious and subconscious level. It may have reignited earlier experiences that you had long burried. All this testing is merely a distraction from the "real" isues at hand. Clearly the tests have not helped you so far. Therefore, more testing will probably not reassure you. You may benefit from speaking with a therapist who can help you come to terms with the source of these nagging doubts about your "status."

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bad liver

Re: Some interesting questions and answers. new
      #5709 - 06/15/00 10:48 AM

There seems to be a large range of variation in what the test confidence is at the 3 or 6 month points. For instance, we see 3 months as 85%-90% in one quote, and elsewhere we see 99.8%. And some places say 6 months is only 95%-99%. At the bottom end of that range, a 5% chance of the test failing is highly significant!

What going on? Are the people who say 6 months is 99.99% reliable misleading us?

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Jedi Master

Re: Some interesting questions and answers. new
      #5714 - 06/15/00 04:04 PM

Relax buddy. This information I have gathered is very good in some way and it is writing in a proper, familiar way. But yes, im aware of the inconsistence in period. But relax, from all the respected information I have gathered, there are basically two positions: the conservative one, by the CDC and followed by doctor like Gallant and Feinberg: a negative test at 3 months gives you 95% to 99% percent. Gallant believe at least 99%, Feinberg thinks like 95% and suggest to test again if someone is extra worried and to relax completely. The other position in most the rest of the world is that a 6 month will be no more accurate than a 3 month test. So in the most conservative of the cases: 3 months is 95% accurate and 6 months its very close to 100%. But if you are looking for a 100% accurate rate, buddy, you are never going to find it, because in medicine NOTHING IS AND NEVER WILL BE 100%, nevertheless im not telling you in any way to live a miserable life thinking if you could be the 0.000000001% or 1% or 0.00001% or 0.0001% person, because buddy, most likely you would get killed in a car or plain accident or striked by a lightning. There are more actual dangers around us every moment, every day. You certainly dont want to live the rest of your life in a bubble.

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