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HIV Transmission and Education >> Am I Infected?

Anonymous
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OK. Again, more info on the 3 month window period.
      05/10/00 01:09 PM

Some more info Ive gathered about the window period. From hivinsite.com, the body.com and hopkins-aids. Opinions from various doctors, Judith Feinberg, Mark Holodny and Joel Gallant.
Remember, most countries say 3 months. The CDC its extra cautios saying six months of the small number of people how last longer. But this is a very small number, like 5% or 1%.
Joel Gallant, one of the most respect doctors, say its true that almost everyone will be test positive by 3 months. The 6 months is to be downright sure.
Also, Dr. Gallant says that he dont know why a lot of people will not so high risk insist even of getting tested.
3 months is enough for most risks, and they say 6 months be downright sure and a very worrisome experience.
Also, Dr. Gallant have said that it is valid to make conclusions like, giving for example, a low risk and a 3 month negative test makes probabilities almost zero.
Indeed, other places, most places says 3 months is an accurate as 6 months.
Dr. Gallant also have said that in many cases, people rather say that his/her risk was at 6 months or 5 months and not 2 or 3 months because they find the exposure at 6 or 5 months more "socially accepted" that the real exposure they had at 2 or 3 months.

Enjoy all this reading.

Three or six months? A follow-up question on the window period.
Answered ny Nicolas Sheon, HIV InSite Prevention Editor
Question
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.
Answer
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.


Receiving donated blood -- what is the window period for HIV showing up in the blood?
Answered by Nicolas Sheon, HIV InSite Prevention Editor April 1998, updated Feb. 17, 1999
See also the follow-up to this question
Question
I have several questions regarding HIV. If I am receiving donated blood, what is the risk of getting HIV infected blood since the normal HIV test take 3 months in order to detect any antibodies against HIV. Let´s say a person checks him/herself for antibodies and the results say she is clean, but she had last month a sexual intercourse and got the virus, and then donates blood, how can the hospital be so certain to receive HIV free blood? I would like to know what tests can tell me if I have HIV virus in my body after a couple of days of the intercourse.
Answer
This is a very important question that is difficult to answer because there is very little published research on this topic. It is very difficult to find a large group of people who can pinpoint the moment when they became infected and then test them at least once a week for several months. One study was done using a sample of health care workers who were infected by needlesticks. From this study we can make an estimate about the average time it takes to develop antibodies. Until antibodies are present, the infected person will continue to test negative.
In an unpublished study of 51 health care workers infected through needle sticks the median window period was 46 days and the mean was 65 days. Two of the 51 did not seroconvert for more than six months. According to Dr. Michael Busch, who has published many articles on blood screening, this means that 50% of people infected with HIV will develop antibodies by 46 days. At three months about "85-90%" of patients would develop antibodies, and by six months "over 95%." As you can see, the difference between a test at three months and a test at six months is minimal. For most people who had some risk, but are not certain they were exposed to HIV, a test at three months is enough. To be more certain, you should wait until six months. Do not test at one month, because you will need to retest and this is a waste of resources.
According to CDC guidelines on blood screening, the average length of the window period is less than one month (25 days) (See U.S. Public Health Service Guidelines for Testing and Counseling Bloodand Plasma Donors for Human Immunodeficiency Virus Type 1 Antigen). In the US, blood is screened for antibodies and p24 antigen to HIV. The antigen appears in the infected person's blood about one week before the HIV antibodies appear. Therefore this screening test reduces the window period another six days. So let's say that in the US window period for donated blood is about three weeks.
Even so, the risk of receiving one of these infected donations is very small because of screening for other diseases besides HIV. A significant number of people with HIV infection also have other infections, such as hepatitis or syphillis, and these would be screened out for blood donation even if HIV antibodies were not yet present.
Taking all these factors into consideration, it is estimated that blood transfusion recipients in the US have a 1 in 450,000-660,000 chance of being infected with HIV. See the abstract by Lacritz, et al. below.
I don't know about the situation Mexico which may have different testing and donation policies.
There are no tests that will reliably tell you whether you have been infected within a few days of the infection. The most reliable test is the HIV antibody test. This test is probably available for free from a public health clinic in your area. Other tests that can test for sign of the virus before the antibodies develop are the the viral load (PCR) and the p24 antigen test. These tests can be useful in detecting acute infection within the first month, however these tests have much higher false positive rates than ELISA tests antibody test. The new urine testing system may also have a shorter window period, but this is still being studied. Especially interesting is the finding that some people may be antibody positive in urine samples, but negative in blood samples. More research is necessary before we can know the significance of the urine test.
The most reliable test is still the ELISA used for screening blood donations and at your local testing and counseling site. My advice to a person in the situation you describe: Before you decide to test, it is very important to talk to a test counselor, hotline worker or doctor about your specific level of risk. If you know that you have been exposed to HIV by an infected person's blood within the last few days then you should see a doctor to discuss whether you should start prophylactic treatment (antiviral drugs for 28 days).
If you have any doubts about whether the person who may have exposed you to HIV is at risk themselves then you should try to find out what their risks are. Ask them if they have been tested for HIV and other STD's and how long ago. If possible, you could go get tested together with that person. If both of you are negative, then you don't have to worry about the window period, because the likelihood that you are both in the window period is very small. If it is not possible to test with your parter then you should test at six months after the last exposure.
Here are some published sources for the window period information:
Lackritz EM, Satten GA, Aberle-Grasse J, et al. Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995;333: 1721-5.
Abstract
Background. In the United States, transmission of the human immunodeficiency virus (HIV) by blood transfusion occurs almost exclusively when a recently infected blood donor is infectious but before antibodies to HIV become detectable (during the "window period"). We estimated the risk of HIV transmission caused by transfusion on the basis of the window period associated with the use of current, sensitive enzyme immunosorbent assays and recent data on HIV incidence among blood donors.
Methods. We analyzed demographic and laboratory data on more than 4.1 million blood donations obtained in 1992 and 1993 in 19 regions served by the American National Red Cross, as well as the results of HIV-antibody tests of 4.9 million donations obtained in an additional 23 regions.
Results. We estimated that, in the 19 study regions, 1 donation in every 360,000 (95 percent confidence interval, 210,000 to 1,140,000) was made during the window period. In addition, it is estimated that 1 in 2,600,000 donations was HIV-seropositive but was not identified as such because of an error in the laboratory. We estimated that 15 to 42 percent of window-period donations were discarded because they were seropositive on laboratory tests other than the HIV-antibody test. When these results were extrapolated to include the additional 23 Red Cross service regions, there was a risk of 1 case of HIV transmission for every 450,000 to 660,000 donations of screened blood. If the Red Cross centers are assumed to be representative of all U.S. blood centers, among the 12 million donations collected nationally each year an estimated 18 to 27 infectious donations are available for transfusion.
Conclusions. The estimated risk of transmitting HIV by the transfusion of screened blood is very small and nearly half that estimated previously, primarily because the sensitivity of enzyme immunosorbent assays has been improved.
U.S. Public Health Service Guidelines for Testing and Counseling Blood and Plasma Donors for Human Immunodeficiency Virus Type 1 Antigen
The full text is available at: http://hivinsite.ucsf.edu/prevention/federal_guidelines/2098.2741.html
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
Question
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!!!
Answer:
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."
Take care.
Update on the Window Period
http://nysna.org/protected/npalerts/npalert3.htm


Question:
Hi Dr Holodniy, I'll make this brief . . . My friend has undergone tests every month for the past 3 months and the results were negative. I understand that the average time for the antibodies to form takes about 25days and some may take up to 6months. Question: What is the probability that he may be tested positive from 3 to 6 months period. What is the window period that is considered safe after that. thanks, john

Dr. Holodniy's Response:
95-99% of people seroconvert within 3 months. Probably < 1% seroconvert between 3-6 months. Only a handful have seroconverted after 6 months.


Question:
Dear doctor . which tests are the most important one to do to detect HIV at early stage ..and what is the name of the latest generation of viral load test.Thank you doctor for your response.

Dr. Holodniy's Response:
Depends on what early is. Nothing is 100% reliable within the first 4 weeks of infection. DNA PCR and viral load tests become positive by 4 weeks. Antibody tests within 4-12 weeks.
MH

Question:In your opinion what are the chances of showing positive on the antibody test (ELISA) seven weeks after an exposure? Dr. Holodniy's Response:Probably around 90% if someone is truly infected. MH


Question:
What is the time element between exposure and detection? If you were negative a yr ago and are now positive would your assumption be that exposure was within that year? or could you have missed it because the time was too soon on the first one? 800,000 VL and 66 cd4 are considered full blown aids in your patient you had to give a life span prediction to your patient would you?

Dr. Holodniy's Response:
In probably 95-99% of people, detection of antibodies is within 3 months of exposure. Therefore, a little longer than a year in your scenario.
MH

Question:
thanks for reading this dr. i just would like your expert opinion on my matter. i tested negative three times on the antibody test at 1 month, 10 weeks and just over 12 weeks. the encounter i had was unprotected oral sex with a female. i did have unprotected vaginal sex with her 3 times the last being 1 month prior to the oral sex encounter. so it basically is a 3 month negative after oral sex and 17 weeks after intercourse. my doc said 8 weeks is definitive with the current elisa test. aside from what seems like a case of post nasal drip i have had no symptoms such as fatigue, fever etc...i know what the cdc says, i just want to hear YOUR expert opinion. thanks and god bless.

Dr. Holodniy's Response:
Other than the CDC recs, you don't need any further testing.


Question:I'm male and live in the greater Boston area. I had a possible exposure 11 weeks ago (insertive penile-vaginal intercourse with no condom and also oral). The STD clinic AND the city's hotline asked me how I may have been exposed and said that I should wait six weeks from the exposure date and get tested (ELISA antibody). I did. A few weeks later I go back to get the results - negative. I asked to be tested again (@ 9 weeks). They did so very reluctantly, saying the first test was sufficient. I just got the results of the last test - also negative. After reading some of the Q&A here, it sounds like I should go back next week (12 weeks) and get tested yet again (I don't think they will do another free test for me). What to do? Do you think I'm 99% safe now? I don't want to put a current partner of mine at risk. By the way, she said that she read some book recently (by Stuart Brody?) that quoted some big study that the risk of a man being infected via a one-time encounter was 1 in 8,000. Hard to believe? Thanks a ton for your help on this. Dr. Holodniy's Response:the longer you test the more certain you are.
Question:
Sir Mark! How could you not answer this question? That must have scared many others as it has myself. The large majority of questions in this forum are based on possible infection scenarios. I am quite keen in psychology and have gathered that you truly do know of one or more persons that have reported to you that they have tested throughout six (6) months and established a baseline at beginning, and subsequently thereafter the sixth month, reported infection. The psychology part is indicative that you don't wish to stir thing up more... WITH THE TRUTH. You are a superb doctor and we NEED the truth. Please do tell. Kind Regards, D.S.

Dr. Holodniy's Response:
Dear D.S., other than the anecdotal (unconfirmed, undocumented) cases volunteered by others on this forum, I have not personally seen a case of late seroconversion myself. And my polygraph test would bear that out.
MH

My guess as to why there is little information about window period is that, after thinking about it, it must be a very difficult to find people with a definate exposure date and give them weekly serial tests out to 6 months or one year. Even if they did find 20 or 50 such people (HCW or rape victems, etc) it is still only a handful of people and may not be truly representative of the results of millions of people. The only way to truly do this would be to infect 1000 volunteers with diverse ages and backgrounds and races and test them for one year. So this type of study is out of the question. Do we see a show of hands for volunteers? So, once I thought the 6 month window period as being stupid. After thinking about it this way I'm now thinking that the CDC knows that 99% of people will test positive



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