[Question #2258] Female seeking clarification on testing

46 months ago
Hi Doctors! A sincere gratitude for offering this service to the general public...Especially with your credentials and expertise in the field. 

MY EXPOSURE: I am a female who had one time isolated risk. It was unprotected vaginal sex with a male who is known to be promiscuous. I tested at the 35 day mark w/4th Gen test: non-reactive. 
Currently, I am over 7 months removed from my exposure and haven't really worried about HIV infection until a recent symptom I've been dealing with. 

Reading both of your older responses (both Dr. Handsfield and Dr. Hook) you were certain that the 28 day result w/ 4th gen was 100% conclusive. It was definitive and further tests were not warranted. 
1. Can you share why your window period has changed for this specific test when it was once a slam dunk at the 28 day mark?  
2. My blood was tested 5 weeks post exposure @ LabCorp (4th Gen w/ Reflexes). Would you advise further testing for this situation? 
3. Currently, I have had a swollen lymph node in my neck (right side) for nearly 4 weeks now. Doctor has me on antibiotics.  I am currently 7 months out from the exposure. Are people with HIV prone to get swollen lymph nodes in the asymptomatic/ chronic stage? If I was 7 months out and positive without HIV medications, would this be a common symptom/sign of HIV? Does it fit the timeline? 
4. My doctor wants to rule out lymphoma. How soon can lymphoma cancer generally develop in HIV positive people? Is it usually seen down the road or can it happen within the first year of infection?
Again, thank you for taking the time to help and assist the general public. Ive read many threads and I respect both of your tolerance to still answer in a unique, personal manner even if the questions you receive are redundant. :) 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Greetings and welcome to the forum. Thanks for your confidence in our services.

Since you've apparently spent some time on the forum, you probably have seen some of our comments on the relative rarity of HIV in most hetersexual men and women in industrialized countries. Both the media in general and even many health education websites often give the impression HIV is rampant in almost all sexually active groups. In fact, the chance your partner had HIV, even though "known to be promiscuous, probably is in the ballpark of 1 in a thousand. You may also have seen estimates of the transmission risk for vaginal sex, male to female, averages roughly once for ever 1,000 exposures. So even before being tested, the odds you caught HIV from that single exposure were roughtly 1 in a million (1/1000 x 1/1000 = 1/1,000,000). If we now add a test result that is, say, 99% reliable, the odds you have HIV now are 1 chance in 100 million. I trust you'll agree that's extremely low!

To your specific questions:

1) Our advice is never set in stone, always subject to change as new data become available. A recently published analysis by CDC estimated 6 weeks rather than 4 weeks for the 4th generation tests to be conclusive. However, the vast majority of newly infected people have positive results by 4 weeks. On this forum, I often now use such comments as "Generally conclusive at 4 weeks and always by 6 weeks."

2) Your result at 5 weeks was very nearly conclusve; note my guesstimate above of 99%. (That doesn't mean there is a 1% chance you have HIV; see the odds calculation above.)

3) An HIV infection would rarely cause a single inflamed lymph node, almost always abnormal multiple nodes body-wide. And as you imply yourself, 6-7 months after exposure is too long -- onset generally 10-20 days after infection.

4) I suppose it is possible for HIV related lymphoma to appear within a year, but it certainly would be rare.

So I am very confident you don't have HIV, and that your lymph node enlargement has nothing to do with HIV or with your sexual exposure a few months ago. But given your concerns, it would be reasonable for you to have another HIV test. I suggest it entirely for reassurance, not any real suspicion you have it.

Finally, I would suggest a blood test for syphilis if not yet done. It is almost as unlikely as HIV, but it's a conceivable cause of lymph node enlargement.

I hope these comments are helpful, but let me know if anything isn't clear. Best wishes for a speedy diagnosis and nothing serious!

HHH, MD

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46 months ago
Dr. H., Thank you for such a quick and specific response to my questions.  

Re: CDC analysis at which they now consider 6 weeks conclusive for 4th gen test. Is it fair to say that CDC guidelines are always conservative? Looking at your older posts, 4 weeks used to be the only test needed. You even stated it was an urban myth that someone needs additional testing beyond the 28 day mark. 
I'm just more curious as to what has changed. Was there a documented case of an individual that took longer than 4 weeks on a DUO to test positive? 
Have you ever seen or heard of a case where someone testing negative @ 4 weeks and turned out to be positive a few weeks later? 

In past threads, you mentioned  that CDC is outdated and slow to make changes regarding testing window periods.  
Are you able to address why your stance has changed from ALWAYS conclusive at 4 weeks to GENERALLY conclusively 4 weeks?  

Last, in regard to my swollen lymph node. I knew I was past ARS timeline by several months. At this point, I was wondering if swollen lymph node could be a symptom for someone who has HIV  for several months, but hasn't been on treatment. 

Thanks again for addressing my concerns.  Have a great evening 
Best, 
Concerned Female
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
The publication I'm referring to is a review of the performance of available HIV tests by CDC investigators, but it does not constitute CDC policy or guidelines. They simply collated the available research into a single article. It's important to understand that actual research on time to positive results on HIV tests is difficult, in part because few people with new HIV infections know exactly when they were infected, and not many of those are tested repeatedly as would be ideal for such research (e.g. weekly for 3 months or more). So window period estimates are just that, estimates -- based on a combination of actual research plus understanding of the human biological responses to HIV. I'm not aware of any particular individuals tested at 4 weeks, negative, and later found to in fact have HIV. Personally, I have never had nor even heard of any patient in whom it took more than 4 weeks for the 4th generation test to turn positive.

New lymph node enlargement probably could occur beyond the ARS period, but in the first year of HIV infection. However, as I said above, HIV would rarely cause only one enlarged lymph node.

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46 months ago
Dr. H., Thank you for the follow up response. You have been extremely helpful. 
After getting the information about my 5 week test result being 99% accurate and the astronomical odds of me aquiring HIV, I think I'm content with putting this behind me and moving forward. 
I appreciate your insight and your help to put things in perspective for me. 
Best, 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Thanks for the thanks. I'm glad to have helped. Best wishes for a happy outcome of your lymph node workup.

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