[Question #3062] HIV question for Dr Handsfield please.

40 months ago

Hi Dr Handsfield,


Exposure:

I had unprotected insertive vaginal sex twice with a European sex worker in the UK. I’m a circumcised male. 


Risk: 

I know insertive vaginal is classified as low risk but considering she’s a csw and offers this service to all clients I assume she is infected or worse still she was recently infected before our encounter making her highly infectious and therefore a high risk. That would drop the 1 in 1000 chance to 1 in 100 or 200 I assume or possibly even less. 


Tests taken:

14, 21, 28, 35, 42, 49, 63 days post exposure - Alere HIV Combo (antibody/antigen test) (20 min result) - All Negative

38 and 53 days post exposure - HIV DUO Lab test (antibody/antigen) (next day result) - both negative


Also - tested for chlamydia/Gonn/syphillus/hep b/c at 9 weeks - all negative


Here are my questions:


  1. Reading online the cdc have shorterned the window to 45 days for the duo, is this for the lab only test and not the rapid Alere duo? Should this be taken at 45 days for best accuracy, my last lab duo was taken at 53 days. I note the website says most infections will be identified by 45 days, is this a disclaimer for possible missed infections? What does the CDC say about high risk exposure? Do they recommend a test at 3 months? What is conclusive?
  2. the British guidelines say 4 weeks duo will be good for low risk exposure but 8 weeks for a high risk. Being I’m high risk should I take comfort in my lab test at 7.5 weeks or do I need to take this again post 8 weeks? Again BASSH say majority, not all. Why don’t they say conclusive?
  3. Why is there so much confusion on window period. From 4 weeks to 6 weeks to 12 weeks. Which is correct for conclusiveness regardless of risk/exposure?
  4. I plan to test again at 10.5 weeks post exposure and then 12 weeks with the Alere HIV Combo. Is this a good idea and would you say this is required for conclusiveness?

Thankyou all for your advice. 

Edward W. Hook M.D.
Edward W. Hook M.D.
40 months ago

Welcome to the Forum.  As you may know clients on this site are not permitted to request who responds to their questions.  All questions regarding herpes go to Ms. Warren and Dr. Handsfield and I split all other questions.  As it happened, today I happened to pick up your question.  As an FYI, having worked closely for more than 35 years, Dr. Handsfield and I never disagree on the content of our replies although our verbal styles vary.  I will be addressing this question.

I would challenge the assumptions you made in your introductory statements.  In general CSWs are not infected because they take precautions and check regularly for STIs, including HIV, unlike persons whom you might encounter on a "one-night stand: originating in a bar or club.  Irrespective however, your test results unequivocally prove that you did not acquire HIV or the other STIs you tested for from the exposure you describe.  Further testing is a waste of time and money. 


  1. Reading online the cdc have shorterned the window to 45 days for the duo, is this for the lab only test and not the rapid Alere duo? Should this be taken at 45 days for best accuracy, my last lab duo was taken at 53 days. I note the website says most infections will be identified by 45 days, is this a disclaimer for possible missed infections? What does the CDC say about high risk exposure? Do they recommend a test at 3 months? What is conclusive?
The CDC guidance is pertinent for all combination HIV antigen/antibody tests.  Their guidance is always qualified because of their conservative perspective.  With two negative tests taken more than 6 weeks after exposure you can be confident of your results.  They will not change.  The CDC's guidance on test results does not change based on the sort of exposure.  There is no need for further testing, your results are conclusive.

2. the British guidelines say 4 weeks duo will be good for low risk exposure but 8 weeks for a high risk. Being I’m high risk should I take comfort in my lab test at 7.5 weeks or do I need to take this again post 8 weeks? Again BASSH say majority, not all. Why don’t they say conclusive?
BASSH, like the CDC is conservative in its guidance and strange things happen.  In science, because we continually learn new things, no one makes absolute statements.

3. Why is there so much confusion on window period. From 4 weeks to 6 weeks to 12 weeks. Which is correct for conclusiveness regardless of risk/exposure?
There is not confusion on how long it takes for tests to provide definitive results, the recommendations change as new information is gained and as the tests evolve.

4. I plan to test again at 10.5 weeks post exposure and then 12 weeks with the Alere HIV Combo. Is this a good idea and would you say this is required for conclusiveness?
I see no reason for further testing and, although I do not bet, I would be willing to bet a large amount of money that you did not acquire HIV from the exposure you have described.  You can tes as much as you like but I am confident your results are not going to change.

I hope these comments are helpful.  EWH

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40 months ago
Hi Dr Hook. 
Thanks for your reply. 
Just a few follow up questions:
1) I guess what I’m trying to understand is, would I need to test more if the exposure was really high risk? As in let’s say someone had unprotected receptive anal sex with a newly infected hiv+ person, would a post 6 weeks duo still be enough to identify or eliminate infection? Or would they need to test to 12 weeks?

2) I’ve noticed on other forum sites in the past, yourself and Dr Handsfield have often advised that a duo is conclusive post 4 weeks, however now you’re both advising 6 weeks. Is this because of the new cdc recommendations or is it because you have seen a negative duo at 4 weeks change later on?

3) I’m currently just past 10 weeks post exposure. My throat feels a little sore, surely this would be late to seroconvert now? 

4) I’m struggling with HIV fear/anxiety and finding it difficult to believe and move on from my test results.

So in conclusion - in your expert opinion my lab duo at 53 days (7.5 weeks) rules out hiv, regardless of the risk/exposure and even if the csw was HIV+ and highly infectious at the time?
Thankyou. 
Edward W. Hook M.D.
Edward W. Hook M.D.
40 months ago
  Straight to your follow-up questions:
1.  Designated risk categories refer to the likelihood that a member of a specified group is infected with HIV, not the likelihood of infection if exposed.  Men who have sex with other men are, statistically, a higher risk population than heterosexual men.  Most sexually acquired HIV infections arise from the entry of a singe HIV virus, it makes not difference whether you think your exposure was "high risk" or not.  High risk typically refers to the likelihood that a person has HIV but the risk for acquiring infection following exposure is biologically similar whether your partner is "high risk" or not.

2.  Neither Dr. Handsfield nor I have EVER seen a person with a negative combination test at 4 weeks then develop a positive test.  ((% or HIV infections will be detected at 4 weeks following exposure with currently available combination tests.  We have changed our advice to conform to the recent CDC updates.

3.  You are outside of the time when the ARS occurs.  Your sore throat does not reflect seroconversion related to the exposure you have mentioned.

4.  If you cannot deal with your guilt and the resulting anxiety, the way to address this is not with more tests and not by going to the internet but from talking through things face-to-face with a trained counselor. 

So yes, it is my expert opinion that you have now proven that you were not infected at he exposure you have described.  EWH
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40 months ago
Hi,
Final few questions and I guess reassurance:

1) I guess the point I was trying to make and I didn’t make clear was is there any scenario where yourself or Dr Handsfield or the CDC recommend a person to test at 12 weeks? If I knew the csw was hiv+ would that change the algorithm and would the advice change to test at 12 weeks? 

2) In terms of accuracy, in the UK the labs advise the DUO is 99.89% accurate after 28 days. Am I right to assume that by 6 weeks this figure rises to nearer the 100%? I know that no test can ever be 100%. I guess I worry I could be the one the test misses. 

3) I’ve had 2 rapid antibody/antigen tests and 1 lab duo post 6 weeks (45 days). Am I really not infected in your opinion and should I try my best to move on?

4)  I guess my fear is not being diligent enough in testing and potentially infecting others in the future.  You say I don’t need any further testing. Can I ask at what point during the tests I’ve had would you have advised I am conclusively negative? 

5) My last test was at 9 weeks with Alere hiv Combo. I’m currently at 10.5 weeks. Should I just test at 12 weeks for certainty? Would the Alere hiv Combo be sufficient enough at 12 weeks or would it need to be a lab duo?

6) Just to confirm I understand  - based on current CDC guidelines - and yours and Dr Handsfields expert knowledge. If a person has a negative hiv duo post 6 weeks (mine was 7.5 weeks), then they can forget about hiv? And this is regardless of risk/exposure. Eg. Exposure could be receptive anal with hiv+ person. Is my understanding correct?

Thanks and apologies if there’s repetition in questions. 
Edward W. Hook M.D.
Edward W. Hook M.D.
40 months ago
Your follow questions are repetitive.  Asking the same question, whether or not you use different words is not going to change my answer.  My assessment is that you did not get infected with HIV from the encounter you described.  You have proven this with repetitive testing.  There is no need for further testing.  this in answer to your final follow-up questions:
1.  This question is illogical.  I said your results were conclusive.  There is no need to repeat results which are conclusive.
2.  Correct.  For complex mathematical reason, repetitive testing further increases the assurance that these results are correct. 
3.  Correct, see earlier responses.
4.  Repetitive, see earlier answers.  After 4 weeks results are 99% conclusive and after 6 weeks (42 days) they are conclusive.
5.  I see no need for further testing at all.  I cannot prevent you from further testing but there is no need for this.  You might as well take the money which you would spend on further testing and light it on fire.
6.  Repetitive and correct.

This completes the three response we can provide to questions as per Forum Guidelines.  I feel that I should warn you that should you post repetitive, anxiety driven questions, the questions may be deleted without comment and without refund of your fees.  EWH
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39 months ago
Hi Dr Hook. 

I know I’ve asked my questions and I understand that anxiety is getting the better of me. Me and my partner want to try for a baby and I just need to be sure I’m in the clear before that. 

Last question please just for my peace of mind. The lab Duos that I did - One was at 5.5 weeks and the other at 7.5 weeks. Should these have been done at 4 and 6 weeks for maximum accuracy and antigen detection? Could it be that at the times I took them the antigen would be too low to detect and the antibodies not formed? 

Thankyou for your responses. 
Edward W. Hook M.D.
Edward W. Hook M.D.
39 months ago
Final answer.  Beyond the recommended time for testing, the results would not be expected to change.  Thus your 5.5 weeks are just as reliable as results at 4 weeks (or perhaps more so) and, similarly, your results at 7.5 weeks are conclusive.   Believe the results.  This ends this thread.  EWH
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