[Question #4578] Question about seroconversion and test window

28 months ago

Dear Doctors,I your forum extensively before writing and in doing so learned so much about HIV prevention and testing. Thank you very much for that. Because of that, I probably already know the answers you will give me but this worry is getting the best of me.

After an episode of insertive vaginal / oral intercourse as the male party, I followed your advice and got tested with ab/ag tests at the 4 and 6 weeks. Both negative. Just for peace of mind, I took another ab/ag test at 15 weeks - negative. Thanks to you,I know my 6 week negative test was actually enough and whatever symptoms i experienced prior to the 15 week test were not caused by HIV because in presence of symptoms, these tests always give positive results.

Recently, around 21 weeks after the encounter, I started developing flu like symptoms. I have a dry cough, and painful swollen lymph glands which first started on one side of my neck. Pain got a bit better in 3 days but then it started on the other side, around a week after the first one. The pain is maybe around 1.5 - 2 inches below my jaw. The doctor told me I had no visible trace of an infection, except for a very minor case of what looked like pharyngitis, but sill ordered some blood tests. A complete blood count and another test to see if there was any infection caused by bacteria, all came back clean. For the last 10 days, the back of my tongue hurts although there is nothing to see. I also had a painful white spot inside my mouth at the back of my lower lip - in about 3 days it took the shape of an acne-except it was white and started hurting much less. It was gone in 7-8 days.

I get sick every year - at least 3-4 times, but because this time the pattern is different, the unreasonable me is back in control, linking everything to a regretted sexual decision. Is it possible to have acute HIV symptoms 21 weeks after exposure? Is there any way I could have HIV 1 or 2? Should I get a different kind of test?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
28 months ago
Welcome to the forum. Thanks for your confidence in our services, and for researching your question before asking it. That always makes our job easier.

It seems you have learned a lot by reading other threads, and have predicted my main reply: you don't have HIV and it's time to stop worrying, However, you may have missed four overriding themes in all our replies and in the basic facts about HIV testing. I'm going to use this opportunity for a blog-like reply that I can use for future similar questions. Sorry if it's wordier than you were expecting.

1) First, the current tests -- especially the antigen-antibody (AgAb, Duo, 4th generation) and the current standalone antibody tests (3rd generation) are just about the most accurate diagnostic tests ever developed, for any medical condition.

2) Second, all symptoms of HIV or acute retroviral syndrome (ARS, i.e. acute HIV infection) are nonspecific:  that's the medical term for symptoms that go along with many conditions but do not point to any particular cause. That includes all the symptoms you describe.

3) The third point is derived from the first two. The results of HIV testing always overrule everything else in determining whether someone has HIV, such as symptoms and exposure history. No matter how typical the symptoms, or how high the risk of HIV at the time of exposure, a negative AgAb test 6 or more weeks after exposure is unequivocal proof that the person does not have HIV. There are no exceptionsThere are no other medical conditions or drugs that have any effect on this, especially for the AgAb tests, despite claims you can find online about things like immune suppressing drugs and medical condtions. (The only exception is when someone take anti-HIV drugs for post-exposure prophylaxis, or PEP. In that case, the time to reliable testing, in case PEP doesn't work, can be delayed, perhaps to 3 or even 6 months.)

4) The fourth point is that the symptoms of ARS are caused by the body's immune response to the virus, not by HIV itself. Detectable antibody in the blood is the main easily tested measure of that immune response. Therefore, if symptoms are caused by HIV, and if more than a week has passed since onset of the first symptom, antibody must be present. Therefore a negative blood test proves that HIV is not the cause of the symptoms. Period, full stop, no exceptions. Therefore, in some rare cases, a negative blood test might prove someone's symptoms are not from HIV, but still not prove s/he isn't infected. For example, assume you have sore throat and maybe enlarged lymph nodes 10 days after a high risk exposure and have an antibody test (or AgAb test) at 3 weeks. If that result is negative, it proves the symptoms are caused by something other than HIV. But it still might be necessary to be retested at 6 weeks to rule out a new HIV infection, unrelated to the symptoms.

And so back to the bottom line:  It is certain you do not have HIV. There are no other tests that could change that conclusion. Assuming you are not exposed and infected someday in the future, any and all symptoms you have now or at any time in the future are not possibly due to HIV. Do not waste any more money, time, or emotional energy on it. Of course continue to work with your doctor if your symptoms continue.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD



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27 months ago
Thank you very much for your detailed and informative answer Dr. Handsfield.
I now have intermittent pain around my neck, armpits and groin area, for 2.5 weeks now, which makes me think if they point to a body-wide case of swollen lymph nodes, but i think i should look for the reason elsewhere.

I have a few morewl questions if you dont mind, mostly born out of personal curiosity rather than the encounter that made me come to this forum:

1- does the way hiv is transmitted have any effect on the time seroconversion takes place? ie. If a person is infected through transfusion, would they be expected to seroconvert faster, because a higher concentration of the virus is directly introduced to the blood stream?

2-when both sexual partners are infected with the same type/subtype, could they 'reinfect' each other?  And what would be the case if they were infected with different subtypes.

3- because we know ab/ag tests pick up virtually 100% of all infections, would it be accurate to assume that acute hiv infection symptoms always present themselves before the 6 week mark? If not, is it possible to develop acute infection symptoms 20+ weeks post exposure?

4- antibody production is the body's response to the virus, so are the symptoms. Are the symptoms caused by the antibodies? In other words, if someone had delayed antibody production for whatever reason, could they still have symptoms in the absence of antobodies?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
27 months ago
"Intermittent pain around my neck": HIV doesn't do this, and your tests prove you don't have it.

1. The mechanism of exposure or dose of virus has little if any effect on time to positive test results. If any effect, e.g. a very large dose by transfusion, it might make a difference of only a day or two.

2. It isn't completely understood whether people infected with the same HIV strain are at risk for reinfection from partners with the same type. Probably not -- and if it happens, probably it usually is harmless. However, because we don't know for sure, it is best if such couples both be treated with anti-HIV drugs; or if for some reason that isn't possible, that they have only safe sex. Probably no harm if this doesn't always work out, but better safe than sorry.

3. ARS never occurs as late as 20+ weeks, as far as is known. Almost always symptoms start within 2 weeks of exposure.

4. The detailed origins of symptoms are complex. Antibody indicates the immune system is responding to the virus, and that immune response is the cause of the symptoms. But antibody itself probably doesn't cause symptoms. It would be very unusual for an infected person to have symptoms without detectable antibody. And if they did, the virus itself (like the antigen portion of the duo test) would be positive, probably very strongly positive.

So really, don't worry about this. Your negative tests prove for sure you don't have HIV, assuming you have not been reexposed since the events 20 weeks ago.
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27 months ago
Thank you once again for your detailed answer Dr. Handsfield. Your previous reply did give me a lot of reassurance. It is this (these?) swollen lymph nodes under my chin as diagnosed by the doctor after the ultrasound (i believe the words used in the report were minor inflamation) that keeps worrying me, lingering still after more than two weeks. But like you always say in your posts, this is science based information, i know i do not have hiv. If anything, i should try to find the real cause of the inflamation.

Thank you once again, and i apologize for the somewhat repetitive nature of some of my questions. Stay safe and happy holidays.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
27 months ago
Most slightly prominent nodes like this are not due to anything serious. If your doctor has been reassuring, as he probably has, you should accept that and move on.

Thans for the kind words. Happy holidays to you as well.
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