[Question #9536] HIV Testing Questions - New Inquiries (Last Interaction)

31 months ago

Hi there, sorry for comming back so soon. After our last discussion Ive been working really hard to move past this case and I almost got it, if it not were to recurrent symptoms and specially symptoms from my partner, which of course I cannot assume are anxiety driven. I finally resumed unprotected sex with my regular partner after my final test 9 months post exposure (combo test). The thing is that around 10-13 days from starting having sex again, my partner is suffering from heavy nausea, mild fever, extreme weakness and headaches, she defines this as "Ive never felt worse". So you can imagine my anxiety sky rocket again right?

Ive been doing some extra research and there something I would appreciate you can discuss with me that I think will definetly help me and other users.

1) So first of all, late seroconversion or sero-negative patients do exist, is not much of just an "urban myth" but just that these are very very rare and infrequent, but do exist. I'll attach some articles about this after this question. What troubles me is that it seems that this sero-negative patients live on with their life and their negative HIV tests, just to find out they have HIV through PCR tests or P24 tests when they are already heavily hospitalized and doctors and looking for every possible cause. How can someone really be 100% sure they are HIV negative with Antibodies only test even tho it was 9 months or something post exposure, can anyone really be sure?

2) How can you identify this sero negative patients before they are seriously ill?

3) If sero negative patients are possible with HIV 1 and they are diagnose with PCR and P24 Antigens (thats how we indetify them), How can I be sure Im not infected with HIV 2 and am sero negative with HIV 2 but PCR or Antigen test are just not available?

4) I had a PCR test around 6 months and was undetectable. Is it antibodies that clear viral load in elite controllers? If Im an elite controller then my antibodies would be sky high?

5) What made CDC and experts like you change recommendation from 4 to 6 weeks? Cant this recommendation share later on to even further dates?

6) I understand the quote "dont test cheap" and this really worries my because in my country a combo test is worth around 7 dollars and PCR test around 120 dollars. What do you think about this?

7) Is it true that the antigen part of the combo test is not as sensitive as the antibody part?

8) Do PCR tests detect ALL positive individuals with the only exception of elite controller? Meaning you either have a lot of antibodies and are an elitte controller, or you dont have antibodies and have positive PCR test. (or of course you are normal and have both)

9) How can you state that "all combo test perform after 42 days are conclusive" when all tests are different depending manufacturer.The antigens they use are different, the test method is different

10) Do you think me or my partner are in some kind of danger? How could I know before getting to be seriosly ill and becoming one of those "sero negative guys" What do you think about her symptoms and timing?

Article about individual who lasted 4 years to produce antibodies:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4742638/#!po=13.8889

Articles about another sero negative patient already with AIDS:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570926/#CR2

https://pubmed.ncbi.nlm.nih.gov/26861193/

31 months ago

Just to add and clarify about the symptoms my partner is experiencing 10-13 days after we resume unprotected sex. As I said before: "The thing is that around 10-13 days from starting having sex again, my partner is suffering from heavy nausea, mild fever, extreme weakness and headaches, she defines this as "Ive never felt worse"."

So:

- Headache

- Mild fever

- Extreme weakness

- Nausea / vomiting

- Diarrheas

- Abdominal pain

All these at the same time.

H. Hunter Handsfield, MD

31 months ago

Welcome back to the forum. However, most of these questions were answered, or the answers should be obvious from those discussions.

I'll start by commenting on your opening statement, which will largely answer several of your questions. Negative HIV antibody (or antigen-antibody, i.e. AgAb or 4th generation) test results override any and all symptoms. It is not possible to have symptoms caused by HIV and not have detectable antibody. So my replies about all symptom you mentioned is that they are not possibly due to HIV. And there are no HIV cases, including elite controllers, whose HIV antibody tests are negative (even though RNA and HIV antigen may not be detectable). In addition, your simultaneous concern about both symptoms and being an elite controller has no scientific basis. Elite controllers never have symptoms either of HIV itself or of opportunistic diseases due to immune deficiency. So you can be certain you do not have HIV and are not an elite controller.

The case reports you cite are irrelevant. Indeed there are rare HIV infected persons who do not produce detectable antibody. However, all three cases had HIV detected in their blood, i.e. positive RNA test results. It is not possible to have HIV and have neither antibody nor RNA detectable.

1) How to be sure no HIV? Despite your skepticism, which is not scientifically justified, a negative AgAb test >6 weeks after the last possible exposure IS conclusive. Negative antibody after 8 weeks, or RNA testing plus plus antibody after 4 weeks is conclusive.

2) How identify before symptoms? RNA testing would do it, but it's almost never necessary. Despite the small handful of reported cases, for practical purposes negative Ab or AgAb testing a few weeks after the last possible exposure is 100% conclusive. The possible exceptions are in the same probability range as being struck by a meteorite and hence should be disregarded.

3) The antibody tests detect HIV2. In any case, HIV2 is almost absent in the US (under one for every 10,000 HIV cases, with almost all cases in people who acquired the infection in Africa, or in their spouses).

4) All elite controllers have positive HIV antibody tests. I don't know if their antibody levels are any higher than in anyone else.

5) About 5 years ago, a comprehensive review of HIV tests showed that on rare occasions it takes 6 weeks for the AgAb tests to become positive. At that point, both CDC and we on this forum revised our advice to agree with the 6 week window.

6) Costs are far lower in many countries than the US for many medical procedures, tests, and drugs. Lower costs in those countries does not imply that different tests or less reliable ones were used.

7) This doesn't matter. It's the combination of results that is important. Each has different sensitivities depending on duration since infection and other factors.

8) Yes, PCR detects all cases except some elite controllers. The amount of antibody in the blood isn't relevant to this issue.

9) Of course the performance of all tests worldwide cannot be evaluated. But so far there have been no exceptions, and for the most part they all use the same technologies. There is no reason to suspect any significant variation in performance of the similar types of test.

10) You and your partner surely are not in any danger from HIV. Her symptoms cannot be due to HIV that she acquired from you, since you don't have it. If she might have other risks, she should be tested for HIV. And of course she should see a doctor if her symptoms continue and/or she is concerned about them.

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

HHH, MD

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31 months ago

Doctor, thank you so much for taking the time to answer my questions. I do have a few follow ups:

1) I understand that HIV tests cannot be negative when symptoms are present, but I think thats the case only when symptoms are cause by ARS am I right? When this few rare cases of sero negative patients, they present HIV advanced or AIDS symptoms and negative antibodies test

2) I also cited reports of people lasting >6 months to develop antibodies. How can we be sure this will not be the case or even more months in a setting where only antibodies testing is available?

3) Ive read your comments about RNA tests just being 95% conclusive at 14 days, while other may say its 100% conclsuive. When do you consider this test to be conclusive?

4) How exaclty the RNA test works? Can this test miss some strains of the virus? Does it look for some more frequent strains or all of them?

5) Can the PCR test miss any infection? This tests look directly for the virus and the virus should be present in all regular infected people (not elite controller). So is it possible for the test to miss the virus in this kind of people?

6) Could you re asses my risk for me please? I had condom protected oral sex (I received condom protected oral sex) and condom protected vaginal sex with a street prostitute from the streets of Colombia (I specify this because I've seen you make the distinction between high end escorts and street prostitutes and the different risks) It was not an escort from appointment or anything like that, It was a CSW from the streets. If you could include in your assesment the possibility of HIV 2 from this (If you have any knowledge from this country)

7) Im completely sure my partner doesn't have any other risks of HIV besides myself, so she shouldn't be tested unless I may have infected her

My final tests were an Ag/Ab test at 8 months & 26 days. I also had a P24 Antigen test (by itself) at 7 months, and RT-PCR test at almost 6 months. All negative

8) Would you consider us to be completely out of risk from HIV here? What would you say to me if I was your patient?

9) If you could briefly talk about my question about HIV 2. We have PCR and P24 antigen to "protect us" from HIV 1 late seroconversion or sero negative. If this things happen with HIV 1 how can we be sure they dont happen with HIV 2 and how could we know?

H. Hunter Handsfield, MD

31 months ago

It is clear you have done a lot of self education and have learned a lot about HIV virology, immune response, and diagnosis. Unfortunately, there is also extensive evidence that you have misunderstood or misinterpreted much of what you found, undoubtedly reflecting your lack of professional education and training in these areas. I do not have the time, energy or interest to re-educate you or to correct all the misunderstandings displayed; and for the most part these are repetitive questions whose answers are above, or should be obvious from those replies. I'll just add a few more points: Having neither detectable RNA nor HIV antibody rules out symptoms from opportunistic infections or other manifestations of immune deficiency, in addition to HIV itself. Elite controllers cannot have HIV symptoms and cannot acquire OIs or their symptoms. Having used condoms consistently (even for oral sex!), your risk of HIV was zero: and anyway, no matter how high your risk at the time of exposure, it is 100% certain you do not have HIV, including HIV2. I would say all these things in person if you were my patient.

Beyond that, I suggest you re-read my replies above and do your best to accept the reasoned, science based advice and reassurance I have attempted to give you. I also suggest you stop searching the internet about any of this: as for many anxious or obsessed persons, you are selectively finding information that reinforces your misunderstandings or enhances your fears and missing the reassuring information that also is present.

I will have no further comments or advice. I do hope the discussion has been helpful, however. Best wishes and stay safe.

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31 months ago

Thanks doctor. I will finish with just some brief questions:

1) Could PCR tests miss some infections besides elite controllers? From test accuracy for example.

2) Is there any STI that could cause long lasting GI issues? I was diagnosed with "chronic gastritis" but no meds seem to work.

3) Ive recently read in question #9540 Dr Hooks statement on PCR tests for Gono & Clhamydia and the possibility although very rare, of false negative results. Could this be a possibility for me after 2 urethral swabs and 1 urine test?

Thanks!

H. Hunter Handsfield, MD

31 months ago

1) Conceivably, yes: Some ECs have undetectable virus in blood.

2) No STI causes such symptoms. Garden variety chronic gastritis (with no known cause) is a pretty common condition, and lack of response to treatment doesn't hint at what the cause might be. Your GI doctor is a better source than this forum to speculate about causes.

3) As you correctly cite from Dr. Hook, false negative tests for gonorrhea and chlamydia are uncommon. If there were reason to suspect gonorrhea or chlamydia based on exposure risk (which I am reminded was zero, based on what you described in your initial forum question two months ago) or symptoms, there might be reason to suspect false negative results. However, the odds that you would have either one given in these circumstances, and have 6 false negative results (two infection tested 3 times each) is astronomically small -- zero for all practical purposes.

That concludes this thread. Please note that repeated question on the same topic are not permitted. This being your fourth about this exposure, your symptoms, and HIV/STD testing as a result, it will have to be your last; any additional ones will be subject to being deleted without reply and without refund of the posting fee. This policy is based on compassion, not criticism: repeated discussion tends to prolong anxiety rather than resolving it. In addition, such questions have limited educational value for other users, one of the forum's main purposes. Thank you for your understanding. I hope the discussions help you move along without further worry.

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