HIV - Changes in window period

A clinical perspective

Dr Manoj Malu FRCP

Consultant in Genitourinary & HIV Medicine
Clarewell Clinics
Declaration of financial interests
● Clinical Director of Clarewell Clinics
 - Overview of HIV tests
What we’ll - The 2008 and 2020 window periods
cover today - Clinical implications

- Q&A
Does HIV still matter?
HIV is on the decline...

Source: UK data from Public Health England

HIV is on the decline...
Global HIV target

UNAIDS 90-90-90 by 2020

UK Target: Zero transmission by 2030

Earlier detection Reduce onward transmission Reduce risk of acquisition

1.3 million tests / year in SH 110,000 (2020) PrEP (Pre-exposure prophylaxis)

clinics
TasP PEP (Post exposure prophylaxis))
(Treatment as Prevention)
Circumcision
U=U
(Undetectable = Untransmittable) C-section

*Launched in 2014 to end AIDS by 2030

… but the fight is not over
HIV remains a serious infection Future rise in HIV cases

● No cure ● Rising STIs

● Lifelong Rx ● PrEP: Undue expectations

(Side-effects / Cost / Access) ○ Effective
○ Poor access
● Personal cost Relationships, Stigma, ○ Poor uptake
Psychological impact ○ PrEP by proxy

● HIV anxiety ● ? Change in Immigration pattern

● Late diagnosis
Overview of HIV tests
Three key pillars of HIV tests
RNA p24-antigen Antibody

Early Infection X X

Established
X X
Infection
Traditional HIV tests
Generation HIV 1 HIV 2 Group
O

IgG IgM p24 IgG IgM Remarks

1st Gen. X
Does not detect HIV 2
2nd Gen. X X

3rd Gen. X X X X X
Does not distinguish between
4th Gen. X X X X X X
HIV 1 & 2
Advanced 4th Gen. X X X X X X

5th Gen. Distinguishes between HIV 1 &

X X X X X X
2
Tests not discussed today
Qualitative tests Quantitative tests

1. HIV 2 RNA PCR 1. HIV 1 RNA PCR (viral load)

2. HIV 1 & 2 RNA PCR 2. HIV 2 RNA PCR (viral load)

3. HIV 1 proviral DNA 3. HIV 1 Limiting Antigen (LAg)-Avidity EIA

4. HIV genotype/ resistance test

5. Western blot
The 2008 change
From 90 days > 28 days
Published in Transfusion Medicine Reviews, April 2007
Figure demonstrating the comparative timing of the detection of primary HIV seroconversion (mean value).
What does the evidence say?
The paper cited for 28 days window period (2008):
“The National Blood Service (England) approach to evaluation of kits for detecting infectious agents”

There is no explicit connection between the cited paper and what is recommended in the guidelines.

● It was used to evaluate blood testing kits.

● Exercise was undertaken for blood donation rather than STI testing.

● There was no comment on 4th generation testing window periods.

The 2020 change
From 28 days > 45 days
STUDY 1
Taylor D, Durigon M, Davis H et al. Probability of a false-negative HIV antibody test result during the
window period: a tool for pre- and post-test counselling. Int J STD AIDS 2015; 26: 215–224.

Data from commercial and literature-reported seroconversion panels were evaluated:

● To calculate the window period for third and fourth-generation tests.

● To calculate the probability of a negative test result during the window period.
STUDY 1 (Conclusion)

Cumulative probability of a 3rd gen. Tests 4th gen. Tests

negative test result Days post-exposure Days post-exposure

5% 40 days 34 days

1% 85 days 42 days

0% 99 days 50 days
STUDY 2
Delaney KP, Hanson DL, Masciotra S et al. Time until emergence of HIV test reactivity following
infection with HIV-1: implications for interpreting test results and retesting after exposure. Clin Infect
Dis 2017; 64: 53–59.

● 222 longitudinally collected plasma specimens from HIV-1 seroconverters from the USA.

● 20 US FDA-approved HIV immunoassays against the Aptima HIV-1 RNA test was evaluated.

● Time between detection of HIV RNA and reactive immunoassay results was combined with simulated
eclipse period data.

● Estimated the window period for each immunoassay.

STUDY 2 (conclusion)
99th percentile
99% of HIV infections would be picked up by:
Types of tests window period
(days)
- 45 days using 4th gen tests
Antibody/antigen laboratory 44.3 days
- 50 days using 3rd gen tests
IgG/IgM-sensitive laboratory 49.5 days
- 90 days using any test
IgG-sensitive rapid screening 56.7 days

IgG-sensitive supplemental 58.3 days

Western blot (viral lysate) 64.8 days

 PREVIOUS Window Period NEW Window Period
(Days from exposure) (Days from exposure)

4th Gen 28 days 45 days

(8 weeks if high risk)

3rd Gen 35-42 days 60 days

POCT 90 days

References 2008 - BHIVA / BASHH / BIS UK 2020 - BHIVA/BASHH/BIA adult HIV testing
guidelines for HIV testing guidelines

2014 - BASHH/EAGA statement on

HIV window period
Implication 1
What is the window period of
4th gen. POCT?
Abbott’s HIV Ultra
● No commitment to window period on their website

● We are awaiting a response from Abbott

Implication 2
How do we approach patients
tested between 2008 and 2020?
Approaching patients tested between 2008 & 2020?
If high risk - Yes

● How many patients we may have missed with HIV window period of 28 days?
○ 10 million + tests over 12 years (UK)
● Is there a need for a look-back exercise ?

● Duty of candour
● Psychological impact
● Logistical issue
● Economical issue
Implication 3
Reduce false negatives
Let’s discuss Mr. Grey
Implication 4
Reduce false positives
Likely to reduce false positives
False positive
Recent HIV Established HIV
infection infection Repeat test
Initial test
(in 4-6 weeks)

p24 antigen Reactive Negative Reactive Reactive/Negative

HIV-1 IgG Positive Positive Negative Negative

HIV-1 IgM Positive Negative Negative Negative

Implication 5
Reduce reliance on p24 antigen
A note on the p24 antigen
Transient
Not detectable once it has formed a complex with antibodies (lasts for approx. 4-8 weeks).

Variable levels
Present when HIV-1 RNA level above 10,000 copies/ml meaning sometimes p-24 antigen levels may be too low
for detection, esp those on PrEP.

Not sufficient to make a HIV diagnosis

Dilemma when p24 is detected but HIV antibodies are not

(rare) Second window period

p24 antigen has become undetectable and the antibody is yet to appear.
Query 1
Can we detect HIV earlier than
45 days?
HIV-1 RNA (Qualitative) PCR Tests
Consistently detectable after 10 days post exposure
Not detectable once it has formed a complex with antibodies.

Routinely used for screening blood and organ donors (WHO)

Often used alongside 4th generation HIV tests.

Food for thought (we will ask for your opinion in our feedback form).

1. Should we rely more upon HIV-1 RNA PCR testing for earlier HIV detection?
2. We often accept what is available to us. As such, if diagnostic companies could detect HIV-1 RNA and
HIV antibody in one test, would we still use 4th generation HIV testing?
Further benefits of RNA testing
● Blood and organ donors

● Child born to a HIV positive mother

● Pregnant women with HIV exposure late in the pregnancy

● Transmission anxiety and its effect on relationship

● Suspected PrEP or PEP failure

Query 2
Are we making things difficult?
MSM clinic visits from Day 1
Day 1 Day 7 Day 14 Day 21 Day 45 Day 90 Day 135 Day 180

PEP

Gonorrhoea Chlamydia HIV Syphilis (HIV), Hep

& (Syphilis) (HIV) B&C
Gonorrhoea

Hep B Vacc. Hep B Vacc. Hep B Vacc.

Dose 1 Dose 2 Dose 3

HPV Vacc. HPV Vacc. HPV Vacc.

Dose 1 Dose 2 Dose 3
45 days = 6.43 weeks

Why not simply 7 weeks?

A final thought
We need to understand the reasons behind our guidelines

Because experts might not always be right

And such U-Turns can undermine patient confidence

Which makes it harder for us to fight HIV

Acknowledgments
My patients at Clarewell Clinics who have taught me more about HIV testing in last 2 years than I learnt in
preceding 20 years.

And, of course, Bharti Raghav (Clinical research scientist, Clarewell clinics) and Kelly Warner (Medical writer,
Clarewell clinics) for assistance on this presentation.
Q&A
Please type your questions into the message board.
References
Public Health England: Trends in HIV testing, new diagnoses and people receiving HIV-related care in the
United Kingdom: data to the end of December (2019)

BHIVA: Consultation version of the BHIVA/BASHH/BIA Adult HIV Testing Guidelines (2020)

BHIVA: UK National Guidelines for HIV Testing (2008)

BASHH: BASHH/EAGA statement on HIV window period (2014)

International Journal of STD & AIDs: Probability of a false-negative HIV antibody test result during the window
period: a tool for pre- and post-test counselling (2015)

National HIV Curriculum: Acute and recent HIV infection (2020)

References
UNAIDS: Progress towards the Start Free, Stay Free, AIDS Free targets (2020)

World Health Organization: HIV/AIDS (2020)

Transfusion Medicine Reviews: The National Blood Service (England) approach to evaluation of kits for
detecting infectious agents (2007)

International Journal of STD & AIDS: Probability of a false-negative HIV antibody test result during the window
period: a tool for pre- and post-test counselling (2015)

Clinical Infectious Diseases: Time until emergence of HIV test reactivity following infection with HIV-1:
implications for interpreting test results and retesting after exposure (2017)