Q/A: HIV Window Period, Testing, PEP, and Acute Infection
Can an infected person transmit HIV to others during the window period? Yes. During the window period, and despite a negative test result, an HIV-infected person may transmit the virus to others.
What is the “window period”? The “window period” occurs between the time of HIV infection and the time when diagnostic tests can detect HIV. The length of the window period varies depending on the type of diagnostic test used and the method the test employs to detect the virus.
How long can the window period last? The window period varies slightly from person to person, but virtually everyone infected with HIV develops antibodies within 3 months of infection.
When is follow-up HIV testing warranted? If a person tests negative for antibodies 3 months after a potential exposure to HIV, he or she does not require further testing. However, follow-up testing is warranted for individuals with repeated potential exposures during that 3-month period or when the antibody test results are incompatible with the person’s clinical history.
What are the recommendations for routine HIV testing for adults? The New York State Department of Health (NYSDOH), the U.S. Centers for Disease Control and Prevention (CDC), and the U.S. Preventive Services Task Force (USPSTF) recommend offering HIV testing to all adults as part of routine healthcare. New York State law requires that all persons between the ages of 13 and 64 be offered an HIV test at least once. The law also requires healthcare providers to offer an HIV test to any person, regardless of age, if there is evidence of risk activity.
Who should be offered ongoing HIV testing? Testing should be offered at least annually to anyone whose behavior increases his or her risk for exposure to HIV. Since many people choose not to disclose their risk behaviors, providers should consider adopting a low threshold for recommending the test.
How often should individuals who engage in high-risk behavior be tested? Clinicians should recommend testing every 3 months for individuals who engage in unprotected anal sex, sex with multiple or anonymous partners, needle-sharing, or sex with partners who share needles. In these high-risk cases, testing is used to ensure early access to care and to prevent transmission to others if the patient becomes infected.
Should pre-exposure prophylaxis (PrEP) be offered to individuals with high-risk behavior? Yes. PrEP to prevent HIV infection should be considered for persons with ongoing high-risk behaviors. PrEP should be prescribed as part of a comprehensive prevention strategy that includes risk-reduction counseling about safer sex practices, condom use, and safer injection practices, as well as referral to syringe exchange programs and drug treatment services when appropriate. The NYSDOH AIDS Institute guidance for PrEP is available online.
|NYSDOH, CDC, and USPSTF recommend HIV testing for all adults as a routine part of healthcare.|
HIV Diagnostic Testing Algorithm
What is the HIV diagnostic testing algorithm? This is a laboratory-based diagnostic algorithm that recommends a combination of laboratory tests performed in a defined sequence. Extensive evidence supports this algorithm for maximal sensitivity, specificity, and accuracy for HIV detection.
What is the initial test of the HIV diagnostic testing algorithm? The algorithm begins with an immunoassay (sometimes called a “4th generation test”) that detects both HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen. The HIV-1 p24 antigen appears before antibodies develop so that acute HIV infection can sometimes be detected.
What steps are taken when the initial test is reactive? Specimens reactive on the initial assay are tested with a supplemental assay that differentiates HIV-1 and HIV-2 antibodies. Specimens that are reactive on the initial assay but nonreactive or indeterminate on the antibody differentiation assay are then tested for HIV-1 RNA to differentiate acute HIV infection from a false-positive screening result. The final interpretation is based on a combination of test results. The NYSDOH Testing Toolkit provides more information about HIV diagnostic tests and the algorithm. The NYSDOH AIDS Institute’s guidelines on HIV Testing and Lab Monitoring of ART Side Effects and Allergic Reactions should be consulted as well.
|It is important to know which HIV tests are being used by your agency or laboratory so you can provide patients with accurate information regarding their HIV test results.|
Exposure to HIV and Post-Exposure Prophylaxis (PEP)
What are the recommendations for persons who report an exposure? HIV exposure is a medical emergency. If the patient reports a significant exposure, the first dose of PEP should be given. Other testing and evaluation can be continued following the first dose. When PEP is initiated immediately after an exposure (ideally, within 2 hours), it can prevent HIV infection. Please consult the NYSDOH AIDS Institute’s clinical guidelines on PEP for HIV Prevention.
PEP is most likely to prevent infection when initiated within 36 hours of exposure. The decision to start PEP later, beyond 36 hours post-exposure, should be made jointly by the clinician and the exposed individual, with the understanding that PEP is less likely to prevent HIV infection the longer it is delayed.
Can HIV infection be detected immediately after exposure? HIV infection is not immediately detectable.
How often should an exposed individual be tested? NYSDOH protocols recommend testing at baseline and at 4 and 12 weeks post-exposure.
Are the guidelines for PEP different for different types of exposure? The NYSDOH AIDS Institute provides specific guidelines for PEP following occupational exposure, non-occupational exposure, and sexual assault.
Acute HIV Infection
What is acute HIV infection? Acute HIV infection is the very early, initial stage of HIV infection when the virus is multiplying rapidly and the body has not yet developed antibodies to fight it.
What are the symptoms of acute HIV infection? Symptoms of acute HIV infection are similar to flu symptoms and may include fever, fatigue or malaise, joint pain, headache, loss of appetite, rash, night sweats, myalgia, nausea or diarrhea, and pharyngitis.
If acute HIV infection is suspected, what steps should be taken for testing? If a patient presents with signs/symptoms of acute HIV, then HIV RNA testing should be requested in conjunction with an initial 4th generation (recommended) or 3rd generation (alternative) screening test. In the absence of serologic evidence of HIV infection:
- If HIV RNA is not detected, no further testing is needed.
- Detection of HIV RNA with ≥5,000 copies/mL indicates a preliminary diagnosis of HIV infection.
- Detection of HIV RNA with <5,000 copies/mL requires repeat HIV RNA testing.
- If a diagnosis of HIV infection is made on the basis of HIV RNA testing alone, a new specimen should be collected 3 weeks later, and HIV diagnostic testing should be repeated.
|When acute infection is suspected, an HIV RNA assay should always be requested in conjunction with an HIV screening test.|
Why is it so important to diagnose HIV infection during the acute phase? In most infected persons, HIV viral load increases quickly after exposure, peaks at about 3 weeks post exposure, and then declines over the next several months. An HIV-infected person is most infectious during this acute phase because of the high viral load. The NYSDOH AIDS Institute Diagnosis and Management of Acute HIV Guideline recommends ART for all patients diagnosed with HIV infection.
Is specialty consultation required for pregnant women with acute HIV infection? Yes. If acute HIV infection is suspected in a pregnant woman, request HIV RNA testing in addition to a 4th generation (recommended) or 3rd generation (alternative) screening test. If reactive, consultation with a provider experienced in diagnosing and evaluating acute HIV infection is important. Earlier diagnosis and treatment can reduce the risk of mother-to-child transmission.
How can I locate an experienced HIV care provider? The CEI line, which is available through the NYSDOH Clinical Education Initiative, provides access to providers with experience in acute HIV infection: 866-637-2342.
Provider Guide to HIV Testing (Quick Reference Guide)
Medical Care Criteria Committee, January 2013
Testing Law, Information, and Consent
The requirement to offer testing applies to persons receiving inpatient or emergency department services at hospitals; persons receiving primary care services through hospital outpatient clinics and diagnostic and treatment centers; and persons receiving primary care services from physicians, physician assistants, nurse practitioners and midwives regardless of setting.
Provide the patient with the following key points of information regarding HIV testing:
- HIV is the virus that causes AIDS. It can be spread through unprotected sex (vaginal, anal, or oral sex); contact with HIV-infected blood by sharing needles (piercing, tattooing, drug equipment, including needles); by HIV-infected pregnant women to their infants during pregnancy or delivery, or by breastfeeding.
- There are treatments for HIV/AIDS that can help a person stay healthy.
- People with HIV/AIDS can use safe practices to protect others from becoming infected.
- Testing is voluntary and can be done without giving your name at a public testing center (anonymous testing).
- By law, HIV test results and other related information are kept confidential (private).
- Discrimination based on a person’s HIV status is illegal. People who are discriminated against can get help.
- Consent for HIV-related testing remains in effect until it is withdrawn verbally or in writing. If the consent was given for a specific period of time, the consent applies to that time period only. Persons may withdraw their consent at any time.
- Consider patient’s ability, regardless of age, to comprehend the potential outcomes of HIV testing. If the patient does not have the ability to understand these outcomes, defer testing or discuss with person who has legal authority to consent to HIV testing for the patient.
- If domestic violence (DV) concerns are raised, make referrals as appropriate (see Resources section, below).
- For information about consent in New York State, please see NYSDOH Authorization for Release and Complaint Forms.
Providing Test Results
Providing a Negative (Non-Reactive) Test Result
- A negative HIV test result may be provided in-person, by mail, by email, or by telephone as long as patient confidentiality is protected.
- Explain that a negative result almost always means that the person is not infected with HIV.
- Indicate that there is a possibility of recent infection if the person engaged in risk behaviors in the three months prior to the test and may need to be re-tested.
- Discuss the importance of avoiding future risky behaviors.
Note: If acute HIV is suspected, a negative antibody test would be expected and follow-up with viral load testing may be indicated.
Providing a Positive (Reactive) Test Result
When a patient has a reactive result on the rapid HIV screening, a second, confirmatory test must be conducted by a certified laboratory. If the second test is also positive, it is considered a positive test result that needs to be provided to the patient.
Post-Testing Counseling, Notification, and Domestic Violence Screening
Topics: Post-test counseling should cover the following topics:
- Coping with the consequences of learning the test result
- The potential for discrimination
- Preventing the transmission of HIV to others through risk behaviors and/or perinatally
- HIV reporting is required by law (see information about DOH-4189 Form below)
- The availability of treatment and their right to have a follow-up appointment made for HIV medical care
- How to access prevention and supportive services. Outside of New York City, the New York State Department of Health (NYSDOH) Partner Services staff can also assist in providing post-test counseling.
Partner notification: Discuss the provider’s responsibility to report name(s) of known partner(s)/spouse to NYSDOH.
- Review options for patient to notify his or her partners, and actively link the patient to the Partner Services (PS) program. For more information on PS, see What Health Care Providers Need to Know about Partner Services
Domestic violence screening: Conduct domestic violence (DV) screening for each partner, following these steps:
- Discuss domestic violence (DV) before eliciting partner names.
- Screen for risk of DV for each partner to be notified.
- Provide referral(s) for DV services and discuss release form.
- Make determination(s) regarding HIV Partner Services.
- Discuss and implement Partner Services option(s). For any partner where the provider defers notification based on DV risk, Partner Services staff will contact the provider in 30 to 120 days to discuss DV risk and steps in place to address it.
- Collaborate with the local department for Partner Services.
- Revisit Partner Services and DV risk throughout the continuum of care. For more information on the Required Domestic Violence Screening Process, please see NYSDOH Protocol – Domestic Violence Screening in Relation to HIV Counseling, Testing, Referral & Partner Notification.
|DOMESTIC VIOLENCE SCREENING RESOURCES|
Documentation and follow-up: Complete the Medical Provider HIV/AIDS and Partner/Contact Report Form (DOH-4189) within 14 days. Send one copy (yellow) to NYSDOH; keep one copy (white) for patient’s record if appropriate (call 518-474-4284 to obtain forms).
Provide or schedule a follow-up appointment for HIV medical care. If you do not provide HIV medical care, the patient’s medical record should reflect the name of the provider/facility where the appointment was made.
For ALL patients:
- Document the provision of post-test counseling, including the test results.
- For HIV positive patients, also document results of DV screening and arrangements for partner services.
- Wadsworth Laboratory (518-485-5378): To register as a limited test site to offer rapid HIV testing.
- New York State Department of Health: Lists information for HIV/AIDS programs, services, laws, regulations, training, materials, etc.
- To order Medical Provider HIV/AIDS and Partner/Contact Forms (DOH #4189/4189A), call 518-474-4284.
- NYSDOH Partner Services (1-800-541-2437): Referrals for free, confidential help in notifying exposed partners/spouse, outside of NYC area.
- New York City Department of Health and Mental Hygiene, Contact Notification Assistance Program (CNAP) (212-693-1419)
- NYS HIV/AIDS Hotline (English: 1-800-541-2437; Spanish: 1-800-233-7432): General information and referral to HIV counseling and testing, including anonymous HIV counseling and testing sites, prevention programs and health care and support services for people living with HV/AIDS.
- NYS HIV TDD Information Line (1-800-369-2437): Voice callers can use the New York Relay System: 711 or 1-800-421-1220 and ask the operator to dial 1-800-541 2437.
- ADAP Plus (1-800-542-2437): Free medications and care for uninsured HIV-infected persons.
- NYSDOH HIV Confidentiality Hotline (1-800-962-5065): General information, “Breach of Confidentiality” forms, and referrals for further assistance.
- NYS Division of Human Rights (718-741-8400)
- NYC Commission on Human Rights (212-306-7500)
- NYS Domestic Violence Hotline (English: 1-800-942-6906; Spanish: 1-800-942-6908)
- NYC Domestic Violence Hotline (Safe Horizons) (1-800-621-4673; Hearing Impaired: 1-800-604-5350)
- NY/NJ AIDS Education & Training Center (212-304-5530)
HIV Care Provider Definitions
New York State Department of Health AIDS Institute, April 2017
Experienced HIV care provider: Practitioners who have been accorded HIV-Experienced Provider status by the American Academy of HIV Medicine (AAHIVM) or have met the HIV Medicine Association’s (HIVMA) definition of and experienced provider are eligible for designation as an HIV Experienced Provider in New York State.
Nurse practitioners and licensed midwives who provide clinical care to HIV-Infected individuals in collaboration with a physician may be considered HIV Experienced Providers provided that all other practice agreements are met (8 NYCRR 79-5:1; 10 NYCRR 85.36; 8 NYCRR 139-6900)
Physician assistants who provide clinical care to HIV-infected individuals under the supervision of an HIV Specialist physician may also be considered HIV Experienced Providers (10 NYCRR 94.2)
Expert HIV care provider: A provider with extensive experience in the management of complex patients with HIV.
Online Resources for Education, Information, and Services
AIDSinfo: Training for Health Care Providers
Centers for Disease Control and Prevention (CDC):
E-patients.net: Salzburg Statement on Shared Decision Making
National Center for Transgender Equality: 2015 U.S. Transgender Survey
New York State Department of Health (NYSDOH):
Scientific American: Life Cycle of HIV Animation (2018)
UCSF: HIV InSite
US Occupational Safety and Health Administration:
US Department of Veterans Affairs:
AIDSinfo (DHHS guidelines): https://aidsinfo.nih.gov/
CDC HIV Guideline: HIV Testing: http://www.cdc.gov/hiv/guidelines/
IAS-USA Practice Guidelines: https://www.iasusa.org/guidelines
New York City (NYC) Health: Reporting Diseases and Conditions
U.S. Courts: courtsystem.org
New York City (NYC) Health: STD and HIV Services, including Clinic Locations and Hours
New York eHealth Collaborative: NYEC
New York State (NYS):
U.S. Occupational Safety and Health Administration: