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HIV And Still Test Negative

Bob Hall writes: These are responses to three fellow readers.

Tim Evanson writes: “I hope that your article (“PCR-DNA Shocker-update,” May 14, 2004, 15:15 PM PST) is tongue-in-cheek. That the PCR-DNA test is not useful in identifying who has HIV and who does not, nor in determining which person “was infected first,” has been well-documented for many years and is a well-known fact.”

Viral load tests such as PCR-DNA are recommended by the National Institutes of Health when early detection is needed. The last paragraph of this NIH web page states that viral load tests are appropriate for early detection; PCR-DNA tests are approved by the FDA for viral load assays. So they’re an FDA approved way of carrying out an NIH recommendation. They’re very useful for diagnosis in specific circumstances and have been used under those circumstances for several years. No one is using viral load to figure out who was infected first.

No one can create a test that someone can’t figure out how to dodge. Witness the cat and mouse games played between sports authorities and the athletes who use steroids. As soon as a new test is created, someone figures out a way to cheat. In the case of PCR-DNA HIV testing, someone who was HIV-positive and being treated for the infection could cheat just by taking their medicine, as Tim points out. However, the PCR-DNA tests have been very successful at early diagnosis of HIV infection. So far, no one has attempted to cheat. If that happens, AIM could check for cheaters by requiring an ELISA test every three months. But that would be useful only for discouraging cheating. It would do nothing for early detection of HIV infection. For that, you still need a viral load test.

As Tim points out, anyone with HIV can potentially infect anyone else. However, the risk of infection increases with increased viral load. In other words, the more of the virus you have in your body, the more likely you are to infect someone else. There is typically a huge spike in the viral load during the first one or two months after infection. Notice that I didn’t say the spike always occurs, just that it typically occurs. HIV-positive people are always infectious, but they are even more infectious during this spike. The primary reason for using PCR-DNA is early detection, but an added advantage is that it sometimes catches infected people at their most infectious so they can be pulled from the talent pool. Darren James tested positive with a relatively low viral load; if he had a spike, it had already passed. But Lara Roxx was caught with a high viral load; she appeared to be at or near the peak of a spike, when she was most infectious. Tim says that the PCR-DNA test isn’t useful in determining who has HIV and who doesn’t. The fact is that it is useful, and for porn performers, it’s the best test available.

Darrin writes: “I do NOT know the details of how AIM screwed up with Marc Wallice (tell me where to see both sides of the argument please), but they have a chance to do a great thing and avert a crisis in light of Darren James’ HIV positive diagnosis.AIM tests for the presence of HIV antibodies, not the actual HIV virus.”

I don’t see how AIM could be accused of screwing up. Marc Wallice’s negative HIV tests were done at a Northeast Valley Health Corporation clinic, not at AIM. There’s some evidence that he had someone else pose as him when the blood samples were taken. He was very reluctant to be tested at AIM, and his test returned positive the first time he tested there. AIM figured out that he was the only person in the affected group who hadn’t tested with them, they leaned on him to take the test, and they caught his infection the first time they tested him. I’ve read the rumors that Sharon Mitchell was hiding Wallice’s test results, but the actual available evidence is that AIM did some sharp detective work, figured out that Wallice was probably the source of the epidemic, and pressured him into testing so that he could be stopped from infecting more people.

AIM uses the PCR-DNA test, which tests for the actual HIV virus, not the anti-bodies. The information is on their web site; During the current crisis, AIM used a battery of five tests to confirm infection whenever someone tested positive with the PCR-DNA test. Those five tests include anti-body tests. However, the test that every performer takes every twenty-eight days at AIM is the PCR-DNA, which tests for the virus, not the anti-bodies.

Tabetha Yang raises a good question: Why not test every two weeks instead of every four? The three women thought to have been infected by Darrin James worked with him less than fourteen days after his initial test, so testing every fourteen days wouldn’t have helped them. Just the same, it seems like common sense that testing twice as often would cut the risk in half. I don’t think that two week testing will work, and I think I have a persuasive explanation of why it won’t work, but you’ll have to decide for yourself.

First of all, some obvious facts. Testing doesn’t protect you from HIV. If you have sex with someone who has HIV, all the tests in the world won’t stop you from getting it. All a test can do is tell you if you got it or not.

A second obvious fact is that someone can be carrying HIV and still test negative. That’s what appears to have happened with Darren James. He was infected by HIV, he took a test that said he wasn’t infected by HIV, and he apparently infected three other people before taking a test that said he was infected. (I’m avoiding saying that James definitely was the source of infection because it hasn’t been proven yet.) A test result that says that you’re not infected when you are is called a false negative. False negatives happen, and they can lead to further infections.

If a test returns a positive result, there’s no question about what that means. During the time that AIM has been using the PCR-DNA test, they’ve never had a false positive. A positive test result means that the person tested is infected with HIV. AIM does additional tests to confirm the positive result, but that’s basically to make sure the infected person doesn’t have any doubts about their status, and to cover AIM’s ass legally.

However, a negative result is ambiguous. There’s no way of being sure what it means. If false negatives occur, then a negative test result can be a true negative or a false negative. Ironically, positive results don’t really need confirmation, but get it anyway. Negative results do need confirmation, but there’s no way to confirm a negative immediately. Since most of the results from the AIM tests are negative, that means that most of the tests produce ambiguous results. We know what to do about a positive result, but we need more information before we know what to do about a negative result. And we have to wait for that information.

The PCR-DNA test administered by AIM measures the viral load, which is the amount of virus in your blood. When you are first infected, the amount of virus is so low that the test can’t detect it. For most people, it takes between fourteen and twenty eight days for the virus to create enough of itself to show up on the test. If you test too early, you’ll get a false negative because there isn’t enough of the virus yet to show up on the test. That apparently happened with James. He is believed to have been infected on March 10, and had a false negative on March 17. Seven days wasn’t long enough for the virus to become detectable in his case.

The fact that a negative test result is ambiguous is important for porn performers. For their own safety, they should always assume that a fellow performer’s previous test was a false negative, and act accordingly. Performers are currently tested every twenty eight days. If a performer’s previous test was a false negative, the next test will be a true positive; enough time will have passed since the infection that the next test will detect the HIV infection. If you assume that a performer’s previous test was a false negative, then any performer who has skipped their monthly test is HIV-positive. The only way they can prove that the previous test wasn’t a false negative is to take the test again. I’ll restate that; a negative test result confirms the previous negative test result, and a missing test is a signal that the performer is infected with HIV. So porn performers should avoid performers who have skipped a test and assume that they would have tested positive if they had taken the test.

I need to be careful about what I’m saying here. A missing test is not proof that a performer is infected with HIV. It is a signal that tells other performers what to do; it tells them to avoid the performer with the missing test. A green light is a signal that it is safe to go through an intersection, but it isn’t proof that it’s safe. Someone might be running the red light. In the same way, a performer who skips a test is signaling that they have HIV, but they may just be forgetful.

There’s a contradiction built into the AIM testing program. Performers pay for their own tests, but the tests don’t protect the performer who pays for them. The tests protect all the other performers. A performer who pays AIM for a test gets no protection in return. Not only that, but every time a performer takes the AIM test, they risk losing their job. If the test is positive, not only does the performer have a dangerous and expensive disease, but their days as a porn performer are over and they no longer have any way of paying for the necessary health care. Why would a performer do that? Why pay the money and go through the hassle and take the risk to do something that doesn’t help you personally? Because other performers won’t work with you and producers won’t hire you unless you take the test. Nobody trusts anybody else and everybody wants proof you’re safe to work with. This is a system that benefits everybody, but is based on reciprocal distrust and suspicion.

So here’s the situation; if you’re a performer, all the other performers want you to pay for your next test and go through the hassle of taking it on schedule in order to confirm that your previous test wasn’t a false negative. But you personally want to minimize your own expense and the amount of effort you have to expend and the risk you take. So you want to put off taking the test as long as possible. Your fellow performers would like you to take the test every day. You want to take it only during regular medical check ups, or less often.

The compromise is to delay the next test until it confirms the previous test. Remember that there is a period after infection during which a test will return a false negative. Most people can be tested after two weeks, but there are a certain number of people who won’t test positive until twenty eight days after infection. That means that if you test every fourteen days, there is a good chance of having two false negatives in a row. And that means that the next test doesn’t confirm the previous test. In other words, the performer who pays for the test isn’t getting what they’re paying for. The first false negative at least confirms that the previous test returned a valid result. But the second false negative doesn’t even do that. So the money and effort spent on the second test that returns a false negative is completely wasted.

It is true that the next test in a fourteen day testing program is not completely wasted because it confirms the test taken prior to the previous test. But the problem is that nobody cares about the test take prior to the previous test. It is the previous test that everyone needs to assume is a false negative, and therefore it is the previous test that a performer needs to confirm was valid in order to continue working. And no test can be confirmed in fourteen days if it takes twenty eight days to get accurate results.

Let’s imagine a shoot. The camera crew, which is being paid by the hour, is assembled at the shoot location, which is being rented for a few hundred dollars an hour. The performers show up, and all but one performer has been tested within the previous fourteen days. That one performer was tested twenty days ago. Under the current testing program, the shoot proceeds because there are no missing tests. Under a fourteen day testing program, there’s a missing test, but the shoot will proceed anyway.

The producer and the other performers know that the negligent performer’s previous test was negative, and they know that even if the performer has HIV, a missing test under a fourteen day program might have been a false negative also. Under a twenty eight day testing program, a false negative gives useful information and a missing test is a signal that the performer has HIV. Under a fourteen day testing program, a false negative provides no information and a missing test isn’t a signal of anything. The producer needs to produce a movie to pay for the camera crew’s wages and the location rent, and the performers need to earn a living. So the shoot proceeds.

After this happens a few times, performers learn that they can skip tests and still work. Since each performer pays for their own tests but don’t get any benefit from their own tests, they skip as many tests as possible. And after a while, the AIM testing program breaks down and stops protecting performers.

In economics, this is sometimes called a signaling problem. The testing program signals performers whether to work with a given performer or not. But the signals won’t be produced if it costs too much to produce them. A way around the signaling problem would be to pass a law in Sacramento, or for LA county to issue a health regulation, requiring HIV tests every two weeks. But enforcing the law or regulation would require that producers document that they used only tested performers. And then the documents would have to be stored for a certain number of years. Creating and storing the documents is an additional cost for producers. Producers are already required to document that their performers aren’t underage, and to store the documents. I’ve been told that this requirement is a major pain in the tuchis. In other words, it’s a cost.

Producers are already going out of country to shoot films in an effort to lower their costs. Requiring two week testing would improve protection for performers in LA by a small amount, but would drive some more production out of country, where performers aren’t covered by the AIM program. It is believed that the current HIV crisis in LA originated during out of country production while Darrin James was performing in Brazil. The question for performers is whether their safety is improved by a law that results in more out of country production.

Ren Galskap


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