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NOTE

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Note: The antiretroviral treatment of HIV/AIDS (HAART) continues to evolve, and guidelines for use are regularly updated (https://aidsinfo.nih.gov/guidelines). This chapter focuses on the primary care aspects of HIV/AIDS including initial evaluation, drug side effects, and infectious disease prophylaxis.

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CASE 9.1

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A 23-year-old female presents to your clinic complaining of sore throat, fever, and body aches. She reports that the illness began about a week ago and has persisted despite therapy with NSAIDs, acetaminophen, and sore throat lozenges. She denies cough, abdominal pain, nausea, or vomiting, but reports a persistent headache. Her past medical and surgical history is unremarkable. The patient smokes about one pack of cigarettes a week, drinks occasional alcohol, and denies other drugs, including intravenous (IV) use. She is heterosexual, and has had eight sexual contacts in the past year. She takes oral contraceptives, and her partners usually do not use condoms.

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On examination, her vital signs are T 38.9°C, P 112 bpm, BP 115/68 mm Hg, R 20 bpm. She has pharyngitis and enlarged tonsils with exudates. There is diffuse cervical lymphadenopathy, but the neck is supple. There are enlarged lymph nodes in her axillae and inguinal areas as well. The spleen is palpable and nontender. The rest of the examination is unremarkable. You obtain a throat culture, CBC with differential, and heterophile antibody (Monospot) test. Given her history of unprotected intercourse with eight new partners within the last year, you also consider testing for HIV.

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Question 9.1.1 The most appropriate laboratory test(s) to rule out the acute retroviral syndrome would be:

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A) HIV-1 antibody by ELISA followed by a Western blot.

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B) HIV-1 antibody by rapid detection method.

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C) HIV DNA by PCR.

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D) CD4 T lymphocyte count.

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E) Combined HIV-1 antibody and antigen ELISA test.

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Answer 9.1.1 The correct answer is "E." This presentation is consistent with an acute retroviral syndrome, which occurs very early in the infection and is characterized by a mononucleosis-like illness that can last several weeks. Current HIV diagnostic ELISA methods include the option for both antibody and antigen detection. Since the antibody to HIV will not develop for at least 2 to 8 weeks after infection and the retroviral syndrome typically occurs before seroconversion, HIV antibody tests, including rapid detection methods ("B"), may well be negative. During the acute HIV infection, HIV viral loads are very high, and patients are more infectious compared to other times during their HIV infection. Consequently, the HIV antigen assay, which measures HIV p24 protein, is typically positive during this period. Not all laboratories have adopted the HIV antibody–antigen ELISA. If this option is not available, the alternative ...

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