Chapter 30-9: Primary HIV Infection - Acute Retroviral Syndrome

TEXTBOOK PRESENTATION

Symptoms of acute retroviral syndrome are generally nonspecific and resolve spontaneously without treatment. The most common findings are fever, lymphadenopathy, sore throat, rash, myalgia/arthralgia, headache, and mucocutaneous ulcers.

DISEASE HIGHLIGHTS

1. The highest risk populations for HIV infection are:

   1. Men who have sex with men

   2. Injection drug users

   3. Commercial sex workers

   4. People with high number of sexual partners with inconsistent condom use

2. Transmission of HIV is common in the first 3 months of an infection.

   1. This is a period of high viral load.

   2. There are high levels of virus in blood and genital secretions.

   3. Patients often do not know they are infected.

   4. Early diagnosis is thus important to decrease rates of transmission.

EVIDENCE-BASED DIAGNOSIS

1. Clinical presentation

   1. The usual lag between exposure to HIV and development of symptoms is 2–4 weeks.

   2. 50–90% patients with acute HIV infection experience symptoms of acute retroviral syndrome.

   3. Symptoms seen in over 50% of patients with symptomatic acute retroviral syndrome are:

      1. Fever

      2. Fatigue

      3. Rash

      4. Headache

      5. Lymphadenopathy

      6. Pharyngitis

      7. Myalgia or arthralgia

      8. Nausea, vomiting, or diarrhea

      9. Weight loss

   4. Painful mucocutaneous ulcerations

      1. Less common but distinctive manifestation of the syndrome

      2. Often shallow and sharply demarcated

      3. Can involve the oral mucosa, anus, penis, or esophagus

   5. Table 30-5 lists test characteristics for findings suggestive of acute HIV infection.

2. Laboratory testing

   1. Laboratory testing is appropriate for patients in whom there is a clinical suspicion for acute retroviral syndrome.

   2. Testing should include:

      1. Fourth-generation HIV Immunoassay

         1. HIV can be detected as early as 18 days after infection.

         2. Older HIV antibody tests (ELISA and Western blot) have a longer window period.

         3. Sensitivity, 99–100%

         4. Specificity, 98–100%

      2. HIV viral load assay

         1. HIV virus can typically be detected 11 days after infection.

         2. Patients with acute retroviral syndrome typically have high viral loads of > 100,000 copies/mL.

         3. False-positive result should be suspected if viral load is < 10,000 copies/mL.

         4. Sensitivity, 95–98%

      3. Genotype resistance testing is recommended in all patients with primary HIV infection, since transmission of drug-resistant HIV strains has been documented.

   Because HIV antigen/antibody tests may be negative at the time of acute seroconversion, an HIV viral load assay should always be sent when this diagnosis is being considered.

TREATMENT

1. Antiretroviral therapy is recommended for all individuals with HIV; this includes patients with acute and early HIV infection.

2. Referral to an HIV specialist is recommended if the provider is not trained in management of HIV.

3. Genotypic drug resistance testing ...