HIV infection

See also CDC website

Essentials

• Identification of the HIV-infected persons is most essential.
• Suspect HIV infection on clinical grounds
  • in patients exposed to HIV infection in unprotected sex or via injections
  • in patients with a history of high-risk behaviour and who present with symptoms suggesting primary HIV infection
  • in patients with unexplained immunosuppression or recurring bouts of fever of unknown origin, unintentional weight loss, dementia, oesophageal candidiasis, thrombocytopenia or anaemia without a clear cause.
• An HIV test will become positive in 1 to 3 months after contracting the infection. To exclude the possibility of HIV infection, the development of antibodies should be followed up until 3 months have elapsed. The primary symptoms may become manifest 2 to 6 weeks after the transmission.
• Persons infected with HIV should be referred to specialized care according to local guidelines immediately after the diagnosis has been made.
• There is no cure for HIV infection, but a combination therapy (HAART – highly active antiretroviral therapy) has greatly improved the patients' outlook.

Epidemiology

• According to WHO, in 2014 an estimated 2 million new infections with HIV were diagnosed worldwide, a total of 1.5 million people died of HIV/AIDS-related causes and there were almost 37 million people living with HIV/AIDS.
• In Western Europe, new infections are mainly related to tourism, prostitution and use of intravenous drugs.

Natural course of HIV infection

Primary infection

• Primary HIV infection develops in 30–50% of infected patients, 2–6 weeks after contracting the virus.
• The symptoms may include: fever, tiredness, sore throat, headache, diarrhoea, myalgia, arthralgia and occasionally enlarged lymph nodes as well as an eruption of small papules on the body. Primary infection often resembles mononucleosis.
• The symptoms resolve within a month.
• Diagnosis is made difficult by the fact that during primary infection part of the patients still have a negative result in the HIV-AgAb test. HIV-AgAb test should thus be repeated after 3 months if primary infection is suspected and the first test remained negative.

Asymptomatic phase

• Lasts for several years, in some cases over 10 years.
• A high viral load will hasten the disease progression.

Symptomatic HIV infection

• CD4 cell count has often decreased to below 0.35 × 10⁹/l.
• An increasing viral load is often predictive of symptom emergence.
• Symptoms are non-specific, such as weight loss, fever and persistent diarrhoea.
• Herpes zoster (shingles), oropharyngeal candidiasis and seborrhoeic eczema)"?> are also indicative of reduced immune response. See also picture .

AIDS

• AIDS is defined as an HIV infection with at least one of the officially listed opportunistic diseases.
• The introduction of HAART has significantly reduced the occurrence of opportunistic diseases.
• The most common opportunistic diseases in Western Europe are:
  • fungal oesophagitis or stomatitis
  • Pneumocystis jirovecii pneumonia
  • infections caused by atypical mycobacteria (M. avium-intracellulare)
  • Kaposi's sarcoma.
• Tuberculosis is a common associated disease in many countries.

Indications for an HIV test

• An HIV test may be indicated particularly in the following clinical conditions:
  • there is a history of high-risk behaviour: unprotected sex with occasional partners or with prostitutes, or use of intravenous drugs
  • sexually transmitted diseases
  • fever, diarrhoea, weight loss or dementia of unknown origin
  • unexplained thrombocytopenia tuberculosis in a young or middle-aged person
  • pneumonia caused by Pneumocystis jiroveci (opportunistic pneumonia typically presenting with slow onset, dyspnoea on exertion, hypoxaemia, and mild or moderate fever)
  • widespread oral candidiasis associated with dysphagia or pain on swallowing (oesophageal candidiasis)
  • Kaposi's sarcoma (wine-red or violet spots or tumours in the palate, gums or skin)
  • hepatitis B or C is diagnosed
  • patient has symptoms and signs suggesting primary HIV-infection
  • cervical cancer, at least if it is diagnosed in a young woman
  • lymphoma diagnosed
  • tuberculosis
  • community-acquired pneumonia.
  • HIV test is recommended to be included in the health check-ups of immigrants coming from endemic regions.
• HIV serology should always be tested when requested by the patient.
• The patient should be informed about an intention of HIV testing. If the patient declines the test, the problems and possible harm caused by the delayed diagnosis, both for the patient himself/herself, the treating personnel (extra investigations and prolonged treatment time) and other people (infection risk), should be further explored with the patient.
• During the follow-up period, a condom must be used during sexual intercourse .
• Pregnant women are offered voluntary screening at maternity clinics.

Diagnosis

• Combined HIV-AgAb test
  • When a patient is for the first time identified as HIV positive, it is advisable to take a control sample to exclude potential mix-up of samples. Additional samples may be needed e.g. for archival purposes according to national legislation.
  . A positive sample is retested; if it remains positive the laboratory will request a further sample before submitting a result.
• The test will become positive 2–4 weeks after symptom onset or at latest 3 months after contracting the virus. If the person has been given prophylactic HIV medication after the exposure, test results are monitored for up to 6 months from the exposure.

Investigations and patient education in primary care

• Adequate time must be allocated for breaking the news of a positive test result. The patient should also be given contact details of how to obtain more information or moral support (HIV help lines, peer support organisations, etc.). If necessary, an infectious-disease specialist may be consulted before meeting the patient.
• If the result is negative the patient should be given advice regarding high-risk behaviour and the possible need of a repeat test.
• Any unit carrying out HIV testing should be able to provide a patient whose HIV test result is positive with general information regarding the mode of HIV transmission, course of the disease and the treatment choices available. The unit should also be prepared to answer any questions relating to daily hygiene needs etc. .
• The disease staging and the assessment of an individual patient's prognosis, as well as the decision on specific drug therapies, are carried out by a specialist team.
• As soon as a positive test result is obtained every effort should be made to identify and inform the patient's past contacts, who should be encouraged to agree to be tested.
• An official notification of an infectious disease should be made.
• If the patient is an intravenous drug user, a hepatitis B vaccination programme is commenced unless the patient has had the disease or has already been vaccinated. Also the HCV antibodies should be investigated.
• The follow-up of the patient is usually permanently undertaken by an infectious disease team. Patients on drug treatment should be seen at least every 3 to 6 months.

Treatment

Specific treatment with HIV drugs

• Treatment of an HIV infection requires specialist skills, and the prescription and implementation of drug therapies should be undertaken only by those experienced in their use.
• The development of HIV drugs has significantly improved the prognosis of an HIV infection. No cure exists, but it may be possible to add several tens of years to the life expectancy of an HIV positive patient. Quality of life has also improved significantly as has the patients' ability to continue in working life.
• Drug therapy for HIV infection is offered to all infected persons who are capable of committing to the therapy. Starting drug therapy is particularly important for those with a symptomatic disease and for pregnant women (to prevent vertical transmission) . Indications for starting drug therapy for an HIV infection are: symptomatic disease (particularly if AIDS is diagnosed) asymptomatic disease, if CD4 cell count falls below 0.35 × 109/l. an HIV positive pregnant mother (to prevent vertical transmission) . "?>
• The treatment is usually carried out with the combination of three antiviral drugs (HAART) .
• During effective drug treatment, the viral load in plasma is below detection threshold (20 copies/ml) and due to successful treatment, the CD4 cell count increases and the risk of complications decreases.
• Once antiviral drug therapy has been started, its uninterrupted continuation is of vital importance.
  • Development of drug resistance and loss of efficacy may follow irregular adherence to therapy.
  • The treatment must not be interrupted without prior consultation with the treating physician.
  • HIV drugs interact with several other drugs. There is potential for too high or too low concentrations of some of the drugs. Specialist consultation should always be sought in unclear cases.
  Long-term effective drug therapy greatly decreases the infectivity of HIV.
• Patient compliance is the most important factor in successful drug therapy for HIV infection.
  • Adverse effects are common, particularly in the beginning.
  • To facilitate dosing at the same time every day may involve some lifestyle changes.
  • To maintain a long-term treatment response, at least 95% of the drug doses should be taken at the specified time.
• The risk of foetal transmission is below 1% provided that the maternal infection is detected in time and that the HAART-treatment decreases the viral load in maternal plasma below detection threshold before delivery.
• See also guidelines by the CDC and the European EACS .

HIV and the general practitioner

• The asymptomatic phase lasts for a long time, and an early start of the specific antiviral drugs effectively reduces the occurrence of opportunistic diseases. These patients will visit their GP more often than before with common public health problems, such as hypertension, diabetes, common infections, skin or dental problems or with problems totally unrelated to their positive HIV status.
  • When an HIV positive patient presents with a febrile illness the treating specialist unit should be consulted over the telephone in all unclear cases, particularly if the patient’s CD4 count is especially low. Abnormal headache, paralysis, impaired consciousness or visual disturbances in an HIV positive patient always warrant an immediate referral to specialist care for further investigations.
• By prophylactic drug treatment it is possible to significantly reduce the risk of HIV infection after both work-related and other exposure incidents (e.g. condom breakage during intercourse of a HIV discordant couple). Prophylactic treatment is recommended to be started as soon as possible, preferably within 2 hours but not later than 72 hours after the exposure. The nearest centre responsible for treating HIV patients should be consulted whether prophylactic treatment is indicated.

The working capacity of HIV carriers

• During the asymptomatic phase the working capacity of the patient usually remains normal.
• The decreased working capacity during primary infection is transient. Loss of working capacity caused by AIDS may be restored during antiviral treatment.
• Infection risk does not usually contribute towards the patient's inability to work.

Guidelines for health care professionals

• When exposure to blood is a possibility, gloves and a facial shield protecting also the eyes should be worn.
• Gloves should be worn when taking blood samples, but there is no need to wear a facial shield (if vacuum tubes are used).
• Particular attention should be paid to following recommended procedures in order to avoid needle stick injuries.
• Occupational exposure to HIV, see .

Related resources

• Cochrane reviews
• Other evidence summaries
• Other Internet resources
• Literature

Ədəbiyyat

1. Ryom L, Boesecke C, Gisler V et al. Essentials from the 2015 European AIDS Clinical Society (EACS) guidelines for the treatment of adult HIV-positive persons. HIV Med 2016;17(2):83-8.