II. Precautions

  1. Primary infection is often asymptomatic
  2. At least 12% of patients are unaware they are infected
  3. Acutely infected patient is high risk of transmission

III. Findings: Typical Presentation

  1. Mononucleosis-like illness
  2. Occurs 2-3 weeks after exposure in up to 90% of patients
  3. Precedes seroconversion by 10-21 days
  4. Self limited
  5. Medical attention sought in 20-30% of patients

IV. Findings: Acute Retroviral Syndrome

  1. Fever (low-grade <102) occurs in 80-90%
    1. Fever over 102 with rigors suggests occult infection
  2. Fatigue (70-90%)
  3. Erythematous Maculopapular Rash (40-80%)
    1. Face and Trunk
    2. Extremities involving palms and soles
  4. Headache (32-70%)
  5. Generalized Lymphadenopathy (40-70%)
  6. Pharyngitis (50-70%)
  7. Myalgia or Arthralgia (50-70%)
  8. Gastrointestinal symptoms (30-60%)
    1. Nausea or Vomiting
    2. Diarrhea
  9. Hepatosplenomegaly (14%)
  10. Night Sweats (50%)
  11. Oral Aphthous Ulcers or Thrush (10-20%)
  12. Genital Ulcers (5-15%)
  13. Neurologic symptoms (12%)
    1. Aseptic Meningitis (25%)
    2. Peripheral Neuropathy
    3. Facial palsy
    4. Guillain-Barre Syndrome
    5. Brachial Neuritis
    6. Cognitive Impairment
    7. Psychosis
  14. Malaise
  15. Anorexia
  16. Weight loss (70%)
  17. Wasting Syndrome
    1. Unexplained weight loss of >10% usual body weight

V. Evaluation: Initial

  1. What is the current risk of HIV progression?
    1. Based on CD4 Count and HIV Viral Load
    2. Are Antiretrovirals indicated at this point?
  2. What is the current risk of opportunistic infection?
    1. Based on CD4 Count and comorbid conditions
    2. Is prophylaxis or screening indicated?
      1. See HIV Prophylaxis of Secondary Infection
  3. What symptoms are present related to HIV status?
    1. Acute Retroviral Syndrome
    2. Manifestations suggesting advanced HIV (See AIDS Defining Illness and HIV Course)
  4. Identify comorbid conditions related to HIV Infection
    1. Sexually Transmitted Infections (e.g. Gonorrhea, Chlamydia, Syphilis)
    2. Viral Hepatitis (e.g. Hepatitis B, Hepatitis C)
    3. Substance Abuse
    4. Sexual practices (highest risk in Men who have Sex with Men)
  5. Identify Health Maintenance needs and other serious comorbidities
    1. Routine preventive care as indicated (e.g. Pap Smear, Mammogram, skin exam, Colonoscopy)
    2. Diabetes Mellitus
    3. Hypertension or Hyperlipidemia
    4. Major Depression

VI. Imaging: Chest XRay Indications

  1. Pulmonary symptoms on presentation or
  2. Tuberculin Skin Test positive

VII. Labs: HIV Diagnosis

  1. See HIV Screening for Lab protocol

VIII. Labs: Initial labs at time of diagnosis

  1. Labs often abnormal at diagnosis
    1. Complete Blood Count with Platelet Count
      1. Thrombocytopenia (45%)
      2. Leukopenia (40%)
    2. Liver Function Tests
      1. Hepatic enzyme (transaminase) levels may be elevated
  2. Baseline labs prior to starting medications
    1. Serum Creatinine
    2. Serum Glucose
    3. Lipid profile (affected by Protease Inhibitors)
    4. Urinalysis
  3. HIV Staging labs
    1. CD4 Count
      1. Best marker of HIV-related immunosuppression, infection duration and prognosis
      2. Varies from person to person, lab to lab, by time of day, and most significantly by acute comorbid illness
    2. Plasma HIV RNA level or Viral load
      1. See Protocol above
      2. Obtain 2 assays at 1-2 weeks apart
    3. Genotypic Antiretroviral Resistance Testing
      1. Test at baseline to direct Antiretrovirals
      2. Requires a viral load above lab cutoffs (typically >500/ml)
  4. Screen for infections prior to Immunization
    1. Hepatitis B Surface Antigen (HBsAg)
    2. Hepatitis A Serology (xHAV IgG)
  5. Screen for comorbid illness and immunity
    1. Hepatitis C Antibody (xHCV)
    2. Rapid Plasma Reagin (RPR)
    3. Toxoplasmosis IgG
    4. Cytomegalovirus IgG (CMV IgG)
    5. Neisseria gonorrhoeae PCR
    6. Chlamydia trachomatis PCR
    7. Tuberculosis Testing
      1. Tuberculin Skin Test (PPD) with >5mm positive in HIV, or
      2. Interferon Gamma Release Assay (Quantiferon Gold)
    8. Varicella IgG (VZV IgG)
      1. Test before Post-exposure Prophylaxis

IX. Monitoring: HIV Specific

  1. CD4 Count
    1. Initial
      1. Baseline (as above), then
      2. At 3 months after starting Antiretroviral therapy, then
      3. Repeat every 3-6 months for first 2 years
    2. After first 2 years
      1. CD4 >300 cells/mm3 for 2 years with suppressed viral load
        1. Obtain CD4 Count every 12 months
      2. CD4 >500 cells/mm3 for 2 years with suppressed viral load
        1. CD4 Count testing optional
  2. HIV Viral Load
    1. Baseline, then
    2. At 2-8 weeks after starting Antiretroviral therapy, then
    3. Repeat every 4-8 weeks until viral load <200 copies/ml, then
    4. Repeat every 3 to 6 months while viral load <200 copies/ml
  3. Antiretroviral drug therapy related testing
    1. Genotypic Antiretroviral Resistance Testing
      1. Baseline, then
      2. As indicated per therapy response
      3. Consider integrase resistance testing
    2. Other testing to consider
      1. G6PD Deficiency (risk of Septra or Dapsone induced Hemolytic Anemia)
      2. HLA-B*5701 (risk of Abacavir reaction)

X. Monitoring: Other testing

  1. Annual screening
    1. PPD Skin Test and Chest XRay
    2. Pap Smear
      1. Obtain every 3-6 months, then if 3 results normal, every 3 years
      2. HPV testing after 30 years old
    3. Anal cytology
      1. Not typically recommended aside from high risk men (esp. anal condyloma)
  2. Other annual tests depending on risks
    1. Rapid Plasma Reagin (RPR)
    2. Gonorrhea Antigen
    3. Chlamydia Antigen
    4. Hepatitis C Serology
    5. Hepatitis B Serology
    6. Toxoplasma IgG
  3. Periodic comorbidity screening depending on risks
    1. Complete Blood Count with Platelets
      1. Every 3 to 6 months
    2. Comprehensive metabolic panel (renal and liver function)
      1. Baseline, then
      2. At 2-8 weeks after starting Antiretroviral therapy, then
      3. Every 3 to 6 months
      4. Also monitor phosphate while on Tenofovir Disoproxil fumarate
    3. Urinalysis
      1. Obtain yearly (or every 6 months if on Tenofovir Disoproxil fumarate)
  4. Testing if CD4 Count <100 cells/mm3
    1. Acid fast bacteria Blood Culture for MAI Complex
    2. Dilated Funduscopic Exam for CMV q3-6 months

XI. Differential Diagnosis

  1. HIV related disease
    1. Occult infection (especially if CD4 Count< 200 cells)
    2. Anti-microbial agents (Drug Reaction in HIV)
      1. Most frequent cause of Drug Induced Fever
  2. Most Common
    1. Epstein-Barr Virus Infection (Mononucleosis)
    2. Influenza
    3. Severe Streptococcal Pharyngitis
    4. Viral Gastroenteritis
    5. Viral upper respiratory tract infection
  3. Less Common
    1. Drug Reaction
    2. Primary Herpes Simplex Virus Infection
    3. Viral Hepatitis
    4. Secondary Syphilis
  4. Least Common
    1. Aseptic Meningitis
    2. Primary Cytomegalovirus infection (CMV)
    3. Toxoplasmosis
    4. Rubella
    5. Brucellosis
    6. Measles
    7. Malaria
    8. Typhoid

XII. Management

  1. See HIV Course
  2. See HIV Treatment Strategy
  3. See Combination Antiretroviral Therapy (CART)
  4. Consult with HIV specialist to start management
  5. Consult social services, case management and HIV education
  6. Starting Antiretrovirals is usually not urgent
    1. Combination Antiretroviral Therapy (CART) is recommended as of 2014
    2. Early treatment and prevention (regardless of CD4 Count)
  7. Initial agents should be chosen carefully
    1. Genotypic Antiretroviral Resistance Testing is typically indicated prior to starting Antiretroviral agents
    2. Best response to therapy is with the first attempt
    3. Informed Consent for longterm compliance is critical
    4. Identify and manage barriers to compliance

XIII. Prevention: Strategies at diagnosis

  1. See HIV Prophylaxis of Secondary Infection
  2. Acute Retroviral Syndrome is high risk of transmission (10 fold increased risk)
    1. Peak viremia occurs with Acute Retroviral Syndrome
  3. Immunizations
    1. See Immunization in HIV
    2. General
      1. Do not give Live Vaccines (e.g. oral polio, Varicella Vaccine, Flumist) if CD4 Count <200
      2. Defer non-urgent vaccinations until after Antiretroviral therapy initiated to boost immune response
    3. Specific vaccinations
      1. Pneumovax (try to give when CD4 Count >200)
      2. Hepatitis B Vaccine (if HBsAg negative)
      3. Hepatitis A Vaccine (if risks)
      4. Influenza Vaccine annually
      5. Routine Tetanus Vaccine (Tdap or Td)
      6. Consider Hib Vaccine
  4. Health Maintenance
    1. Routine preventive care as indicated (e.g. Pap Smear, Mammogram, skin exam, Colonoscopy)
    2. Manage comorbidities including Cardiovascular Risk Factors

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Ontology: Acute HIV infection (C0343752)

Concepts Disease or Syndrome (T047)
ICD10 B23.0
SnomedCT 111880001
English Acute HIV infection syndrome, acute HIV infection, Acute human immunodeficiency virus infection (disorder), Acute HIV infection (disorder), HIV infection acute, Acute HIV infection (diagnosis), Acute HIV infection, Acute human immunodeficiency virus infection, Acute human immunodeficiency virus seroconversion illness, Acute infection with HIV, HIV seroconversion illness
Italian Infezione acuta da HIV, Malattia da sieroconversione HIV, Infezione acuta con HIV
Dutch HIV-seroconversieziekte, acute infectie met HIV, Acuut HIV-infectiesyndroom, acute HIV-infectie
French Séroconversion VIH, Infection aiguë à VIH, Infection à VIH aiguë
German HIV-Serokonversion, Akutes HIV-Infektionssyndrom, akute HIV-Infektion
Portuguese Infecção aguda com HIV, Doença de seroconversão HIV, Infecção por HIV aguda
Spanish Enfermedad por seroconversión VIH, Infección aguda por VIH, infección aguda por HIV, infección aguda por VIH (trastorno), infección aguda por VIH, Infección VIH aguda
Japanese HIVセロコンバージョン病, 急性HIV感染, HIVセロコンバージョンビョウ, キュウセイHIVカンセン
Czech Akutní HIV infekce, Choroba sérokonverze HIV
Korean 급성 HIV감염 증후군
Hungarian HIV seroconversio betegség, acut HIV-fertőzés, Acut fertőzés HIV-vel

Ontology: Acute retroviral syndrome (C1868989)

Concepts Disease or Syndrome (T047)
English Acute retroviral syndrome
Dutch acuut retroviraal syndroom
French Syndrome rétroviral aigu
German akutes retrovirales Syndrom
Italian Sindrome retrovirale acuta
Portuguese Síndrome retroviral agudo
Spanish Síndrome retroviral agudo
Japanese 急性レトロウイルス症候群, キュウセイレトロウイルスショウコウグン
Czech Akutní retrovirální syndrom
Hungarian acut retroviralis syndroma