In addition to this post please see the these other posts about the screening and treatment of sexually transmitted diseases (STDs):
- How To Take A Sexual History – Help From The Centers For Disease Control And Prevention (CDC)
Posted on November 29, 2018 by Tom Wade MD - #41 PrEP For HIV Prevention- Help From The Curbsiders
Posted on November 29, 2018 by Tom Wade MD - “#127 STIs Syphilis, Gonorrhea and Chlamydia” – Help From The Curbsiders
Posted on November 29, 2018 by Tom Wade MD
Knowing how and when to take a sexual history is a critical skill in the diagnosis of STDs and that is why I’ve included the above link on How To Take A Sexual History.
Today I’ve embedded the podcast of the Curbsiders‘ Episode #121 below [for my convenience].
And here is the link to the outstanding show notes.
And here are some excerpts from the show notes:
HIV Pearls from Dr. Saag
- Dr Saag recommends that clinicians screen every patient for HIV at initiation of care with an HIV 1/2 Antibody/Antigen (Ab/Ag) test and then every 3-4 months if risk factors are identified.
- Screen for HIV anytime you treat someone for a new sexually transmitted infection (STI). -Dr Saag
- The HIV Ab/Ag test will only miss individuals infected within the last 10-12 days. HIV viral load (RNA) is positive about 10 days after infection.
- Follow up a positive HIV Ab/Ag test with an HIV viral load.
- Screen for HLA-B*57:01 allele in each patient at diagnosis, and do not start treatment with abacavir if this is pending or positive due to abacavir hypersensitivity.
- Start treatment for HIV within 2 weeks of diagnosis. -Dr Saag
- Integrase inhibitor regimens are preferred due to potency and low side effect profile.
- Regimens that include the integrase inhibitors, dolutegravir or bictegravir, are first-line because they provide a one pill per day regimen. Raltegravir probably has the least likelihood of drug-drug interactions, but has a higher pill burden.
- The CD4 count is not a measure of immune system function!!! A high viral load CAUSES immune system dysfunction! Immune function returns rapidly once the viral load is suppressed. –Dr Saag
- Dr Saag recommends not following the CD4 count once viral load has been persistently suppressed (Saag JAMA 2018 PMID: 30043070) because it becomes irrelevant to management.
HIV Test Details
There are two major categories of testing for HIV: 1) the rapid HIV Antibody test and 2) the fourth generation HIV 1&2 Antibody/Antigen test. The rapid HIV antibody test is slightly less sensitive (98% vs. 99.5-99.7%). Dr Saag notes the rapid HIV test is more useful in public health settings or when follow up is uncertain. The fourth-generation antibody/antigen test is used to test for established infection (HIV 1 and 2 Antibodies) and acute phase infection (p24 Antigen: p for protein, 24 for kD -which is where the protein travels on a Western blot). The fourth-generation antibody/antigen test misses infection acquired within the last 10-12 days. Tests become positive at different times following viral infection. On average, the HIV RNA (viral load) is positive at 10 days, HIV Ag at 15-20 days, and HIV Antibody at 30 days. HIV 1 and HIV 2 represent different strains of the virus. In the United States, HIV 1 is far more prevalent than HIV 2. HIV 2 infections primarily occur in West Africa.
Additional Resources
(1) Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2018 Recommendations of the International Antiviral Society-USA Panel [PubMed Abstract] [Full Text HTML]. JAMA. 2018 Jul 24;320(4):379-396. doi: 10.1001/jama.2018.8431.
(2) National HIV Curriculum – A free educational web site from the University of Washington and the AETC National Coordinating Resource Center.
It is the goal of the National HIV Curriculum to provide ongoing, up-to-date information needed to meet the core competency knowledge for HIV prevention, screening, diagnosis, and ongoing treatment and care to healthcare providers in the United States.
