HIV Review Study Notes

Recently I reviewed my blog post “#121 HIV Care for the Internist” – Help From The Curbsiders
Posted on November 29, 2018 by Tom Wade MD.

The guest speaker of the podcast was physician-scientist Michael Saag MD, a pioneer in HIV treatment. He has written a book, Positive, about his clinical and laboratory experience in HIV care. It is outstanding. Everyone interested in medical history as well as the history of HIV will be both informed and moved by Dr. Saag’s Journey. We are fortunate that he has shared it with us.

So I reviewed again the complete show notes of #121 HIV Care For The Internist. The tests for HIV are well covered in the show notes.

And Dr. Saag reminds us that we should screen everyone because the earlier HIV infection is diagnosed, the better for the individual and for society.

In his book, Promise, Dr. Seeger discusses the acute seroconversion syndrome which is also called the Acute Retroviral Syndrome.

Here is a great blog post, Acute Retroviral Syndrome In The ED, from the nuem blog:

What is acute retroviral syndrome? [3]

  • A febrile, mononucleosis-like illness that 25-90% of the newly HIV infected patients will manifest
  • Occurs around 2-6 weeks after transmission
  • Characterized by fever, generalized lymphadenopathy, pharyngitis, night sweats, headache, nausea, and other symptoms
  • May last days or weeks
  • Extremely high viral levels, temporarily low CD4 cell counts
  • Virus infects wide variety of tissues, seeds the lymphoid organs

And the patient is extremely infectious during this period. So early diagnosis and treatment can help prevent the transmission of HIV.

Fourth Generation HIV Testing in the Emergency Department

Today’s fourth generation HIV tests detect not only HIV antibodies but also HIV p24 antigens. Testing for the p24 antigen has allowed for detection of primary HIV infections which may have escaped earlier antibody-only testing methods, before the body can mount a detectable immune response. One study of an opt-in HIV screening program using a fourth generation antigen/antibody test revealed close to 25% of the newly diagnosed HIV infections were acute phase infections [9]. However, there will still be a period of time in which the infection may only be confirmed by presence of HIV RNA, via time and cost-intensive nucleic acid amplification testing.

Final Thoughts

  • Question all your febrile patients about HIV risk factors! Acute retroviral syndrome is worth considering in all patients with fever.
  • Recognition and early diagnosis of primary HIV has numerous public health benefits
  • Help diagnose primary HIV, either by:
    • Instituting CDC-recommended HIV Ab/Ag screening for all ED adult patients, with targeted HIV RNA PCR sent on high risk patients with symptoms of acute retroviral syndrome.
    • Sending fourth generation HIV Ab/Ag testing of all febrile patients with risk factors. If negative but still high risk or high risk historical factors, send an HIV RNA PCR or arrange outpatient follow-up for further testing.

And don’t forget that all patients who are at high risk of acquiring HIV infection should be offered PrEP – see #41: HIV, PrEP, and STI screening



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