RECOGNIZING AND MANAGING ACUTE HIV
As noted above, the symptoms of acute (or primary) retroviral syndrome can suggest numerous other infectious processes, including mononucleosis, influenza, or the common cold. The most common symptoms are fever, fatigue, and malaise, but arthralgias, headache, anorexia, nausea, diarrhea, and pharyngitis are also common. The severity of symptoms can range widely, sometimes causing very mild illness and occasionally causing symptoms sufficiently severe to require hospitalization. In a patient presenting with symptoms that may result from acute retroviral syndrome, an HIV RNA test should be performed as it is the earliest indicator of HIV infection. It is critical that a patient suspected of having acute HIV be counseled regarding prevention of transmission since his or her infectivity during the initial infection is extremely high.
The latest US Department of Health and Human Services (HHS) HIV guidelines, published in February 2013, recommend that all patients newly diagnosed with HIV be offered antiretroviral treatment.15 It is likely that earlier initiation of therapy will reduce the viral set point (the level of virus reached after an immune response to initial infection) and potentially reduce overall damage to the immune system.16 As with all HIV-positive patients, those with new infection must be prepared to commit to ongoing antiretroviral therapy, with the goal of achieving an undetectable viral load.
RECOGNIZING AND MANAGING CHRONIC HIV
Most people with HIV infection will be asymptomatic up until approximately 10 years after the initial infection (hence the importance of screening), but some clinical symptoms and signs should bring HIV to mind as a possible cause. Persistent or recurrent fungal infections, especially oral thrush but also vaginal candidiasis, herpes zoster in an otherwise healthy patient, seborrheic dermatitis, unexplained weight loss, or persistent lymphadenopathy should trigger a suspicion of HIV during the differential diagnosis. Patients may also present very late in their HIV infection with far more serious opportunistic complications, including Pneumocystis jiroveci (formally carinii) pneumonia, infectious esophagitis, cryptococcal meningitis, tuberculosis, Kaposi sarcoma, or any of a myriad of other infectious or neoplastic complications of HIV-related immunosuppression. Most of these very serious illnesses will occur only in patients with a severely depressed immune system (CD4 < 200 cells/mm3), but some patients with very low CD4 cell counts may have no or only very mild symptoms.
Because improved screening has been shown to reduce the proportion of people presenting late in the course of HIV infection,17 patients presenting with severe manifestations of HIV-related immune dysfunction should become increasingly rare. Nonetheless, clinicians should include HIV in the differential for any patient presenting with a significant infection or cancer. A full discussion of HIV-related opportunistic infections and cancers is beyond the scope of this article, but further information can be found at www.aidsinfo.nih.gov.
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