Didactic Series Primary HIV Infection Greg Melcher, M.D. UC Davis AETC 8 Nov 2012 ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. Disclosure Statement: Speaker has no personal financial relationship with a commercial interest that produces, markets or distributes health care goods or services 1 discussed in this presentation.
Learning Objectives Recognize the pattern of signs and symptoms that suggest primary HIV infection (PHI) Understand the diagnostic tests available to diagnose acute HIV infection Understand the importance of early diagnosis of HIV infection for reducing transmission 2
Primary HIV Infection (PHI) Why bother? We can always treat it later. Highest risk of transmission Cannot effect behavior change without knowledge of infection Viral loads range from 100,000 copies/ml to several million copies/ml Early diagnosis affords opportunity for early linkage to care and treatment 3
PHI - Clinical Presentation 40 90% of patients with PHI present with symptoms of acute retroviral syndrome Onset 2-6 weeks after HIV exposure Mimics acute viral syndrome with nonspecific symptoms Majority present to medical attention in ED, primary care settings Only 25% receive correct diagnosis Schacker T et al. Ann Intern Med 1996; 125:257-64. 4
PHI - Clinical Presentation Fever Fatigue Pharyngitis Oral ulcerations Maculopapular rash Weight loss Diffuse lymphadenopathy Myalgias Headache Nausea Diarrhea Leukopenia Thrombocytopenia Mild transaminase elevations Kahn JO, Walker, BD. N Engl J Med 1998; 339:33-9. 5
PHI - Clinical Presentation Important to think about acute HIV infection to make the diagnosis May mimic other common viral, bacterial, parasitic and non-infectious illnesses 6
PHI - Differential Diagnosis Viral - EBV, CMV, primary HSV, Influenza, early acute hepatitis, Parvovirus B19, Rubella Parasitic acute toxoplasmosis Bacterial - Streptococcal pharyngitis, secondary syphilis, Rickettsial disease, disseminated gonococcal infection Noninfectious Adult onset Still disease, SLE, systemic vasculitis, drug eruptions 7
Clues to the Diagnosis of PHI Rash Mucosal ulcerations Generalized lymphadenopathy Abnormal neurologic findings Negative EBV heterophile antibody assay results in clinical setting of acute mononucleosis 8
Acute HIV: Oral Manifestations BD Walker, MD 40 th IDSA 2002; Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39 9
Acute HIV - Maculopapular Rash Photograph from David Spach, MD 10
HIV Testing for PHI HIV antibodies detectable within 4-12 weeks, but may be delayed for 6-12 months HIV RNA testing or p-24 antigen testing can be performed p-24 antigen assay may be false negative late in course of PHI HIV RNA levels < 1,000 copies/ml are suspect for PHI need to repeat All RNA testing needs to be confirmed in 4-8 weeks with Western Blot testing 11
Treatment for PHI Reasonable to consider starting antiretroviral therapy for PHI Treatment as prevention; highest viral load is during PHI May improve HIV-specific immune function for individual No data to support individual benefit Need to assess individual s commitment to adherence with treatment plan 12
References Kahn JO, Walker, BD. Acute human immunodeficiency virus type 1 infection [review]. N Engl J Med 1998; 339:33-9. Schacker T et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257-64. Schacker T et al. Biological and virologic characteristics of primary HIV infection. Ann Intern Med 1998; 128:613-20. 13