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Editors

JanneLaine
JanneMikkola

HIV Infection

See also the websites of ECDC http://www.ecdc.europa.eu/en/hiv-infection-and-aids, WHO http://www.who.int/news-room/fact-sheets/detail/hiv-aids and CDC http://www.cdc.gov/hiv/.

Essentials

  • Identification of the HIV-infected persons is most essential.
  • Suspect HIV infection on clinical grounds
    • in patients exposed to HIV infection in unprotected sex or via injections
    • in patients with a history of high-risk behaviour and who present with symptoms suggesting primary HIV infection
    • in patients with unexplained immunosuppression or recurring bouts of fever of unknown origin, unintentional weight loss, dementia, oesophageal candidiasis, thrombocytopenia or anaemia without a clear cause.
  • An HIV test will become positive in 1 to 3 months after contracting the infection. To exclude the possibility of HIV infection, the development of antibodies should be followed up until 3 months have elapsed. The primary symptoms may become manifest 2 to 6 weeks after the transmission.
  • Persons infected with HIV should be referred to specialized care according to local guidelines immediately after the diagnosis has been made.
  • There is no cure for HIV infection, but a combination therapy (cART = combination antiretroviral therapy, earlier HAART - highly active antiretroviral therapy) has improved the patients' life expectancy to be close to that of HIV-negative population.

Epidemiology

  • According to WHO, in 2019 an estimated 1.7 million new infections with HIV were diagnosed worldwide, a total of about 690 000 people died of diseases related to HIV infection and there were almost 38 million carriers of HIV infection.
  • In many European countries, new infections are often related to tourism, prostitution and use of intravenous drugs.

Natural course of HIV infection

Primary infection

  • Primary HIV infection develops in 30-50% of infected patients, 2-6 weeks after contracting the virus.
  • The symptoms may include: fever, tiredness, sore throat, headache, diarrhoea, myalgia, arthralgia and occasionally enlarged lymph nodes as well as an eruption of small papules on the body. Primary infection often resembles mononucleosis.
  • The symptoms resolve within a month.
  • Diagnosis is made difficult by the fact that during primary infection part of the patients still have a negative result in the HIV-AgAb test. HIV-AgAb test should thus be repeated after 3 months if primary infection is suspected and the first test remained negative.

Asymptomatic phase

  • Lasts for several years, in some cases over 10 years.

Symptomatic HIV infection

  • CD4 cell count has often decreased to below 0.35 × 109 /l.
  • An increasing viral load is often predictive of symptom emergence.
  • Symptoms are non-specific, such as weight loss, fever and persistent diarrhoea.
  • Herpes zoster (shingles), oropharyngeal candidiasis and seborrhoeic eczema are also indicative of reduced immune response. See also picture .

AIDS

  • AIDS is defined as an HIV infection with at least one of the officially listed opportunistic diseases.
  • The introduction of cART has significantly reduced the occurrence of opportunistic diseases.
  • The most common opportunistic diseases in Western Europe are:
    • fungal oesophagitis or stomatitis
    • Pneumocystis jirovecii pneumonia
    • infections caused by environmental mycobacteria (M. avium-intracellulare)
    • Kaposi's sarcoma.
  • Tuberculosis is a common associated disease in many countries.

Indications for an HIV test Mass Media Interventions for Promoting HIV Testing

  • An HIV test may be indicated particularly in the following clinical conditions:
    • there is a history of high-risk behaviour: unprotected sex with occasional partners or with prostitutes, or use of intravenous drugs
    • sexually transmitted diseases
    • fever, diarrhoea, weight loss or dementia of unknown origin
    • unexplained thrombocytopenia
    • pneumonia caused by Pneumocystis jiroveci (opportunistic pneumonia typically presenting with slow onset, dyspnoea on exertion, hypoxaemia, and mild or moderate fever)
    • widespread oral candidiasis associated with dysphagia or pain on swallowing (oesophageal candidiasis)
    • Kaposi's sarcoma (wine-red or violet spots or tumours in the palate, gums or skin)
    • hepatitis B or C is diagnosed
    • patient has symptoms and signs suggesting primary HIV-infection
    • cervical cancer, at least if it is diagnosed in a young woman
    • lymphoma diagnosed
    • tuberculosis
    • community-acquired pneumonia.
    • HIV test is recommended to be included in the health check-ups of immigrants coming from endemic regions.
  • HIV serology should always be tested when requested by the patient. HIV testing should be offered if one knows that behaviour exposing a person to HIV infection, such as unprotected occasional sexual contacts or intravenous drug use, has taken place.
  • The patient should be informed about an intention of HIV testing. If the patient declines the test, the problems and possible harm caused by the delayed diagnosis, both for the patient himself/herself, the treating personnel (extra investigations and prolonged treatment time) and other people (infection risk), should be further explored with the patient.
  • The result of a HIV test is reliable when 3 months have passed after the exposure. During the follow-up period, a condom must be used during sexual intercourse Condom Effectiveness in Reducing Heterosexual HIV Transmission.
  • Pregnant women are offered voluntary screening at maternity clinics.

Diagnosis

  • Combined HIV-AgAb test
    • When a patient is for the first time identified as HIV positive, it is advisable to take a control sample to exclude potential mix-up of samples. Additional samples may be needed e.g. for archival purposes according to national legislation.
  • The test will become positive 2-4 weeks after symptom onset or at latest 3 months after contracting the virus. If the person has been given prophylactic HIV medication after the exposure, test results are monitored for up to 6 months from the exposure.

Investigations and patient education in primary care Effects of HIV Counseling and Testing on Sexual Risk Behaviour, Interventions to Reduce HIV Risk with Heterosexual Men, Needle-Change Programs for Prevention of HIV Infection, Behavioral Interventions to Reduce Risk for Sexual Transmission of HIV Among Men Having Sex with Men, Setting and Organization of Care for Persons Living with HIV/AIDS, Population-Based Interventions for Reducing Sexually Transmitted Infections Including HIV

  • Consult local guidelines and policies concerning the appropriate place of treatment and monitoring of patients with HIV infection. Make a referral to specialist care as soon as the infection is detected.
  • Adequate time must be allocated for breaking the news of a positive test result. The patient should also be given contact details of how to obtain more information or moral support (HIV help lines, peer support organisations, etc.). If necessary, an infectious-disease specialist may be consulted before meeting the patient.
  • If the result is negative the patient should be given advice regarding high-risk behaviour and the possible need of a repeat test.
  • Any unit carrying out HIV testing should be able to provide a patient whose HIV test result is positive with general information regarding the mode of HIV transmission, course of the disease and the treatment choices available. The unit should also be prepared to answer any questions relating to daily hygiene needs etc. The Effects of HIV Counseling and Testing (HIV CT) on Risk-Related Practices and Help-Seeking Behaviour.
  • The disease staging and the assessment of an individual patient's prognosis, as well as the decision on specific drug therapies, are carried out by a specialist team.
  • As soon as a positive test result is obtained every effort should be made to identify and inform the patient's past contacts, who should be encouraged to agree to be tested.
  • An official notification of an infectious disease should be made.
  • If the patient is an intravenous drug user, a hepatitis B vaccination programme is commenced unless the patient has had the disease or has already been vaccinated. Also the HCV antibodies should be investigated.
  • The follow-up of the patient is usually permanently undertaken by an infectious disease team. Patients on drug treatment should be seen usually every 3 to 6 months.

Treatment Prophylactic Treatments Against Pneumocystis Carinii Pneumonia and Toxoplasma Encephalitis in HIV-Infected Patients, Cotrimoxazole Prophylaxis for Opportunistic Infections in Adults with HIV, Treatment of Severe or Progressive Kaposi's Sarcoma (Ks) in HIV-1 Infected Adults, Efficacy of Antidepressant Medication Among HIV-Positive Individuals with Depression, Treatment of Oropharyngeal Candidiasis Associated with HIV Infection in Adults, Treatment for Anemia in People with AIDS, Massage Therapy for People with HIV/AIDS, Antifungal Prophylaxis for Cryptococcal Disease in Adults with HIV, Adsorbents for Chronic Diarrhoea in People with HIV/AIDS, Herbal Medicines for Treating HIV Infection and AIDS, Structured Treatment Interruptions in Chronic Suppressed HIV Infection in Adults, Anabolic Steroids for Weight Loss in HIV-Infected Individuals, Nutritional Interventions for Reducing Morbidity and Mortality in People with HIV, Interventions for AIDS-Associated Hodgkin's Lymphoma, Interventions for Decreased Bone Mineral Density Associated with HIV Infection, Structured Treatment Interruptions (Sti) in Chronic Unsuppressed HIV Infection in Adults, Management of Toxoplasmic Encephalitis in HIV-Infected Adults, Adjunctive Corticosteroids for Pneumocystis Jiroveci Pneumonia in Patients with HIV-Infection

Specific treatment with HIV drugs Stavudine, Lamivudine and Nevirapine Combination Therapy for Treatment of HIV Infection and AIDS, Cotrimoxazole for Opportunistic Infections of HIV/AIDS in Patients with Previous History of Hypersensitivity to Cotrimoxazole, A Combination Drug of Abacavir-Lamivudine-Zidovudine (Trizivir) for Treating HIV Infection and AIDS, Therapeutic Drug Monitoring of Antiretrovirals for People with HIV

  • Treatment of an HIV infection requires specialist skills, and the prescription and monitoring of drug therapies should take place in appropriate centres with special expertise.
  • The development of HIV drugs has significantly improved the prognosis of an HIV infection. No cure exists, but it may be possible to add several tens of years to the life expectancy of an HIV positive patient. Quality of life has also improved significantly as has the patients' ability to continue in working life.
  • Drug therapy for HIV infection is offered to all infected persons who are capable of committing to the therapy. Starting drug therapy is particularly important for those with a symptomatic disease and for pregnant women (to prevent vertical transmission) Interventions for Reducing Mother-to-Child Transmission of HIV Infection.
  • The treatment is usually carried out with the combination of three antiviral drugs (cART) Three- or Four-Drug Versus Two-Drug Antiretroviral Maintenance Regimens for HIV Infection.
  • During effective drug treatment, the viral load in plasma is below detection threshold (20 copies/ml) and due to successful treatment, the CD4 cell count increases, the risk of complications decreases and the transmission risk significantly decreases.
  • Once antiviral drug therapy has been started, its uninterrupted continuation is of vital importance.
    • Development of drug resistance and loss of efficacy may follow irregular adherence to therapy.
    • The treatment must not be interrupted without prior consultation with the treating physician.
    • Long-term effective drug therapy greatly decreases the infectivity of HIV.
  • Patient compliance is the most important factor in successful drug therapy for HIV infection.
    • To facilitate dosing at the same time every day may involve some lifestyle changes.
    • To maintain a long-term treatment response, at least 95% of the drug doses should be taken at the specified time.
  • The risk of foetal transmission is below 1% provided that the maternal infection is detected in time and that the cART-treatment decreases the viral load in maternal plasma below detection threshold before delivery.
  • See also the European EACS guidelinehttp://www.eacsociety.org/guidelines/eacs-guidelines/eacs-guidelines.html and the NIH guideline http://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf.

HIV and the general practitioner

  • These patients will visit their GP with common public health problems, such as hypertension, diabetes, common infections, skin or dental problems or with problems totally unrelated to their positive HIV status.
    • HIV drugs interact with several other drugs. There is potential for too high or too low concentrations of some of the drugs. If necessary, consult a physician from the centre responsible for the patient's antiviral pharmacotherapy.
    • When an HIV positive patient presents with a febrile illness the treating specialist unit should be consulted over the telephone in all unclear cases, particularly if the patient's CD4 count is especially low.
  • By prophylactic drug treatment (PEP = post-exposure prophylaxis) it is possible to significantly reduce the risk of HIV infection after both work-related Occupational Exposure to Blood and Body Secretions and other exposure incidents (e.g. condom breakage during intercourse of a HIV discordant couple). Prophylactic treatment is recommended to be started as soon as possible, preferably within 2 hours but not later than 72 hours after the exposure. The nearest centre responsible for treating HIV patients should be consulted whether prophylactic treatment is indicated.
  • Prophylactic drug treatment that is started before exposure (PrEP = pre-exposure prophylaxis), when used correctly, has been shown to prevent HIV infections associated with heterosex, sex between men, and the use of illegal intravenous drugs.
    • The provider of PrEP treatment must be very familiar with HIV infections, as well as with sexually transmitted diseases and sexual behaviour.
    • PrEP is not necessarily reimbursed. Country-specific variation may apply.

The working capacity of HIV carriers

  • During the asymptomatic phase the working capacity of the patient usually remains normal.
  • The decreased working capacity during primary infection is transient. Loss of working capacity caused by AIDS may be restored during antiviral treatment.
  • Infection risk does not usually contribute towards the patient's inability to work.

Guidelines for health care professionals

  • When exposure to blood is a possibility, gloves and a facial shield protecting also the eyes should be worn.
  • Gloves should be worn when taking blood samples, but there is no need to wear a facial shield (if vacuum tubes are used).
  • Particular attention should be paid to following recommended procedures in order to avoid needle stick injuries.
  • Occupational exposure to HIV, see Occupational Exposure to Blood and Body Secretions.

    References

    • Ryom L, Cotter A, De Miguel R ym. 2019 update of the European AIDS Clinical Society Guidelines for treatment of people living with HIV version 10.0. HIV Med 2020;21(10):617-624. [PubMed]