HIV infection.

The levels of evidence [A-D] supporting the recommendations are defined at the end of the "Major Recommendations" field.

Basic Rules

Identification of the human immunodeficiency virus (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 and in young individuals with weight loss, dementia or oesophageal candidiasis, thrombocytopenia, or anaemia without a clear cause
Antibodies will become positive in 1 to 4 months after contracting the infection. To exclude the possibility of HIV infection, the development of antibodies should be followed up until four months have elapsed. The primary symptoms may become manifest 2 to 6 weeks after the transmission.
There is no cure for HIV infection, but a combination therapy (highly active antiretroviral therapy [HAART]) has greatly improved the patients' outlook (Rutherford, Sangani, & Kennedy, 2003) [A].

Epidemiology

According to the World Health Organization (WHO), in 2004 an estimated 5 million new infections with HIV were diagnosed worldwide, a total of 3 million people died of HIV/acquired immunodeficiency syndrome (AIDS)-related causes, and there were 40 million people living with HIV/AIDS.
In Western Europe, new infections are mainly related to sex tourism, prostitution, and use of intravenous drugs.

Natural Course of HIV Infection

Primary Infection

Primary HIV infection develops in 30% to 50% of infected patients, 2 to 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 over 50% of the patients will be HIV antibody negative. The HIV antigen test and polymerase chain reaction (PCR) assay become positive at an earlier stage. A positive PCR assay warrants confirmation with other test methods at a later stage (Owens et al., 1996) [C].

Asymptomatic Phase

Lasts for several years, in some cases over 10 years
A high viral load will hasten the disease progression.

Symptomatic HIV Infection

CD4 cell count has often decreased to below 0.35 x 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 (see Picture 1 in the original guideline document) are also indicative of reduced immune response.

AIDS

AIDS is defined as an HIV infection with at least one of the officially listed opportunistic diseases.
The introduction of HAART has significantly reduced the occurrence of opportunistic diseases.
The most common opportunistic diseases in Western Europe are:
- Fungal oesophagitis or stomatitis
- Infections caused by atypical mycobacteria (Mycobacterium avium-intracellulare)
- Pneumocystis jirovecii pneumonia
- Kaposi's sarcoma
Tuberculosis is common in the rest of the world.

Indications for an HIV Test

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
- Tuberculosis in a young or middle-aged person
- 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)
HIV serology should always be tested on the patient's request.
The patient should be asked for consent before 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.
Pregnant women are offered voluntary screening at maternity clinics.

Diagnosis

HIV antibody test. A positive sample is retested; if it remains positive the laboratory will request a further sample before submitting a result.
The test will become positive 2 to 4 weeks after symptom onset or 1 to 4 months after contracting the virus.
HIV nucleic acid test should be considered when strong suspicion of the infection exists in a patient with primary symptoms and if urgent diagnosis is required and the antibody test is negative.

Investigations and Patient Education in Primary Care

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 (AIDS help lines are available 24 hours a day).
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. (Wolitski et al., 1997) [B].
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 hepatitis C virus (HCV) antibodies should be investigated.
The follow-up of the patient is usually undertaken by an infectious disease team.

Treatment

See the National Guideline Clearinghouse (NGC) summary of the Centers for Disease Control and Prevention (CDC) guideline: Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.

Specific Treatment with HIV Drugs

Treatment of an HIV infection requires specialist skills, and the prescription and implementation of drug therapies should be undertaken only by those experienced in their use.
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.
Indications for starting drug therapy for an HIV infection are:
- Symptomatic disease (particularly if AIDS is diagnosed)
- Asymptomatic disease, if CD4 cell count falls below 0.35 x 10⁹/L
- An HIV positive pregnant mother (to prevent vertical transmission) (Brocklehurst, 2002) [A]
The treatment is carried out with the combination of at least three antiviral drugs (HAART) (Rutherford, Sangani, & Kennedy, 2003) [A].
During effective drug treatment, the viral load in plasma is below detection threshold (40 copies/mL) and due to successful treatment, the CD4 count increases and the risk if complications 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.
- HIV drugs interact with several other drugs. There is potential for too high or too low concentrations of either drug. Specialist consultation should always be sought in unclear cases.
Patient compliance is the most important factor in successful drug therapy for HIV infection.
- Adverse effects are common, particularly in the beginning.
- 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 HAART-treatment decreases the viral load in maternal plasma below detection threshold before delivery.

HIV and the General Practitioner

The asymptomatic phase lasts for a long time, and the correct timing of the specific antiviral drugs effectively reduces the occurrence of opportunistic diseases. These patients will visit their general practitioner (GP) more often than before with common infections, skin or dental problems, or with problems totally unrelated to their positive HIV status.
- 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 antiretroviral medication has been introduced.
- Abnormal headache, paralysis, impaired consciousness, or visual disturbances in an HIV positive patient always warrant an immediate referral to specialist care for further investigations.
HIV is not curable with current drug therapies, and the introduction of terminal care may have to be broached at some stage. The options include home nursing services, hospices, or general hospital wards. The situation should be anticipated in good time to allow the appropriate staff time to undertake any additional training.

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. AIDS might cause permanent loss of working capacity or it may be restored by 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.

Post-Exposure Prophylaxis in an Occupational Setting

The risk of infection is very small. After verified HIV exposures associated with needle stick injuries, the risk has been around 0.1 percent.
In percutaneous exposure, where the source patient is known to be HIV positive, prophylaxis is recommended with a combination of three drugs for four weeks. The treatment should be started within two hours of the exposure, but it has an effect even when started within two days. Post-exposure prophylaxis has been found to be effective (Talbot, 2004) [B] but should be reserved for cases where the potential for infection transmission exists because of the potentially dangerous adverse effects. Prophylaxis after mucous membrane exposure is discretionary. An infectious disease physician should be consulted in uncertain cases and in order to obtain assistance in risk assessment.
The decision about initiating post-exposure prophylaxis must be made by a physician with HIV experience. Health care staff must have access to post-exposure prophylaxis 24 hours a day.
An HIV antibody test should be taken without delay and again after 1, 3, and 6 months.
If antiviral medication was prescribed for prophylaxis, antibody testing may be continued for even longer.
Official notification must always be made of a needle stick injury.
During the follow-up period, a condom must be used during sexual intercourse (Weller & Davis, 2002) [B].

Related Resources

Refer to the original guideline document for related evidence, including Cochrane reviews and other evidence summaries.

Definitions:

Levels of Evidence

Quality of Evidence: High
Further research is very unlikely to change confidence in the estimate of effect
- Several high-quality studies with consistent results
- In special cases: one large, high-quality multi-centre trial

Quality of Evidence: Moderate
Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.
- One high-quality study
- Several studies with some limitations

Quality of Evidence: Low
Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.
- One or more studies with severe limitations

Quality of Evidence: Very Low
Any estimate of effect is very uncertain.
- Expert opinion
- No direct research evidence
- One or more studies with very severe limitations

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