Make the Diagnosis: Early HIV Disease
Prior Probability of Unrecognized HIV Disease
Among persons 13 years of age and older, there are approximately 14 patients per 100 000 in the United States living with undiagnosed human immunodeficiency virus (HIV) infection.1 This is a lower rate than was reported in the initial Rational Clinical Examination series article on early HIV infection.
Population in Whom Early HIV Disease Should Be Considered
During the early 6-month period of HIV infection, 50% to 90% of patients develop an acute retroviral syndrome characterized by a constellation of symptoms including one or more of fever, nausea or vomiting, weight loss, arthralgia or myalgia, pharyngitis, oral ulcers, rash, and lymphadenopathy. However, this means many patients with infection will not have any symptoms. The prevalence of HIV disease varies with different behavioral risk factors (eg, men who have sex with men), race/ethnicity, gender, and region of the country. The US Centers for Disease Control and Prevention recommends screening all adults where the prevalence of disease is ≥0.1%.2
Assessing the Likelihood of Early HIV Disease
Many symptoms reported by the patient increase the likelihood of early HIV disease. The physical examination in early disease focuses on the presence of lymphadenopathy and genital ulcers. The most useful findings are shown in Table 96-1. The absence of symptoms or signs does not alter the likelihood of HIV disease, with no likelihood ratio (LR) less than 0.5. The positive LR does not vary based on the prevalence of disease. In studies with a higher prevalence of HIV disease, the absence of lymphadenopathy was more useful for identifying patients less likely to have HIV disease.
Table 96-1.Useful Findings for Assessing the Likelihood of Early HIV Disease |Favorite Table|Download (.pdf) Table 96-1. Useful Findings for Assessing the Likelihood of Early HIV Disease
|Findings ||LR+ (95% CI) ||LR- (95% CI) |
|Patient-reported symptoms |
|Genital ulcers ||5.4 (2.5–12) ||0.99 (0.97–1.0) |
|Weight loss ||4.7 (2.1–7.2) ||0.83 (0.72–0.94) |
|Vomiting ||4.6 (2.5–8.0) ||0.90 (0.73–0.97) |
|Swollen lymph nodes ||4.6 (1.3–8.0) ||0.91 (0.83–0.99) |
|Fever ||3.4 (2.4–4.4) ||0.74 (0.64–0.84) |
|Physical examination |
|Lymphadenopathy ||3.1 (1.0–5.2) ||0.70 (0.49–0.92) |
|Genital ulcer ||2.4 (1.5–3.6) ||0.89 (0.49–0.99) |
Laboratories establish the presence or absence of HIV infection based on an algorithm of serum or plasma tests approved by the US Food and Drug Administration.3
Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data-United States and 6 dependent areas-2012. HIV Surveillance Supplemental Report 2014;19(No. 3). http://www.cdc.gov/hiv/pdf/surveillance_report_vol_19_no_3.pdf
. Published November 2014. Accessed June 20, 2015.
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