Primary HIV Infection

Primary HIV Infection
Acute retroviral syndrome occurs at the time the infection is acquired in 60% to
80% of HIV-infected persons. The illness resembles infectious mononucleosis
from infection with Epstein-Barr virus (EBV). Risk factors for transmission of HIV
include history of a sexually transmitted disease, especially genital ulcers;
unprotected anal or genital intercourse; and multiple sexual partners.
I. Clinical signs and symptoms
A. The period between acquisition of HIV and onset of symptoms is about
14 days, and the characteristic signs and symptoms range from a mild
fever and sore throat to a severe mononucleosis-type syndrome with high
spiking fevers and a measles-like rash.
B. In those patients with symptomatic seroconversion, the five most
common signs and symptoms are fever, fatigue, pharyngitis, weight loss,
and myalgias. Characteristic symptoms of acute retroviral syndrome
occur in 50% to 90% of patients.

II. Laboratory features
A. Primary HIV infection is diagnosed by a positive plasma HIV RNA
obtained on the same day as a negative Western blot assay. When
suspicion for acute infection is high, such as in a patient with a report of
recent risk behavior in association with symptoms and signs of acute HIV
infection, a test for HIV RNA should be performed.
B. Clinical evaluation of possible primary HIV infection often includes a
heterophil antibody (Monospot) test to rule out EBV mononucleosis,
cytomegalovirus antigen or antibody, acute and convalescent serologic
tests for rubella and toxoplasmosis, rapid plasma reagin test, Western
blot assay for herpes simplex virus, and serologic tests for hepatitis
(including hepatitis C virus RNA polymerase chain reaction).
III. Initial management
A. When the diagnosis of primary HIV has been established, the patient
should be examined for syphilis, herpes simplex, venereal warts,
gonorrhea, and hepatitis.
B. If the patient was identified as HIV RNA-positive and HIV EIA-negative,
a follow-up HIV antibody test should be obtained 2 to 3 weeks after
resolution of symptoms to establish that seroconversion has taken place.
C. A baseline CD4+ count should be obtained at the time of diagnosis. In the
earliest stages of infection, the CD4+ count can sometimes be below 200
cells/:L. After the first several weeks of infection, a rebound in the CD4+
count to near normal levels may occur.
IV. Treatment of Primary HIV Infection
A. The therapeutic regimen for acute HIV infection should include a
combination of two nucleoside reverse transcriptase inhibitors and one
potent protease inhibitor. Potential combinations of agents are the same
as those used in established infection and include the following regimens:
Recommended Antiretroviral Agents for Initial Treatment of Established
HIV Infection
Antiretroviral drug regimens are comprised of one choice each from columns A and
B. Drugs are listed in alphabetical order.
Column B
Column A
Didanosine (Videx) + Lamivudine (Epivir)
Efavirenz (Sustiva)
Stavudine (Zerit) + Didanosine
Indinavir (Crixivan)
Stavudine + Lamivudine
Nelfinavir (Viracept)
Zidovudine (Retrovir) + Didanosine
Ritonavir (Norvir)+ Indinavir (Kaletra)
Zidovudine + Lamivudine
Ritonavir + Lopinavir
Ritonavir + Saquinavir (Fortovase or
Invirase)
B. Patient Follow-Up
1. Testing for plasma HIV RNA levels and CD4+ T cell count and toxicity
monitoring should be performed on initiation of therapy, after 4 weeks,
and every 3-4 months thereafter.
2. Antiretroviral agents should be continued indefinitely because viremia
has been documented to reappear or increase after discontinuation
of therapy.
C. Postexposure prophylaxis
1. Combination chemotherapy results in fewer transmissions, and use of
combination chemotherapy, including a protease inhibitor, is
suggested following a significant intravenous exposure.
2. Postexposure prophylaxis should also be initiated following sexual
exposure.
3. Postexposure prophylaxis treatment regimens
a. Zidovudine (ZDV): 300 mg PO bid and
b. Lamivudine (3TC, Epivir): 150 mg bid
c. Protease Inhibitor: Indinavir (Crixivan) 800 mg q8h or Nelfinavir
750 mg tid (if needed to ensure 2 new antiviral drugs or for very
risky exposure).