Diagnosis of HIV infection
During ARS, the viral load is very high—often >100,000 copies/mL. The standard test to detect ARS is the reverse transcriptase-polymerase chain reaction (RT-PCR). False-positive HIV viral loads do occur. If ARS is suspected, viral loads of <10,000 copies/mL should be repeated as this result may be a false positive or can indicate that the patient has had chronic HIV. Practitioners should note that the standard test for diagnosing HIV is the enzyme-linked immunosorbent assay (ELISA), which is confirmed with a Western blot. During ARS, the ELISA will likely be negative; the Western blot may be negative or indeterminate. These findings are consistent with the time needed for seroconversion—the development of antibodies to HIV. Seroconversion can take three to six months after infection.
After the diagnosis
Morbidity and mortality from HIV/AIDS has decreased significantly and people with HIV are living longer and developing chronic diseases common to aging such as diabetes, cardiovascular disease, and osteoporosis. This shift is attributable to the introduction of highly active antiretroviral therapy (HAART). Antiretroviral agents can be classified into six basic categories:
- nucleoside reverse transcriptase inhibitors
- non-nucleoside reverse transcriptase inhibitors
- protease inhibitors
- entry inhibitors
- fusion inhibitors
- integrase inhibitors.
Some of these drugs are manufactured in combination forms. Current recommendations suggest that if a patient is ready to start therapy, a three-drug regimen is preferable. (See NIH Web site for current guidelines on the use of antiretroviral agents in persons with HIV infection.)
Despite its benefits, HAART may be a lifelong regimen, and has short- and long-term implications that need to be considered when initiating therapy. Viruses can become resistant to certain antiretrovirals, and resistant virus can be transmitted to others in the same ways wild-type virus is transmitted (via blood or breast milk, sexually, or perinatally). Genotype resistance testing can be done to try to identify mutations that confer drug resistance.
Additionally, many of the HIV medications interact with commonly prescribed drugs. One study has estimated that HIV-positive individuals have an average life span 21 years shorter than their HIV-negative counterparts.7 This is why after being diagnosed as HIV-positive, the patient should undergo a full history and physical examination to detect additional health issues that may be exacerbated by HIV and therapy. Initial labs must include an HIV viral load and CD4 T cell count, which will inform prognosis and determine the degree of urgency for initiating prophylaxis for opportunistic infections and HAART. Opportunistic infection can manifest at any CD4 T cell level; however, risk increases once CD4 T cell count drops below 200 cells/mm3. Accepted thresholds of 200, 100, and 50 cells/mm3 have been established, signifying risk of Pneumocystis jiroveci, Mycobacterium avium, andToxoplasma gondii complex infections, respectively; primary prophylaxis is recommend at these points.8 Standard recommended initial laboratory workup is summarized in Table 2. Recommendations for prophylaxis of opportunistic infections can be found on the CDC Web site.
Referral to an HIV specialist is preferred, although initial laboratory workup can be done prior to the consultation to foster a more thorough discussion of the patient’s options. Research has shown that quality of care for HIV patients is improved when the provider is an HIV specialist;9 often the specialists are nurse practitioners or physician assistants.
In most cases, CD4 T cell levels and HIV viral load are checked every three months, with monitoring of CBC, metabolic panels, and lipid profiles every three to six months. Yearly tuberculosis testing (PPD), RPR testing, ophthalmologic and dental exams, gynecology exams (possibly necessary every six months if CD4 T cell count is low and/or dysplasia is present) should be done. Routine health maintenance screenings as per the general population include mammography, prostate-specific antigen screening, colonoscopy, electrocardiograms, and stress testing.
Compassionate, knowledgeable health-care providers can improve the likelihood that persons newly diagnosed with HIV infection will obtain the appropriate information to make good choices, prevent spread of the disease, and improve their own morbidity and mortality risks.
In summary, primary-care practitioners should:
- Verify presence of HIV infection with Western blot.
- Obtain baseline labs and perform a comprehensive physical assessment.
- Consult with an HIV specialist for plan of care.
Reassure patient that with 100 % adherence to therapy, life expectancy is much longer than it was when HIV infection first came to the forefront when medication options were limited.
Dr. Stewart is assistant professor, Sacred Heart University Nursing Program, in Fairfield, Conn. Dr. Weinberg is a family nurse practitioner specializing in HIV at Stamford Hospital in Stamford, Conn.
- Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. Abstract T1-B1101, presented at the National HIV Prevention Conference, Atlanta, June 2005. Abstract T1-B1101.
- Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic—United States, 2003. MMWR. 2003;52:329-332.
- Liddicoat RV, Horton NJ, Urban R, et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med. 2004;19:349-356.
- Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR14):1-17.
- Brenner BG, Roger M, Routy J-P, et al. High rates of forward transmission events after acute/early HIV-1 infection. J Infect Dis. 2007;195:951-959.
- HealthHIV. HealthHIV state of primary care survey. HealthHIV.org. May 12, 2010.
- Harrison KM, Song R, Zhang X. Life expectancy after HIV diagnosis based on national HIV surveillance data from 25 states, United States. J Acquir Immune Defic Syndr. 2010;53:124-130.
- Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. 2009;58(RR04):1-198.
- Wilson IB, Landon BE, Hirschhorn LR, et al. Quality of HIV care provided by nurse practitioners, physician assistants, and physicians. Ann Intern Med. 2005;143:729-736.
All electronic documents accessed June 10, 2010.