The number of patients admitted to the hospital with unrecognized HIV infection in the United States remains high.1 Despite efforts to increase HIV testing among at-risk populations, most infections are identified late in the disease when patients present with significant immune suppression and HIV-associated illness.
Early diagnosis enables patients to derive maximum benefit from highly active antiretroviral therapy (HAART). Primary care practitioners can play a key role in the timely identification of HIV infection.
In this article, we discuss the manifestations of both acute and chronic HIV infection and describe clues that point to the diagnosis. We also review the latest testing protocols for patients with risk factors, pregnant women, and patients in whom an established infection is suspected. Additional resources that can be helpful to clinicians who lack specialized training are listed in the Box.
Since the introduction of HAART in the mid-1990s, HIV-associated morbidity and mortality have significantly declined.2 The epidemic has stabilized over the past few years in the United States, thanks to public health interventions that target risk reduction and increased HIV testing.
However, certain sectors of the population continue to be disproportionately affected. African Americans accounted for 50% of all HIV/AIDS cases diagnosed in 2003. Although men account for the majority of infections, women represent the fastest growing population of persons with HIV/AIDS.2 Women are more likely to be infected through heterosexual contact and are often unaware of their male partners' risk factors for HIV infection (eg, unprotected sex with multiple partners, sex with men, or injection drug use).3
Routine risk assessment and testing in the clinical setting present opportunities to monitor high-prevalence communities more closely, perform risk-reduction counseling, and destigmatize HIV testing.4 Conduct an HIV risk assessment with every new patient and regularly with all patients, regardless of their symptoms.
Begin a sexual risk assessment with an assurance of confidentiality and an explanation of why these questions are important. In the sexual history, focus on specific sexual behaviors (ie, "vaginal intercourse") rather than a person's sexual orientation (ie, "straight" or "gay"). Ask about frequency of condom use. Elicit any history of injection drug use--specifically, needle sharing. In addition, question the patient about past tattoos, blood transfusions, and needle sticks and other occupational hazards.5
If one or more risk factors for HIV infection are identified (Table 1) or if the patient is pregnant, HIV testing is indicated. The CDC is expected to release new guidelines this summer that will recommend HIV screening for all patients between the ages of 13 and 64 years, even in the absence of risk factors.
Providers who offer HIV testing need to be familiar with pretest and post-test counseling services and with the "opt-out" informed consent protocol. In opt-out consents, patients are offered HIV testing as part of routine laboratory screening.
Pretest counseling includes education about HIV/AIDS, the HIV testing process, the meaning of positive and negative test results, modes of transmission, and prevention.
Post-test counseling usually begins with a review of the patient's understanding of positive and negative test results. When a result is negative, emphasize that it may not reflect HIV acquisition during the 3 months immediately preceding the test (the "window period"). If a result is positive, it is important to provide emotional support while giving honest and factual information. Be aware of appropriate community organizations, social agencies, peer support groups, and other resources to which you can refer patients who need additional counseling for emotional distress, peer support, or other services.
Counseling and testing can lead to changes in high-risk sexual and drug-use behavior. Most important, they lead to earlier diagnoses, which allow infected persons to seek treatment with HAART, prophylaxis against opportunistic infections, and vaccines that prevent life-threatening infections associated with HIV infection. Prevention counseling among HIV-infected persons may encourage safer behaviors, thereby decreasing HIV transmission to others.
1. Centers for Disease Control and Prevention. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR. 1993;42(RR-2):1-6.
2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003. Vol 15. Atlanta: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2004:1-46. Available at: http://www.cdc.gov/hiv/topics/ surveillance/resources/reports/index.htm. Accessed May 17, 2006.
3. Hader S, Smith DK, Moore JS, Holmberg SD. HIV infection in women in the United States: status at the millennium. JAMA. 2001;285:1186-1192.
4. Centers for Disease Control and Prevention. Revised guidelines for HIV counseling, testing, and referral. MMWR. 2001;50(RR-19):1-58.
5. Mountain Plains AETC; Department of Medicine, Division of Infectious Diseases, University of Colorado Health Science Center, Denver. HIV Risk Assessment: A Quick Reference Guide. Available at: http://www.mpaetc.org/scripts/prodList.asp. Accessed June 6, 2006.
6. Sande MA, Volberding PA. The Medical Management of AIDS. 6th ed. Philadelphia: WB Saunders; 1999.
7. Pantaleo G, Graziosi C, Fauci AS. New concepts in the immunopathogenesis of HIV infection. N Engl J Med. 1993;328:327-335.
8. Constantine N. HIV antibody assays. HIV InSite Knowledge Base. Available at: http://hivinsite.ucsf/ InSite?page=kb-02-02-01. Accessed May 17, 2006.
- Boyer CB, Barrett DC, Peterman TA, Bolan G. Sexually transmitted disease (STD) and HIV risk in heterosexual adults attending a public STD clinic: evaluation of a randomized controlled behavioral risk-reduction intervention trial. AIDS. 1997;11: 359-367.
- DiClemente RJ, Wingood GM, Harrington KF, et al. Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. JAMA. 2004;292:171-179.
- CDC Guidelines for HIV Counseling, Testing, and Referral (November 9, 2001). Available at: http://www.AIDSinfo.nih.gov.
- Public Health Service Task Force Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States (November 17, 2005). Available at: http://www.AIDSinfo.nih.gov.