HIV infection: identification, initial management and referral of patients with HIV infection to health care facilities

HIV infection is a disease that progresses from asymptomatic forms to AIDS as a late manifestation. The rate of progression of the disease is different. The time interval between HIV infection and the development of AIDS can vary from a few months to 17 years (an average of 10 years). Most adults and adolescents infected with HIV do not have symptoms for a fairly long period of time, however, virus replication can be detected in asymptomatic individuals, gradually increasing as the immune system weakens. In fact, all HIV-infected people will eventually develop AIDS; one study found that AIDS developed in 87% of adult HIV infections within 17 years of infection. An additional number of AIDS cases is expected in HIV-infected individuals who have a disease that is asymptomatic for a longer period.

The increased concern of both patients and health professionals about risky behavior has led to an increase in the frequency of HIV testing and earlier diagnosis of HIV infection, often before the onset of symptoms. This early detection of HIV infection is important for some reasons. Currently, there are funds that can slow down the destruction of the immune system. In addition, in HIV-infected individuals, due to the weakening of the immune system, there is an increased risk of diseases such as pneumonia caused by Pneumocystis carinii, toxoplasmosis encephalitis, disseminated complex infection caused by Mycobacterium avium (MAC), tuberculosis (TB) and bacterial pneumonia, conditions against which there are means of prevention. Due to the impact on the immune system, HIV affects the results of diagnosis, examination, treatment and follow-up in many other diseases, and can also affect the effectiveness of antimicrobial therapy of certain STDs. Finally, early diagnosis of HIV suggests a timely opportunity for counseling and helps prevent the transmission of HIV infection to others.

The correct management of patients with HIV infection should be conducted taking into account the set of behavioral, psychosocial and medical aspects of the disease. Since STD clinics do not treat patients with HIV infection, it is therefore recommended that patients be referred to specialized medical facilities for HIV-infected people. STD clinics should be aware of the existing choice of treatment facilities, in which patients can be sent from different populations. When a STD clinic is visited, an HIV-infected patient should be educated about HIV infection and the various options available for treatment.

Given the complexity of the care and management of patients with HIV infection, detailed information, especially concerning medical care, is not presented in this manual; this information can be obtained from other sources. This section is mostly intended to provide information on diagnostic tests for HIV-1 and HIV-2, counseling and training HIV-infected patients for the specifics of the upcoming HIV treatment. Also, information is provided on the management of sexual partners, as this can and should be done in STD clinics before being sent to clinics for HIV-infected people. At the end of the section, questions about HIV infection in pregnant women, infants and children are considered.

Diagnostic testing for HIV-1 and HIV-2

HIV testing should be offered to all patients who, due to their behavior, are at risk of infection, including those who have been referred for diagnosis and treatment of STDs. Counseling before and after testing is an integral part of the testing process and is described in the section "Advising patients with HIV infection".

Diagnosis of HIV infection is most often done using tests for antibodies to HIV-1. Antibody testing begins with such a sensitive screening test as an enzyme immunoassay (ELISA). The positive result of the screening test should be confirmed by an additional test, such as Western Immunoblotting (WB) or Immunofluorescence (IF). If the positive antibody test result is confirmed by an additional test, then this indicates that the patient is infected with HIV and is capable of infecting others. Antibodies to HIV are detected in at least 95% of patients within 3 months after infection. Although negative results usually mean that a person is not infected, antibody tests can not rule out an infection if less than 6 months have elapsed since infection.

The prevalence of HIV-2 in the US is extremely low, and the CDC does not recommend routine testing for HIV-2 in all health facilities other than blood transfusion centers or if there is demographic or behavioral information about the detection of HIV-2 infection. The risk group for HIV-2 infection is people who come from countries where the spread of HIV-2 infection is epidemic, or the sexual partners of such persons. The endemic spread of HIV-2 infection has been reported in some parts of West Africa, and an increase in HIV-2 prevalence has also been reported in Angola, France, Mozambique and Portugal. In addition, testing for HIV-2 should be carried out in those cases where there are clinical signs or suspicion of HIV infection, and the test for antibodies to HIV-1 gives negative results [12].

Given that antibodies to HIV penetrate the placental barrier, their presence in children younger than 18 months is not a diagnostic criterion for HIV infection (see "Special notes: HIV infection in infants and children").

Special recommendations for diagnostic testing are as follows:

• Prior to testing, informed consent must be obtained for its conduct. Some states require written consent. (To discuss counseling issues before and after testing, see "Advice to patients with HIV". 
• Before ascertaining the presence of HIV infection, the positive results of screening tests for HIV antibodies should be confirmed by a more specific confirmatory test (or WB or IF) 
• Persons with positive HIV antibody tests should undergo a medical and psychosocial screening and register with the relevant services.

Acute retroviral infection syndrome

Medical workers should be wary of the appearance of symptoms and signs of acute retroviral infection syndrome, which is characterized by fever, malaise, lymphadenopathy and skin rash. This syndrome often occurs in the first few weeks after HIV infection, before the result of the antibody test is positive. Suspicion of the syndrome of acute retroviral infection should be a signal for DNA diagnosis to detect HIV. Recent findings indicate that initiating antiretroviral therapy in this period can reduce the severity of HIV complications and affect the prognosis of the disease. If the test reveals a syndrome of acute retroviral infection, health workers should either inform the patient about the need to initiate antiretroviral therapy, or urgently send it to a specialist for consultation. The optimal regimen for antiretroviral therapy is not currently known. To reduce the severity of complications of HIV infection zidovudine is shown, however, most specialists recommend using two reverse transcriptase inhibitors and a protease inhibitor.

Advising patients with HIV infection

Services that provide psychological and psychosocial support are an integral part of health facilities serving patients with HIV infection and should be available at the place of residence or where the patient is sent when he is diagnosed with HIV. Patients usually experience emotional stress when they first learn about the positive results of the HIV test and face the upcoming solution to the basic adaptation problems:

• to realize the possibility of reducing life expectancy,
• to adapt to a change in the attitude of other people to them because of the disease they have,
• develop a strategy for maintaining physical and mental health and
• attempt to change their behavior to prevent the transmission of HIV.

Many patients also need help in dealing with reproductive issues, choosing health care facilities and insurance, and preventing discrimination at work and in the family.

The cessation of HIV transmission is entirely dependent on changes in the behavior of individuals who have a risk of transmission or acquisition of infection. Although some studies on viral cultures confirm that antiviral therapy reduces the virulence of viruses, clinical data to decide whether therapy can reduce the possibility of transmission is not enough. Infected people, being a potential source of infection, should receive maximum attention and support in the implementation of actions to interrupt the chain of transmission and prevent the infection of other people. A targeted program to change the behavior of HIV-infected individuals, their sexual partners or those with whom they share the same needles for drug injections is an important part of the current AIDS prevention efforts.

Specific recommendations for counseling HIV-infected persons are presented below:

• Consultation of people with positive HIV antibody test results should be conducted by an employee or medical staff who are able to discuss the medical, psychological and social consequences of HIV infection in the field or in the institutions to which the patient is referred.
• Appropriate social and psychological support should be provided at the place of residence or in other institutions where the patient is directed, in order to help him cope with emotional stress.
• Persons who are at risk of HIV transmission should receive assistance in order to change or stop the behavior in which other people may be infected.

Planning care and continuing psychosocial care

The methods of providing primary care for HIV differ depending on local resources and needs. Primary care providers and staff of outpatient facilities should be confident that they have sufficient resources to assist each patient and should avoid fragmenting this assistance as much as possible. It is desirable that HIV-infected persons receive care in one institution, but a limited number of such institutions often necessitate the coordination of outpatient, clinical and other health services located in different locations. The health worker should do everything possible to avoid fragmentation of care and long delays between the diagnosis of HIV infection and medical and psychosocial services.

If HIV infection is detected recently, this does not mean that it was recently acquired. The patient who is first diagnosed with HIV infection can be at any stage of the disease. Therefore, the health care provider should be wary of the symptoms or signs that indicate the progression of the HIV infection, such as fever, weight loss, diarrhea, cough, shortness of breath and oral candidiasis. The presence of any of these symptoms should be a signal for the urgent referral of the patient to medical facilities, where he will be assisted. The paramedic should be vigilant also in relation to possible manifestations of signs of severe psychological stress and, if necessary, send the patient to the appropriate services.

STD clinic staff should advise HIV-infected clients about treatment, which can be initiated if necessary [11]. In situations where the patient does not require emergency care, the initial management of HIV-positive patients usually includes the following components:

• A detailed history of the disease, including the history of sexual life, including possible rape, a history of STDs and specific symptoms or diagnoses that indicate HIV.
• Physical examination; in women, this examination should include a gynecological examination.
• In women, testing for N. Gonorrhoeae, C. Trachomatis, Pap test (Pap smear), and a wet vaginal secretion study.
• Clinical blood count, including platelet count.
• Testing for antibodies to Toxoplasma, detection of markers for hepatitis B virus, serological test for syphilis.
• Assay for CD4 + T-lymphocyte count and plasma HIV RNA detection (ie amount of HIV).
• Tuberculin skin tests (using PPD) by the Mantoux method. This test should be evaluated after 48-72 hours; in HIV-infected individuals, the test is considered positive for a papule size of 5 mm. The value of the test for energy is controversial.
• Radiography of the chest.
• Careful psychosocial expertise, including the elicitation of behavioral factors indicative of the risk of HIV transmission and an explanation of the need to obtain information about all partners who need to be notified of a likely HIV infection.

On subsequent visits, when the results of laboratory tests and skin tests have already been obtained, the patient may be offered antiretroviral therapy, as well as specific treatment aimed at reducing the incidence of diseases caused by opportunistic microorganisms, such as pneumocystic pneumonia, toxoplasmosis encephalitis, disseminated MAC infection and TB. Vaccination against hepatitis B should be offered to patients who do not have hepatitis B markers, vaccination against influenza should be offered annually, and antipneumococcal vaccination should be performed. For more information on immunization of HIV-infected patients, refer to the ACIP recommendations "Use of vaccines and immunoglobulins in individuals with reduced immunological activity" [20].

Special recommendations for planning medical care and for providing psychosocial support are listed below:

• HIV-infected persons should be sent for appropriate monitoring to specialized agencies providing HIV care. 
• Health workers should be wary of psychosocial conditions that require urgent attention. 
• Patients should be informed about the features of follow-up. 

Management of sexual partners and partners in the use of intravenous drugs

When partners of people who are infected with HIV are identified, the term "partner" includes not only sexual partners, but also UVN-addicts who use shared syringes and other injecting equipment. The rationale for notifying partners is that early diagnosis and treatment of HIV infection can reduce morbidity and contribute to changing risk behaviors. Notification of partners about HIV infection should be conducted confidentially and will depend on the voluntary cooperation of the HIV-infected patient.

To notify sexual partners, two complementary tactics can be used: notification by the patient and notification by the medical officer. In the first case, the patient directly informs his partners that they are at risk of HIV infection. When notified by a health professional, specially trained personnel identify partners based on the names, descriptions and addresses provided by the patient. When notifying partners, the patient remains completely anonymous; his name is not communicated to sexual partners or those with whom he uses the same needles for injecting drugs. In many states, health authorities provide appropriate assistance, providing staff to notify partners.

The results of one randomized study confirmed that the tactic of notifying partners by medical professionals is more effective than the tactic of notifying partners by the patient himself. In this study, the effectiveness of notifying partners by a health worker was 50% of partners, and the patient - only 7%. However, there is little evidence that behavioral change was the result of notification of partners, and many patients are reluctant to report the names of their partners because of fear of discrimination, rupture of relations and loss of trust of their partners and possible violence.

Specific recommendations for notifying partners are as follows:

• It is necessary to encourage HIV-infected persons to notify their partners and send them for counseling and examination. Medical workers should assist them in this process either directly or by informing the health departments implementing programs to notify partners. 
• If the patient refuses to notify their partners or if they are not sure that their partners will turn to consult a doctor or health department staff, confidential procedures should be used to make sure that partners are notified. 

Special Remarks

Pregnancy

All pregnant women should be recommended to be tested for HIV as early as possible. This is necessary for the early initiation of treatment aimed at reducing the likelihood of perinatal HIV transmission, as well as medical care for the mother. HIV-infected women should be specially informed about the risk of perinatal infection. Current evidence suggests that 15-25% of children born to HIV-infected mothers are infected with HIV, and the virus can also be transmitted from an infected mother during feeding. It is now known that zidovudine (ZDV) given to a woman late in pregnancy, during childbirth and in the first 6 months of life, reduces the risk of HIV transmission to an infant from about 25% to 8%. Therefore, HFA treatment should be offered to all HIV-infected pregnant women. Pregnancy in HIV-infected people does not lead to an increase in maternal morbidity or mortality. In the US, HIV-infected women should be consulted about the need to stop breastfeeding their children.

There is insufficient information on the safety of HFA or other antiretroviral drugs when they are used in the early stages of pregnancy; however, based on the studies, HFA is shown to prevent perinatal HIV transmission from mother to fetus as part of a treatment regimen including oral HFA, beginning between 14 and 34 weeks of gestation, intravenous HFV during labor and the administration of HFA syrup to a newborn after birth. Glaxo Wellcome, Inc., Hoffmann-La Roche Inc., Bristol-Myers Squibb, Co., and Merck & Co., Inc., in cooperation with SOS, are registered for the evaluation of zidovudine (ddl), didanosine (ddl), indivar ( IND), lamivudine (3TC), saquinavir (SAQ), stavudine (d4t) and zalcitabine (ddC) during pregnancy. Women who receive these drugs during pregnancy should be registered (register 1-800-722-9292, ext. 38465). There is still insufficient data to estimate the risk of birth defects due to the appointment of ddl, IDV, 3TC, SAQ, d4t, ddC or ZDV, or a combination thereof, to pregnant women and their developing fetus.

However, the recorded data do not show an increase in the number of congenital malformations with HFA monotherapy in comparison with the expected level in the population as a whole. In addition, there are no characteristic defects of the fetus, which could indicate the existence of a regularity.

Women should be consulted to decide on their pregnancy. The purpose of counseling is to provide the HIV-infected woman with up-to-date information for making decisions on a principle similar to genetic counseling. In addition, HIV-infected women who want to avoid pregnancy should be offered counseling on contraception. Prenatal observation and termination of pregnancy should be available at the place of residence or in the relevant institutions where the woman should be directed.

Pregnancy in HIV-infected women is not a factor contributing to an increase in maternal morbidity or mortality.

HIV infection in infants and children

Diagnosis, clinic and management of cases of HIV infection in infants and young children differ from those in adults and adolescents. For example, from the moment of the transplacental transition of maternal antibodies to HIV to the fetus, it is expected that tests for antibodies to HIV in the blood plasma will be positive for both uninfected and infected infants born to seropositive mothers. Confirmation of HIV infection in infants <18 months of age should be based on the presence of HIV in the blood or tissues in the culture method, DNA diagnosis or antigen detection. The number of CD4 + lymphocytes is significantly higher in infants and children under 5 years of age than in healthy adults, which should be interpreted accordingly. All children born from HIV-infected mothers should begin prevention of PCP at the age of 4-6 weeks and continue it before they are excluded from HIV infection. Other changes are recommended in the activities of medical institutions serving infants and children; for example, vaccination against poliomyelitis with an oral live vaccine should be avoided if the child is infected with HIV or in close contact with the HIV-infected person. The management of infants, children and adolescents known or suspected of having HIV infection requires referrals to specialists who are familiar with the manifestations of the disease and the treatment or close cooperation with pediatric patients with HIV infection.

[1], [2], [3], [4], [5],