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

HIV infection is a disease that progresses from asymptomatic infection to AIDS as a late manifestation. The rate of disease progression varies. The time between HIV infection and the development of AIDS can range from a few months to 17 years (average 10 years). Most adults and adolescents infected with HIV remain asymptomatic for a considerable period of time, but viral replication can be detected in asymptomatic individuals, gradually increasing as the immune system weakens. Virtually all HIV-infected individuals will eventually develop AIDS; one study found that 87% of adult HIV infections developed AIDS within 17 years of infection. Additional cases of AIDS are expected in HIV-infected individuals who remain asymptomatic for longer periods.

Increased concern about risk behavior on the part of both patients and health care providers has led to increased rates of HIV testing and earlier diagnosis of HIV infection, often before symptoms develop. Such early detection of HIV infection is important for several reasons. Treatments are now available that can slow the destruction of the immune system. In addition, HIV-infected individuals, because of their weakened immune systems, are at increased risk for diseases such as Pneumocystis carinii pneumonia, toxoplasmic encephalitis, disseminated Mycobacterium avium complex (MAC), tuberculosis (TB), and bacterial pneumonia, conditions for which there are preventive treatments. Because of its effects on the immune system, HIV affects the diagnosis, testing, treatment, and follow-up of many other diseases and may affect the effectiveness of antimicrobial therapy for some STDs. Finally, early diagnosis of HIV allows for timely counselling and helps prevent transmission of HIV to others.

Appropriate management of patients with HIV infection should take into account the complex behavioral, psychosocial, and medical aspects of the disease. Since STD clinics do not treat patients with HIV infection, it is recommended that patients be referred to specialized HIV-infected health care facilities. STD clinics should be aware of the available options for referral of patients from different population groups. When visiting an STD clinic, the HIV-infected patient should be educated about HIV infection and the various treatment options available.

Given the complexity of care and management of patients with HIV infection, detailed information, particularly regarding medical care, is not provided in this guide; this information can be obtained from other sources. This section is intended primarily to provide information on diagnostic tests for HIV-1 and HIV-2, counseling, and preparation of HIV-infected patients for the specifics of future HIV treatment. Information on the management of sexual partners is also provided, as this can and should be done in STI clinics before referral to HIV clinics. The section concludes with a discussion of HIV infection in pregnant women, infants, and children.

Diagnostic testing for HIV-1 and HIV-2

HIV testing should be offered to all patients who, due to their behavioral characteristics, are at risk for infection, including those seeking diagnosis and treatment for STIs. Pre- and post-test counseling is an integral part of the testing process and is described in the section on Counseling Patients with HIV Infection.

HIV infection is most often diagnosed using tests for HIV-1 antibodies. Antibody testing begins with a sensitive screening test called an enzyme-linked immunosorbent assay (ELISA). A positive screening test must be confirmed by an additional test such as a Western immunoblot (WB) or immunofluorescence assay (IF). If a positive antibody test is confirmed by an additional test, the patient is infected with HIV and is able to infect others. HIV antibodies are detectable in at least 95% of patients within 3 months of infection. Although negative results usually mean that the person is not infected, antibody tests cannot rule out infection if less than 6 months have passed since infection.

The prevalence of HIV-2 in the United States is extremely low, and CDC does not recommend routine HIV-2 testing in any health care setting except in blood centers or when demographic or behavioral information about HIV-2 infection is available. Persons at risk for HIV-2 infection include those who have traveled from countries where HIV-2 infection is endemic or who have sexual partners with those who have traveled from countries where HIV-2 infection is endemic. Endemic HIV-2 infection has been reported in parts of West Africa, and increasing prevalence has been reported in Angola, France, Mozambique, and Portugal. In addition, HIV-2 testing should be considered when HIV infection is clinically suspected or suspected and HIV-1 antibody testing is negative [12].

Given that HIV antibodies penetrate the placental barrier, their presence in children under 18 months is not a diagnostic criterion for HIV infection (see "Special Notes: HIV Infection in Infants and Children").

Specific recommendations for diagnostic testing are as follows:

• Informed consent must be obtained before testing. Some states require written consent. (For a discussion of pre- and post-test counseling, see "Counseling Patients with HIV Infection."
• Before HIV infection can be established, positive HIV antibody screening tests must be confirmed by a more specific confirmatory test (either WB or IF)
• Individuals who test positive for HIV antibodies should undergo medical and psychosocial assessment and register with appropriate services.

Acute retroviral infection syndrome

Health care providers should be alert for symptoms and signs of acute retroviral syndrome (ARS), characterized by fever, malaise, lymphadenopathy, and rash. This syndrome often occurs in the first few weeks after HIV infection, before antibody testing becomes positive. Suspected ARS should prompt DNA testing for HIV. Recent data suggest that initiating antiretroviral therapy at this time may reduce the severity of HIV complications and impact prognosis. If testing reveals ARS, providers should either advise the patient to initiate antiretroviral therapy or promptly refer the patient for specialist advice. The optimal antiretroviral regimen is unknown. Zidovudine has been shown to reduce the severity of HIV complications; however, most experts recommend two reverse transcriptase inhibitors and a protease inhibitor.

Counseling patients with HIV infection

Services providing psychological and psychosocial support are an integral part of health care settings serving patients with HIV infection and should be available at the patient's place of residence or where the patient is referred when diagnosed with HIV infection. Patients usually experience emotional distress when they first learn of a positive HIV test result and are faced with the following major adjustment issues:

• to realize the possibility of shortening life expectancy,
• adapt to changes in the way other people treat them because of the illness they have,
• develop a strategy to maintain physical and mental health and
• make attempts to change your behavior to prevent the transmission of HIV.

Many patients also require assistance with reproductive issues, choosing health care providers and insurance, and avoiding discrimination at work and in the family.

Interruption of HIV transmission depends entirely on changes in the behavior of individuals at risk of transmitting or acquiring the infection. Although some studies on viral cultures suggest that antiviral therapy reduces viral virulence, there is insufficient clinical evidence to determine whether therapy can reduce transmission. Infected individuals, as potential sources of infection, should receive maximum attention and support in taking steps to interrupt the chain of transmission and prevent infection of others. A targeted program of behavior change among HIV-infected individuals, their sexual partners, or those with whom they share needles for injecting drugs is an important component of current AIDS prevention efforts.

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

• Counseling for individuals who test positive for HIV antibodies should be provided by a health care provider or providers who are able to discuss the medical, psychological, and social consequences of HIV infection in the community or setting to which the patient is referred.
• Appropriate social and psychological support should be provided at the patient's place of residence or in other institutions where the patient is referred to help him or her cope with emotional stress.
• People who remain at risk of transmitting HIV should receive help to change or stop behaviors that may infect others.

Care planning and continuation of psychosocial services

The delivery of primary HIV care varies according to local resources and needs. Primary care providers and community-based providers must ensure that they have sufficient resources to care for each patient and should avoid fragmentation of care as much as possible. Although it is desirable for HIV-infected individuals to receive care in a single facility, the limited number of such facilities often necessitates coordination of community, clinical, and other health services located in different locations. The provider 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 newly diagnosed, it does not mean that it was recently acquired. A patient newly diagnosed with HIV infection may be at any stage of the disease. Therefore, the health care provider should be alert to symptoms or signs that indicate progression of HIV infection, such as fever, weight loss, diarrhea, cough, shortness of breath, and oral thrush. The presence of any of these symptoms should prompt urgent referral to a health care facility where the patient can receive care. The health care provider should also be alert to possible signs of severe psychological distress and, if necessary, refer the patient to appropriate services.

STD clinic staff should counsel HIV-infected clients about treatment that can be initiated if needed [11]. In non-emergency situations, initial management of HIV-positive patients typically includes the following components:

• A detailed medical history, including sexual history including possible rape, history of STIs, and specific symptoms or diagnoses suggestive of HIV.
• Physical examination; in women, this examination should include a pelvic examination.
• For women - testing for N. gonorrhoeae, C. trachomatis, Papanicolaou test (Pap smear) and examination of wet mount of vaginal secretions.
• Complete blood count, including platelet count.
• Testing for antibodies to Toxoplasma, determination of markers for the hepatitis B virus, serological testing for syphilis.
• Analysis of CD4+ T-lymphocytes and determination of HIV RNA in plasma (i.e. the amount of HIV).
• Tuberculin skin testing (using PPD) by Mantoux method. This test should be evaluated after 48-72 hours; in HIV-infected individuals the test is considered positive when the papule size is 5 mm. The value of the anergy test is controversial.
• Chest X-ray.
• A thorough psychosocial assessment, including identification of behavioural factors indicating the risk of HIV transmission and explanation of the need to obtain information about all partners who need to be notified of possible HIV infection.

At subsequent visits, when laboratory and skin test results are available, antiretroviral therapy may be offered, as well as specific treatments to reduce the incidence of opportunistic infections such as pneumocystis pneumonia, toxoplasmosis encephalitis, disseminated MAC infection, and TB. Hepatitis B vaccination should be offered to patients who are negative for hepatitis B, influenza vaccination should be offered annually, and pneumococcal vaccination should be given. For more information on immunization of HIV-infected patients, see the ACIP guidelines, Use of Vaccines and Immune Globulins in Immunocompromised Persons [20].

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

• HIV-infected individuals should be referred for appropriate monitoring to specialized institutions providing care for HIV infection.
• Healthcare workers should be alert to psychosocial conditions that require urgent attention.
• Patients should be informed about the specifics of follow-up care.

Management of sexual and intravenous drug using partners

When identifying partners of HIV-infected individuals, the term "partner" includes not only sexual partners but also drug users who share syringes and other injecting equipment. The rationale for partner notification is that early diagnosis and treatment of HIV infection can reduce the incidence of HIV infection and promote changes in risky behavior. Notification of partners of HIV infection should be done confidentially and will depend on the voluntary cooperation of the HIV-infected patient.

Two complementary tactics can be used to notify sexual partners: patient notification and health care provider notification. In patient notification, the patient directly informs his or her partners that they are at risk for HIV infection. In health care provider notification, trained personnel identify partners based on the names, descriptions, and addresses provided by the patient. In partner notification, the patient remains completely anonymous; the patient's identity is not disclosed to sexual partners or to anyone with whom the patient shares needles to inject drugs. In many states, health departments provide assistance by providing personnel for partner notification.

Results from one randomized trial confirmed that health care provider partner notification was more effective than patient partner notification. In this study, health care provider partner notification was 50% effective compared to 7% effective for patients. However, there is little evidence that partner notification resulted in behavioral change, and many patients are reluctant to disclose their partners' names due to fear of discrimination, relationship breakdown, loss of their partner's trust, and possible violence.

Specific recommendations for notifying partners are as follows:

• HIV-infected persons should be encouraged to notify their partners and refer them for counselling and testing. Health workers should assist them in this process either directly or by informing health departments that implement partner notification programmes.
• If the patient refuses to notify their partners or is unsure that their partners will seek advice from the physician or health department staff, confidential procedures should be used to ensure that partners are notified.

Special Notes

Pregnancy

All pregnant women should be advised to be tested for HIV as early as possible to allow early initiation of treatment to reduce perinatal transmission of HIV and to provide maternal health care. HIV-infected women should be specifically counseled about the risk of perinatal infection. Current data indicate that 15-25% of infants born to HIV-infected mothers are infected with HIV, and the virus can also be transmitted from an infected mother through breastfeeding. It is now known that zidovudine (ZDV) given to the woman in late pregnancy, during labor, and to the infant in the first 6 months of life reduces the risk of HIV transmission to the infant by approximately 25% to 8%. Therefore, ZDV treatment should be offered to all HIV-infected pregnant women. Pregnancy in HIV-infected individuals does not increase maternal morbidity or mortality. In the United States, HIV-infected women should be counseled about the need to avoid breastfeeding their infants.

There is insufficient information on the safety of ZDV or other antiretroviral agents when used in early pregnancy; however, based on available studies, ZDV is indicated for the prevention of perinatal transmission of HIV from mother to fetus as part of a regimen that includes oral ZDV beginning between 14 and 34 weeks of gestation, intravenous ZDV during labor, and ZDV syrup given to the neonate after birth. Glaxo Wellcome, Inc., Hoffmann-La Roche Inc., Bristol-Myers Squibb, Co., and Merck & Co., Inc., in collaboration with the SOC, are conducting a registration to evaluate zidovudine (ZDV), didanosine (ddl), indivar (IND), lamivudine (3TC), saquinavir (SAQ), stavudine (d4t), and zalcitabine (ddC) in pregnancy. Women receiving these drugs during pregnancy should be registered (registry 1-800-722-9292, ext. 38465). There are not enough data to evaluate the risk of birth defects from administration of ddl, IDV, ZTC, SAQ, d4t, ddC, or ZDV, or a combination, to pregnant women and their developing fetuses.

However, the reported data do not show an increase in the incidence of birth defects with ZDV monotherapy compared to the expected rate in the general population. In addition, there are no characteristic fetal defects that would indicate a pattern.

Women should be counselled regarding decision-making regarding their pregnancy. The aim of counselling is to provide the HIV-infected woman with up-to-date information for decision-making, in a manner similar to genetic counselling. In addition, HIV-infected women who wish to avoid pregnancy should be offered contraceptive counselling. Prenatal care and termination of pregnancy should be available in the community or at appropriate facilities to which the woman should be referred.

Pregnancy in HIV-infected women is not a factor that increases maternal morbidity or mortality.

HIV infection in infants and children

The diagnosis, clinical presentation, and management of HIV infection in infants and young children differ from those in adults and adolescents. For example, since maternal HIV antibodies pass transplacentally to the fetus, plasma HIV antibody tests are expected to be positive in 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 blood or tissue by culture, DNA testing, or antigen detection. CD4+ lymphocyte counts are significantly higher in infants and children < 5 years of age than in healthy adults and should be interpreted accordingly. All infants born to HIV-infected mothers should begin PCP prophylaxis at 4 to 6 weeks of age and continue it until HIV infection is excluded. Other changes in health care practices serving infants and children are recommended; For example, vaccination against polio with oral live vaccine should be avoided if the child is infected with HIV or has been in close contact with an HIV-infected person. The management of infants, children, and adolescents known or suspected to be infected with HIV requires referral to or close collaboration with specialists who are familiar with the presentation and treatment of pediatric patients with HIV infection.

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