Human Immunodeficiency Virus Infection

About 50% of patients acquiring HIV infection develop an acute infective illness similar to glandular fever within wks of acquiring the single-stranded RNA retrovirus (the HIV seroconversion illness).

If these patients have a negative infectious mononucleosis test, perform an HIV antigen–antibody test or HIV rapid test, which may have to be repeated in 4 wks or so if negative.

If positive, confirm diagnosis with western blot test.

Patients invariably recover to enter a long period of good health for 5 yrs or more.

The level of immune depletion is best measured by the CD4 +ve T-lymphocyte (helper T-cell) count—the CD4 cell count. The cut-off points for good health and severe deficiency disease appear to be 500 cells/μL and 200 cells/μL respectively. The level determines when to initiate combined antiretroviral therapy (cART).

Progress of the disease can be measured with the viral load test.

Clinical stages of HIV disease

• Acute seroconversion illness

• Asymptomatic phase or persistent generalised lymphadenopathy

• Symptomatic:

  • – early (e.g. constitutional symptoms, oral candidiasis, herpes zoster)

  • – late (e.g. pneumocystis jirovecii pneumonia [PJP], Kaposi sarcoma)

  • – advanced (e.g. CMV retinitis, cerebral lymphoma)

Typical common clinical presentation of HIV/AIDS

• Fever of unknown origin

• Weight loss (usually severe)

• Respiratory: non-productive cough, increasing dyspnoea and fever: due to opportunistic pneumonias (pneumocystis pneumonia may have abrupt or insidious onset)

• Gastrointestinal including oral cavity:

  • – chronic diarrhoea (many causes) with weight loss or dehydration

  • – oral candidiasis and oral hairy cell leukaemia

• Neurological disorders (e.g. headache, dementia, ataxia, seizures, visual loss)

• Skin—Kaposi sarcoma and shingles, esp. multidermatomal, infections (viral, bacterial or fungal)

Definition of AIDS HIV +ve plus one or more of clinical diseases that are a feature of AIDS, e.g. PJP, KS or CD4 <200.

Management Patients with HIV infection require considerable psychosocial support, counselling and regular assessment from a non-judgmental, caring practitioner.

The holistic approach to life is recommended ( 493)

Support groups and continuing counselling.

Medication: current thinking favours treatment, as early as possible (even with CD4+ cell counts >500µL), which should be directed by a HIV specialist, usually at <350 µL.

Currently the use of three antiretroviral drugs for ART is preferred: usu. 2 from the NRTI class with one from either the NNRTI or the protease inhibitor group. The HAART (highly active antiretroviral therapy) strategy is a combination of 3 (or more) agents with one or more penetrating the blood–brain barrier. ART treatment does control HIV and allow a near normal lifespan but only two cases of cure have been confirmed as of early 2019.

Common regimens

• TRIPLE: e.g. emtricitabine + tenofovir disoproxil + efavirenz

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