Antiretroviral Therapy for HIV-Infected Adults Initial Assessment

Clinical Presentation

Signs, symptoms, and lab findings of acute HIV infection with recent (within 2-6 weeks) high-risk exposure to HIV may include but are not limited to:

• Constitutional symptoms (eg fever, weight loss, loss of appetite)
• Skin rash
• Headache, dizziness
• Diarrhea, rectal bleeding
• Myalgia, arthralgia
• Pharyngitis
• Chronic cough, shortness of breath especially on exertion
• Lymphadenopathy
• Oral ulcers
• Urethral discharge, genital ulcers
• Leukopenia, thrombocytopenia
• Elevated transaminase level

History

In history taking, high-risk exposures should be noted such as sexual contact with an HIV-infected person or with an individual at risk for HIV, sharing of injection drug use paraphernalia, and contact with potentially infectious blood with mucous membranes or breaks in the skin.

Screening

During the initial client visit, it must be remembered that HIV testing should be offered to all persons requesting HIV testing for any reason. HIV testing is recommended for all persons requesting evaluation for sexually transmitted infection (STI) and not known to have HIV infection. HIV screening, testing, and counselling should be voluntary and undertaken only with the patient’s knowledge and understanding that HIV test is being planned. Persons at high risk for HIV should be screened for HIV at least yearly. In screening, the 5 Cs are observed: Informed consent, counseling, confidentiality, correct test results, and linkage to care. It must be noted that general informed consent is enough to cover consent for HIV testing. If a client were to decline an HIV test, this decision should be documented in the medical record. HIV screening should be part of the routine panel of prenatal screening tests for all pregnant women. This allows HIV-infected women and their infants to benefit from timely and appropriate interventions (antiretroviral therapy [ART] medications, scheduled cesarean delivery, etc.).  

In all types of HIV epidemics, health care providers must recommend HIV testing and counselling as part of the standard care to individuals who present to health facilities with signs, symptoms or medical conditions that indicate a probable HIV infection. In places with low-level and concentrated epidemics, HIV testing and counseling is not recommended to all persons attending health facilities. In such settings, the priority is to recommend HIV testing and counseling to all clients who present with signs and symptoms suggestive of an underlying HIV infection and to children who have been exposed prenatally to HIV. In generalized epidemics, HIV testing and counseling should be recommended to all individuals seen in all health facilities. HIV testing should be part of the normal standard of care provided to clients, regardless of the presence or absence of symptoms, or the reason for the client’s visit to the health facility.  

Regardless of the type of epidemic setting, HIV testing and counseling are recommended to the following:

• Patients of all age groups who present with signs and symptoms or medical conditions that could indicate HIV infection, including TB
• HIV-exposed children or children born to HIV-positive women
• Malnourished children in generalized epidemics who are not responding to appropriate nutritional therapy
• Men who desire circumcision as an HIV prevention intervention

Pretest Counseling and Informed Consent  

Risk assessment and education that are focused on prevention should be done prior to and after receiving HIV test results. The following information should be provided by healthcare providers when recommending HIV testing and counseling:

• Reasons why HIV testing and counseling is being offered and their benefits and potential risks (eg discrimination, abandonment)
• Services that are available, including ART, in either an HIV-positive or an HIV-negative test result
• That the client has a right to decline the test and that the result will be treated with confidentiality
• In critically ill or unconscious patients where informed consent is not possible, permission should be sought from the patient’s next-of-kin, guardian or other caregiver; in the absence of such person, the health care provider should act according to the best interest of the patient
• In the case of a positive HIV test result, disclosure to other persons who may be at risk of exposure to HIV should be encouraged
• An opportunity for the client to ask the health care provider questions

HIV Test  

The choice of HIV test depends on various factors such as cost and availability of equipment or test kits, lab expertise, availability of staff, number of samples to be tested, collection and transport of samples, convenience, setting where testing will be performed, and the ability of the client to come back for the results. Testing strategies are either done as parallel setting or serial testing. Parallel testing is recommended when using whole blood samples. In this method, 2 tests are simultaneously done using assays based on different antigens. Concordantly negative or positive results are reported as true negatives or positives, respectively. On the other hand, in serial testing, if the HIV antibody test is negative, it is reported as “negative”. If the test result is positive, the specimen undergoes a second test using an antigen different from the first. In serial testing, a second positive result is considered a true positive. In low prevalence setting where false positive results are likely, a third confirmatory test may be done. Serial testing is recommended due to its cheaper cost. The second test is only required for reactive initial test results.  

It is recommended that reactive enzyme-linked immunosorbent assays (ELISA) or a rapid test be followed by a Western blot. A negative ELISA or rapid test or a reactive ELISA or rapid test with negative or indeterminate Western blot should be followed by a virologic test (ie p24 Ag or HIV RNA assay). A positive virologic test in this case is consistent with acute HIV infection. If an acute HIV infection is diagnosed by a positive virologic test and preceded by a negative HIV antibody test, a confirmatory HIV antibody test should be performed over the next 3 months to confirm seroconversion.  

Rapid HIV Tests
Examples: OraQuick Rapid HIV-1/2 Antibody test, Reveal G3 Rapid HIV-1 Antibody Test, Uni-Gold Recombigen HIV Test, Clearview HIV-1/2 Stat Pack, Clearview Complete HIV-1/2, Multispot HIV-1/HIV-2 Rapid Test  

Rapid HIV tests may either be done as serial or parallel testing. These tests provide accurate results within a much shorter time compared with traditional ELISA. Advantages of rapid testing include visibility of the test and quick turn-around time, testing outside lab settings, and not needing specialized equipment. However, trained lab supervisors are required to supervise the tests and ensure quality control.  

ELISA  

ELISA are almost always serially done in nature. It is the preferred method when large numbers of tests need to be performed as it allows a large number of samples to be tested efficiently at one time. The disadvantages include longer time to assemble enough samples to make a test run, longer reporting time of the results (half a day), precluding outpatients receiving the test result at the same visit, and the requirement of a certified lab staff to manage the test procedure, report results, and to maintain the equipment.  

Post-test Counseling  

All individuals undergoing HIV testing should be counseled when their results are given, regardless of the test result.  

HIV-positive Patients  

In dealing with HIV-positive patients, it is important to clearly inform them of the test result and allow them the time to consider it. Ensure as well that the client understands the test result and allow questions to be asked. Emotional support and crisis management should be provided. Any immediate concerns are discussed, and available and acceptable social networks are determined to offer support. Treatment and follow-up services available, including care and support services, prevention of mother-to-child transmission are also discussed. Information on the prevention of HIV transmission (including provision of male and female condoms and guidance on their use) and relevant preventive measures (eg good nutrition) are also provided. Notification, counseling, and referral for HIV testing of partners and children are also done.  

HIV-negative Patients  

Post-test counseling involves the explanation of the test result, including the information regarding the window period for the appearance of HIV antibodies and a recommendation to re-test in case of recent exposure, education on methods of prevention of HIV transmission, the provision of male and female condoms and guidance on their use, and advising ART to the uninfected partner for prevention.