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HIV Guide
 Zambia HIV National Guidelines
 


Introduction  

HIV Counseling and Testing  

Sexually Transmitted Infections (STIs)  

General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents  

When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents  

Initial Regimen for ARV Therapy  

Adherence  

Baseline evaluation and Monitoring  

Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance  

ARV Therapy for Individuals with Tuberculosis Co-Infection  

Adverse Effects and Toxicity  

Immune Reconstitution Inflammatory Syndrome (IRIS)  

Changing or Stopping ART  

Treatment Failure  

Stopping ARV Therapy  

Post Exposure Prophylaxis  

Cotrimoxazole Prophylaxis  

WHO Staging in Adults and Adolescents  

Nutrition Care and Support  

Palliative Care in HIV and AIDS  

 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Miscellaneous>
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Primary HIV Infection

Laura Herrera, M.D. and Christopher Hoffmann, M.D., M.P.H.
06-15-2009

  • Seroconversion illness may occur in a lower fraction of seroconverters in Africa. A small study of 27 seroconverters in Uganda reported minimal symptoms with no difference from HIV-negative controls
  • When suspected or diagnosed, testing and counselling on reducing transmission is essential given high rate of transmission during early HIV infection. 
  • Natural history and time to progression to CD4 <200 appears to be similar in Africa and Europe/N. America. However some subtype differences may exist. Subtype D infection may progress more rapidly than subtype A. Subtype C, the prevalent subtype in Zambia, may have similar natural history to subtype B (found in Europe/N. America).

REFERENCES

Zambia Information Author: Christopher Hoffmann MD, MPH

PATHOGENS

  • HIV-1 and HIV-2 (HIV-2 predominantly found in West Africa).
  • HIV-1 divided into 3 groups: M (Main) group (worldwide distribution); O (Outlier) group (primarily West Africa, and N (Non-O, Non-M) group (Cameroon).
  • M group further divided into subtypes or clades designated A-K.
  • HIV-1 group M subtype B is predominant cause of HIV-1 infection in U.S.
  • Majority of HIV sexually transmitted with MSM the major mode in U.S. Heterosexual sex is the major mode globally. Injection drug use and mother-to -child transmission are also important modes of infection.
  • A "primary HIV-like" syndrome can occur after discontinuation of ART in 5% of individuals.

CLINICAL

  • Sx occur in up to 50-90% of pts within 1-4 wks of infection. Typically "flu-like" illness similar to other viral syndromes (e.g. influenza, mononucleosis) with low-grade fever, malaise, and headache. Additional symptoms may include lymphadenopathy, anorexia, and weight loss. Duration is usually 1 - 4 wks (median 2 weeks).
  • Hx: fever +/- myalgias, arthralgias, rash, headache, pharyngitis, lymphadenopathy, oral or genital ulcers, thrush.
  • Severity of presentation (& number of Sx) associated with peak HIV RNA level (VL).
  • Exam: maculopapular rash that may extend to palms and soles (20-67%), pharyngeal erythema, oral ulcerations, oropharyngeal candidiasis, lymphadenopathy, & splenomegally (each 10-60%). 
  • Most common lab abnormalities: thrombocytopenia, leukopenia, elevated liver enzymes, atypical lymphocytes. CD4 may be acutely suppressed, usually rises to near normal after acute illness.
  • Rate of CD4 decline to AIDS (<200) from 2 to >20 yrs (without ART). Rate related to VL, multiple other factors are likely important.
  • All individuals with acute HIV infection progress to chronic disease.

DIAGNOSIS

  • ELISA negative or positive with previous negative test and VL>10,000 or p24 antigen positive. Seroconversion occurs 2-8 wks (avg. 25 days) after acute infection = test "window period." 97% seropositive by 3 mos.
  • VL: sensitivity 100%, specificity 97%. False positive rates as high as 1%, but usually associated with low levels (<1000). Viral RNA can be detected as early as 9 days after infection. VL <100,000 unlikely during acute phase; suggests that pt approaching viral set point. VL<1000 rules our ARS but not HIV infection; retest in several wks with serology +/- VL.
  • VL reaches peak of 100,000-10,000,000. Levels decrease spontaneously without treatment by 2 to 3 logs approx 2 wks after onset of Sx.
  • p24 antigen: sensitivity 89%, specificity 100%, may be negative 1-2 mos following infection due to formation of Ag-Ab complexes. Can be detected as early as 2 wks after infection.
  • Dx of HIV using VL or p24 antigen must be confirmed with WB, which may not be fully positive for several weeks.
  • CD4 may be acutely decreased in primary HIV infection (rarely <200)
  • Co-infection with STDs common (30%). Test for gonorrhea, Chlamydia, syphilis, and HSV.

TREATMENT

General Considerations

  • Data currently insufficient to recommend routine use of ART for acute infection, however RCTs are ongoing to explore this issue.
  • Treatment indicated in highly symptomatic acute infection with significant neurological disease.
  • Inconclusive data that treatment during PHI results in reduction in disease progression compared to treatment during chronic infection.
  • Potential risks of early treatment: (1) toxicity, (2) resistance, especially if treatment fails to suppress high viral replication seen in PHI.
  • Consider referral to clinical trial if available.
Transmitted Drug Resistance 

  • In Europe & North America 6 - 16% of transmitted HIV has 1 or more resistance mutations.
  • Obtain resistance test (genotype) to determine if drug-resistant virus was transmitted for future use when ART is needed. Should be obtained promptly before wild-type HIV replaces mutant virus as dominant quasispecies.
Transmission of HIV to Others During Primary HIV Infection 

  • Risk of transmission highest during acute infection, approximately 10x higher than chronic. In some settings most transmission events occur during primary infection. 
  • Educate & counsel on safer sex

FOLLOW UP

  • Obtain CD4 at time of Dx to stage infection and level of immune suppression. Repeat every 3-6 mos. CD4 drawn during PHI may be lower than CD4 setpoint following resolution of acute syndrome.
  • Obtain VL at time of Dx, and follow regularly (e.g. monthly until set point established, then every 3-4 mos).
  • If ART initiated, obtain VL at initiation and repeat after 2-8 wks. Decrease of 1 log by 2-8 wks expected if regimen efficacious. Complete suppression (<50) expected by 16-20 wks. Once undetectable, repeat VL every 3-4 mos to evaluate effectiveness and durability of therapy.

REFERENCES

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