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HIV, Early Recognition and Rapid Testing


Jeff Dubin, MD, Medical Director, Emergency Department, Washington Hospital Center, Assistant Professor, Department of Emergency
Medicine, Georgetown University School of Medicine
Updated: Apr 7, 2009

Introduction

Background
Clinically apparent human immunodeficiency virus (HIV) infection first was recognized in 1981 in homosexual men and
parenteral drug users in San Francisco and New York City who presented with evidence of a profound acquired immune
deficiency syndrome (AIDS). With the continued growing numbers of HIV-infected individuals, physicians need to recognize
acute HIV infection as well as screen for asymptomatic infections. Early diagnosis of acute HIV infection can help identify
patients who may be candidates for antiretroviral treatment, which has been shown to delay the progression to AIDS and
death. Rapid HIV testing may also be useful to quickly confirm HIV status in a patient not known to be HIV positive who
presents with an AIDS-defining illness.

The Centers for Disease Control and Prevention (CDC) recommends HIV screening of all US residents aged 13-64 years.1
This can be completed at any convenient physician encounter, including emergency department visits and even outreach
programs utilizing mobile clinic vans to see patients. Studies have shown that nearly one third of patients screened for HIV by
traditional programs with pretest counseling and blood tests that are sent to a central laboratory fail to return for follow-up visits
to learn the results.2 Rapid HIV testing provides the results during the single counseling session. Identification of
asymptomatic HIV-positive patients benefits the individual and the public health. Seropositive patients can be referred for
treatment and taught about practices that will help reduce the risk of infecting others.

This article reviews presenting signs and symptoms of acute HIV infection and discusses rapid HIV testing.

For more information, see guidelines for HIV Infection: detection, counseling, and referral and revised recommendations for
HIV testing of adults, adolescents, and pregnant women in health-care settings.3,4

Pathophysiology
HIV, or human immunodeficiency virus, is a Lentivirus, a subgroup of the retroviruses. This family of viruses is known for
latency, persistent viremia, infection of the nervous system, and weak host immune responses. HIV has high affinity for CD4 T
lymphocytes and monocytes. HIV binds to CD4 cells and becomes internalized. The virus replicates itself by generating a
DNA copy by reverse transcriptase. Viral DNA becomes incorporated into the host DNA, enabling further replication.

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Electron microscopy of human immunodeficiency virus (HIV)–1 virions. Courtesy of CDC/Dr. Edwin P.
Ewing, Jr.

HIV is transmitted primarily through sexual contact (>70%). Worldwide, it is more common in heterosexual men and women
than in homosexual men. Although the majority of initial HIV-related AIDS cases in the United States were in homosexual
men, increasingly, new cases of HIV infection are in the heterosexual population. Parenteral transmission occurs largely
among intravenous drug users; transmission by contaminated blood products is exceedingly unlikely in the United States,
although this remains a serious problem in developing countries. Since the introduction of universal precaution practices,
infection of health care workers through parenteral exposure remains rare. Children are infected primarily by perinatal
transmission.

In acute HIV infection, the symptoms of the disease are thought to be mediated by the immune response to the high viral load
as the virus rapidly replicates once it infects a new host.

For supplementary information, see eMedicine articles HIV Disease and Early Symptomatic HIV Infection.

Frequency
United States

The US CDC estimates that approximately 1.1 million people are currently living with HIV infection in the United States.2

The CDC estimates that more than 250,000 people are not aware that they are HIV positive.2

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An estimated 56,300 new HIV infections occur each year in the United States.5

International

Since the AIDS epidemic began, more than 20 million deaths have been attributed to AIDS. The current estimate of worldwide
disease prevalence is more than 33 million HIV infections; nearly two thirds of these cases are in developing countries,
generally in sub-Saharan Africa and Southeast Asia.6,7,8

Mortality/Morbidity
The course of HIV infection is characterized primarily by latency. Unfortunately, profound immune suppression eventually
develops and the illness appears to be almost uniformly lethal. More than 500,000 persons have died of AIDS in the United
States.

Progression from HIV infection to AIDS occurs at a median of 11 years after infection. In the recent past, most patients would
not survive more than 1-2 years following diagnosis of AIDS. However, since the introduction of highly active antiretroviral
therapy (HAART) and prophylaxis against opportunistic pathogens, death rates from AIDS have declined significantly. An
HIV-positive patient older than 50 years with a nearly undetectable viral load and a CD4 count more than 350 now has less
than a 5% chance of dying or progressing to full blown AIDS within 3 years.

Race
In the United States, the breakdown of HIV infections by race/ethnicity is as follows:

Caucasians - 35% of all cases

African Americans - 46%

Hispanics - 18%

Asian/Pacific Islander - 1%

American Indian/Alaska Native - <1%

Sex
In the United States, most HIV infections still occur in men via homosexual contact; however, the frequency of infection in
women is increasing. In the United States, fewer than 25% of all HIV cases are in women, whereas worldwide an estimated
50% of all HIV patients are women.5

Age
Most AIDS cases occur in adults aged 25-49 years (70% of cases). Adolescents and young adults (aged 13-24 y) represent
25% of new cases. Young children represent fewer than 1% of AIDS cases in the United States. Internationally, children
younger than 15 years are estimated to account for close to 10% of all HIV cases.5

Clinical

History
Symptoms of HIV infection

Constitutional
Fever
Fatigue

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Night sweats

Ear, nose, and throat


Oral ulcers
Pharyngitis

Gastrointestinal - Diarrhea

Skin
Generalized rash
Genital ulcers

Musculoskeletal - Myalgia/arthralgia

Neurological -Headache

Physical
Physical findings of HIV infection

Constitutional - Fever

Head, eyes, ears, nose, and throat - Oral candidiasis (thrush)

Neck - Lymphadenopathy

Skin -Maculopapular rash (often on the trunk)

Causes

Infection is caused by the human immunodeficiency virus (HIV). The following factors are associated with an increased
risk of acquiring HIV infection. Questions regarding exposure to these risk factors should be part of the history taken in
the emergency department.
Unprotected sex
Receptive anal intercourse carries a particularly high risk.
Parenteral drug use (sharing needles or drug paraphernalia)
Occupational needle stick or body fluid splash (estimated transmission rate <0.3%)
Contaminated blood products (before 1985 in the United States)

Differential Diagnoses
Candidiasis Mononucleosis
Cytomegalovirus Pharyngitis
Idiopathic Thrombocytopenic Purpura Syphilis
Influenza Viral Hepatitis
Meningitis
Other Problems to Be Considered
Pediatric AIDS
Needlestick guidelines

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Workup

Laboratory Studies

Complete blood count


Leukopenia
Thrombocytopenia

Hepatic function tests - Elevated transaminase levels

Other Tests
Rapid HIV tests

Test for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA).

Several rapid tests are available in the United States.


Sensitivity and specificity are greater than 99%.
Rapid test kits results are reported as reactive or nonreactive.

Table. FDA-Approved Rapid HIV Tests

FDA-Approved Rapid Uni-Gold Clearview Stat-Pak Reveal


OraQuick Advance Multispot
HIV Test Recombigen and Complete G-3

Specimen Needed Oral swab or blood Whole blood Whole blood Serum Serum
(fingerstick) (fingerstick) (fingerstick) plasma plasma

Turnaround Time 20 10 15 3 10
(minutes)

CLIA* Requirement Waived Waived Waived Required Required

*CLIA (Clinical Laboratory Improvement Amendment) "waived" means testing does not have to be done by certified laboratory
staff.

Next steps if rapid test positive


Confirm reactive tests with Western blot or immunofluorescent assay (IFA).
Nonreactive tests with high suspicion for acute HIV infection should be followed up with a virologic test such as
HIV RNA assay (viral load).
Viral load is very high (>100,000 copies/mL) in acute HIV infection.
If virologic test is positive, then repeat antibody testing in 3 months after seroconversion.

HIV antibodies - Western blot


Test results are positive, negative, or indeterminate. Indeterminate tests result from nonspecific reactions of
HIV-negative sera with some HIV proteins.
If the test is indeterminate, repeat ELISA test in 1 month.

Procedures
Counseling pre- and post- rapid HIV testing

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Pre- and post-test counseling can be done by nonmedical personnel.

Pre-test counseling can be completed via prerecorded video or pamphlet and takes about 1-20 minutes.

Resources are available for scripting counseling sessions via the CDC website.

Post-testing referrals for positive rapid test results need to be prearranged (dedicated follow-up program).

Treatment

Prehospital Care

Outreach programs can provide rapid HIV testing in the community.

Counseling and testing can be completed anywhere.

These programs provide an opportunity to identify high-risk patients who otherwise would not seek outpatient testing.

Emergency Department Care


Care in the ED consists of the following:

Routine HIV screening of asymptomatic patients and outpatient referral for confirmatory testing and care

Identification of acute HIV infection with possible ED diagnosis and/or referral for further diagnostics and treatment

Confirmation of diagnosis of HIV in patients with AIDS defining illness, previously not known to be seropositive

Consultations
Infectious disease consultants are invaluable to those caring for HIV-infected patients. Formal consultation in the ED rarely is
necessary, but phone discussion regarding management can be very helpful.

Some recommend initiating antiretroviral therapy in the ED for patients with confirmed acute HIV infection. However, this is
controversial given adverse effects of HIV medications and lack of immediate clinical benefits, so infectious disease
consultation is recommended before prescribing these medications.

Medication
The goals of pharmacotherapy are to inhibit viral replication and to reduce morbidity and death. Limited data are available on
the clinical benefits of initiating pharmacotherapy for patients with acute HIV infection. A number of studies, including HIV
genotype analysis, must be performed before antiretroviral therapy is initiated. For these reasons, beginning antiretroviral
therapy at an emergency department visit is never necessary. Outpatient followup with a provider experienced in antiretroviral
therapy should be provided.

For further information on therapy, see HIV Infection, Antiretroviral Therapy.

Follow-up

Further Outpatient Care

Referral for confirmatory testing and further outpatient treatment as needed for HIV-positive patients

Deterrence/Prevention

Transmission of HIV

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Safe sex practice


Abstinence
Needle exchange programs
Universal precautions
Antiretroviral drugs for pregnant HIV patients

Complications

False-positive and false-negative tests do occur with rapid testing.

Positive predictive value is lower in populations with low HIV prevalence, so there will be relatively more false-positive
tests in these groups with very low HIV risk factors.

If HIV seropositivity is expected, then patients whose test results are positive with rapid HIV tests should be told they
likely have HIV and need further confirmatory testing.

If HIV is not likely, a patient with a positive rapid test result should be counseled that he or she may have HIV but as this
is not likely from risk factor screening, a confirmatory test is necessary.

Patients are expected to be anxious after learning rapid HIV test results.

Patients with high suspicion for acute HIV infection and probable false-negative rapid HIV test results should have HIV
RNA viral load testing and be referred for follow up HIV ELISA testing. Remember that during acute HIV infection, the
antibody test ELISA, will usually be negative.

Prognosis

When untreated, HIV infection leads to AIDS with a life expectancy of 2-3 years.

In untreated HIV infection, the CD4 counts decline at a rate of 50-80 per year with more rapid decline as counts drop
below 200.

Patient Education

Provide frank, complete, nonjudgmental information on the routes of transmission.

Teach HIV-infected patients how to minimize the risk to others.

For excellent patient education resources, visit eMedicine's Immune System Center, Sexually Transmitted Diseases
Center, and Yeast and Fungal Infections Center. Also, see eMedicine's patient education articles HIV/AIDS, Rapid Oral
HIV Test, and Candidiasis (Yeast Infection).

Miscellaneous

Medicolegal Pitfalls

Missing HIV diagnosis due to false-negative rapid HIV test result


If acute HIV infection is suspected, send HIV RNA viral load test or recommend repeat HIV test in 4-8 weeks.
Screening for HIV should be completed after counseling. Pre-test counseling is simple and can even be
completed via video device or brochure.

Discharging newly diagnosed HIV patients without proper follow-up for testing or treatment
Make sure follow-up care has been arranged for patients prior to initiating an HIV screening program.

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Special Concerns

Protect patient confidentiality. Patients may not have informed family members or friends of their risk behaviors or
diagnosis.

Multimedia

Media file 1: Electron microscopy of human immunodeficiency virus (HIV)–1 virions. Courtesy of
CDC/Dr. Edwin P. Ewing, Jr.

References

1. CDC HIV/AIDS Science facts: CDC releases revised HIV testing recommendations in healthcare settings. Centers for
Disease Control and Prevention. Available at http://www.cdc.gov/hiv/topics/testing/resources/factsheets
/pdf/healthcare.pdf. Accessed December 1, 2008.

2. Greenwald JL, Burstein GR, Pincus J, Branson B. A rapid review of rapid HIV antibody tests. Curr Infect Dis
Rep. Mar 2006;8(2):125-31. [Medline].

3. HIV infection: detection, counseling, and referral. Sexually transmitted diseases treatment guidelines 2006. National
Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9674&
nbr=5183. Accessed March 25, 2009.

4. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. National
Guideline Clearinghouse. Available at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9799&

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HIV, Early Recognition and Rapid Testing: [Print] - eMedicine Emergen... http://emedicine.medscape.com/article/783434-print

nbr=5246. Accessed March 25, 2009.

5. Centers for Disease Control and Prevention. HIV/AIDS Statistics and Surveillance. Centers for Disease Control and
Prevention. Available at http://www.cdc.gov/hiv/topics/surveillance/incidence.htm. Accessed December 3, 2008.

6. HIV and AIDS estimates and data, 2007 and 2001. 2008 Report on the Global AIDS Epidemic. Available at
http://data.unaids.org/pub/GlobalReport/2008/jc1510_2008_global_report_pp211_234_en.pdf. Accessed April 7,
2009.

7. World Health Organization. Global Summary of the AIDS Epidemic, 2007. Available at http://www.who.int/hiv/data
/2008_global_summary_AIDS_ep.png. Accessed April 7, 2009.

8. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2008 Report on the global AIDS epidemic - Executive
summary. Available at http://data.unaids.org/pub/GlobalReport
/2008/JC1511_GR08_ExecutiveSummary_en.pdf. Accessed April 7, 2009.

9. Branson B. Rapid HIV testing: 2005 update. Centers for Disease Control and Prevention. Available at
http://www.cdc.gov/hiv/topics/testing/resources/slidesets/pdf/USCA_Branson.pdf. Accessed December 1, 2008.

10. Department of Health and Human Services. November 3, 2008; 1-139. Panel on Antiretroviral Guidelines for Adults and
Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and
adolescents. AIDSinfo. Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed
December 1, 2008, pages 38, 70-72; tables 8,11, appendix B Table 1a.

11. FDA-approved rapid HIV antibody screening tests. Centers for Disease Control and Prevention. Available at
http://www.cdc.gov/hiv/topics/testing/rapid/rt-comparison.htm. Accessed December 1, 2008.

12. Greene WC. The molecular biology of human immunodeficiency virus type 1 infection. N Engl J Med. Jan
31 1991;324(5):308-17. [Medline].

13. Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. Aug
6 2008;300(5):520-9. [Medline].

14. Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med. Jul
2 1998;339(1):33-9. [Medline].

15. Stebbing J, Gazzard B, Douek DC. Where does HIV live?. N Engl J Med. Apr 29 2004;350(18):1872-80. [Medline].

Keywords
HIV infection, HIV, AIDS, rapid testing, rapid HIV testing, HIV treatment, HIV symptoms, HIV causes, STD, sexually
transmitted disease, human immunodeficiency virus, acquired immune deficiency syndrome, highly active antiretroviral
therapy, HAART, Lentivirus, retroviruses, HIV-related illnesses, Pneumocystis jiroveci pneumonia, P jiroveci pneumonia,
PCP, cryptococcal meningitis, tuberculosis, TB, cytomegalovirus retinitis, CMV retinitis, CNS toxoplasmosis, central nervous
system toxoplasmosis, toxoplasmosis, HIV-associated malignancies, oral candidiasis, acute retroviral syndrome

Contributor Information and Disclosures

Author

Jeff Dubin, MD, Medical Director, Emergency Department, Washington Hospital Center, Assistant Professor, Department of
Emergency Medicine, Georgetown University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

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Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of
Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American
Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious
Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical
Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Speaking and teaching; Gilead Speaking and teaching; Ortho McNeil Speaking and
teaching; Wyeth Speaking and teaching; Abbott Speaking and teaching; Astellas Speaking and teaching; Cubist Speaking and
teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine


Disclosure: Nothing to disclose.

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor,
Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians,
American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical
Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for
Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical
Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of
Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians,
American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency
Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine
and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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