|Suspicion of Acute HIV-1 Infection:
Evaluation/Diagnosis of Acute HIV-1 Infection:
- Health care providers should consider the possibility of acute HIV-1 infection in individuals with signs, symptoms, or the laboratory findings described below and recent (within 2 to 6 weeks) high risk of exposure to HIV-1.a
- Signs, symptoms, or laboratory findings of acute HIV-1 infection may include but are not limited to one or more of the following: fever, lymphadenopathy, skin rash, myalgia, arthralgia, headache, diarrhea, oral ulcers, leucopenia, thrombocytopenia, and transaminase elevation.
- High-risk exposures include sexual contact with a person who has HIV-1 infection or a person at risk of HIV-1 infection, sharing of injection drug use paraphernalia, or any exposure in which an individual’s mucous membranes or breaks in the skin come in contact with bodily fluid that potentially carries HIV-1.
- Differential Diagnosis: The differential diagnosis of HIV-1 infection may include but is not limited to viral illnesses such as EBV and non-EBV (e.g., cytomegalovirus) infectious mononucleosis syndromes, influenza, viral hepatitis, streptococcal infection, or syphilis.
Antiretroviral Therapy After Diagnosis of Early HIV-1 Infection:
- Acute HIV-1 infection is defined as detectable HIV-1 RNA or p24 antigen (the antigen used in currently available HIV Ag/Ab combination assays) in the setting of a negative or indeterminate HIV-1 antibody test result.
- A reactive HIV antibody test result or Ag/Ab combination test result must be followed by supplemental confirmatory testing.
- A negative or indeterminate HIV-1 antibody test result in a person with a reactive Ag/Ab test result or in whom acute HIV-1 infection is suspected requires plasma HIV-1 RNA testing to diagnose acute HIV-1 infection.
- A positive result on a quantitative or qualitative plasma HIV-1 RNA test in the setting of a negative or indeterminate antibody test result indicates that acute HIV-1 infection is highly likely. In this case, the diagnosis of HIV-1 infection should be later confirmed by subsequent documentation of HIV-1 antibody seroconversion.
- ART is recommended for all individuals with HIV-1 (AI) and should be offered to all patients with early HIV-1 infection.
- A pregnancy test should be performed for all individuals who receive a diagnosis of early HIV infection and who are of childbearing potential (AIII).
- Pregnant patients with early HIV-1 infection should begin ART as soon as possible for their own health and to prevent perinatal transmission of HIV-1 (AI).
- A blood sample for genotypic drug resistance testing should be obtained before initiation of ART to guide the selection of the regimen (AII), but ART should be initiated as soon as possible, often prior to availability of resistance test results. If resistance is subsequently identified, treatment should be modified appropriately.
- If no resistance data are available, then a pharmacologically boosted PI-based regimen is recommended, because resistance to PIs emerges slowly and clinically significant transmitted resistance to PIs is uncommon. Boosted DRV (DRV/r or DRV/c) plus FTC and either TDF or TAF is a recommended regimen in this setting (AIII). For similar reasons, DTG plus FTC and either TDF or TAF are reasonable options, although the data regarding transmission of INSTI-resistant HIV and the efficacy of this regimen in early HIV infection are limited (AIII).
- Preliminary data from Botswana suggested that infants born to women who were receiving DTG at the time of conception have an increased risk of neural tube defects. Until more information is available, DTG should not be prescribed for individuals:
- Who are pregnant and within 12 weeks post-conception (AII);
- Who are of childbearing potential, who are sexually active, and who are not using effective contraception (AII); or
- Who are contemplating pregnancy (AII).
- In patients without transmitted drug-resistant virus, ART should be initiated with one of the combination regimens recommended for patients with chronic HIV-1 infection (see What to Start) (AIII).
- Once initiated, the goal of ART should be sustained plasma virologic suppression, and ART should be continued indefinitely (AIII).