HIV Seroconversion Illness Research Articles

4.0 When to start

4.0 When to start

The Recent Infection Testing Algorithm (RITA) in clinical practice: a survey of HIV clinicians in England and Northern Ireland

In order to estimate HIV incidence among high-risk groups, in January 2009 the Health Protection Agency introduced the Recent Infection Testing Algorithm (RITA) in England and Northern Ireland (E&NI), currently the only regions to inform patients of RITA results. This survey of HIV specialists aimed to investigate the role of RITA in patient management and explore clinicians' views on its role in clinical practice and during partner notification. An online questionnaire was distributed to HIV specialists via the British HIV Association membership email list in February 2011. Forty-two HIV specialists from 32 HIV centres responded to the survey among 90 centres enrolled in the programme (response rate 36%). Testing for recent infection was considered standard of care by 83% of respondents, 80% felt confident in interpreting results and 92% discussed results with patients, particularly in the context of a possible HIV seroconversion illness (96%) or when deciding when to start antiretroviral therapy (70%). A third (36%) of specialists were initially concerned that RITA results may cause additional anxiety among patients; however, no adverse events were reported. The majority (90%) felt that results could assist with contact tracing by prioritizing patients with likely recent infection. However, only a few centres have currently incorporated RITA into their HIV partner notification protocols. RITA has been introduced into clinical practice with no reported patient adverse events. Access to results at centre level should be improved. National guidance regarding use of RITA as a tool for contact tracing is required.

Brachial plexus neuritis in the context of acute HIV seroconversion illness: a case report

We report an unusual case of bilateral brachial plexus neuritis occurring during the seroconversion stage of an HIV infection in a 45-year-old man. Brachial plexus neuritis is thought to be an immune mediated inflammatory reaction resulting in acute onset of shoulder pain followed by muscle weakness and wasting. There is often a history of viral illness, diagnosis is clinical, and treatment is supportive. Many sufferers are left with residual defects. Clinicians should consider the possibility of HIV infection when managing a patient with brachial plexus neuritis.

Barriers to HIV testing among Australian gay men

To investigate the barriers to HIV testing among Australian gay men. An online survey was conducted to explore reasons for avoiding and delaying testing for HIV; 519 non-HIV-positive men completed the online survey. Most non-HIV-positive men (92.9%) had been tested for HIV, with 75.4% indicating they had been tested in the previous year. The most common reasons for avoiding or delaying testing were a belief that they had not done anything risky (41.2%) and the need to return for a second clinic visit to receive results (40.3%). Among men who engaged in unprotected anal intercourse with casual partners (UAIC), those who had not been recently tested were more likely to cite the lack of any symptoms as reasons for not having tested (adjusted odds ratio: 2.34; 95% confidence interval: 1.03-5.31; P=0.041). For men who do not engage in risky sex, the decision not to test is probably reasonable, but those who engage in non condom-based risk reduction may be at some increased risk and should be encouraged to test relatively often. Changes to Australia's national HIV testing policy may ameliorate some of the need to return for second clinic visits to receive results, but the policy still requires full implementation, including the introduction of rapid point-of-care HIV testing to Australia. Among men who engage in UAIC, there appears to be a particular need for information about the benefits of early treatment after HIV diagnosis and about the relative likelihood of experiencing HIV seroconversion illness.

Bilateral facial nerve paralysis and acute HIV-1 infection

Bilateral facial nerve paralysis is a rarely reported but recognized complication that follows acute HIV-1 infection. HIV seroconversion illness or acute HIV infection is present in approximately 40-90% of primary HIV infected patients. Patients with acute HIV-1 infection typically present with fever, rash myalgias, arthralgias, and lymphadenopathy. Most of these appear in two to four weeks following the initial infection. We report a patient experiencing HIV-1 seroconversion as described who presents with bilateral facial nerve paralysis. Related literature of this subject is also reviewed. We report a 33-year-old Hispanic male, with no significant past medical history, who presented with bilateral facial nerve paralysis in the setting of a viral-like prodrome of fevers, malaise, muscle aches and sore throat. After a full workup, the patient was subsequently diagnosed with an HIV-1 infection. His facial paralysis resolved over a course of five months. Unilateral and bilateral facial paralysis occur at over 100-fold greater frequency in HIV-infected patients. However, even among patients with an acute HIV infection, bilateral facial paralysis is exceedingly rare, as only 12 cases have been reported worldwide over the last 20 years. Because the onset of facial paralysis closely follows HIV-1 seroconversion, its presence can facilitate early diagnosis and treatment of those newly infected with HIV-1. In a patient who is at risk and presents with a new facial paralysis, HIV infection should be considered as a possible underlying etiology.

Killing two birds with one stone

In September, 2008, a 56-year-old man presented to our department with fever, myalgia, pharyngitis, and a maculopapular skin eruption. He reported having unprotected sex with a man 2 months prior to the onset of his symptoms. He was diagnosed with HIV seroconversion illness in view of a high HIV viral load (>14 280 000 copies per ml) and a third generation HIV antibody test that was weakly positive. During routine HIV follow-up in March 2009, his previously normal alkaline phosphatase had risen to 486 IU/L and his alanine aminotransferase was 185 IU/L. His total bilirubin was 15 μmol/L. He had no symptoms except for mild occasional right upper quadrant abdominal discomfort. An abdominal ultrasound scan showed multiple large stones in the gallbladder but was otherwise normal. His antimitochondrial antibody was strongly positive (1:4000 IgG, M2 and M4 positive), consistent with a diagnosis of primary biliary cirrhosis. A liver biopsy showed damaged interlobular bile ducts, with granulomas, and increased amounts of eosinophilic cytoplasm and intraepithelial infl ammatory cells, also typical of primary biliary cirrhosis. In April, 2009, his CD4 count was 360 cells per μL, and he was started on tenofovir 245 mg, emtricitabine 200 mg, and efavirenz 600 mg once daily. In June, 2009, owing to central nervous system side-eff ects, efavirenz was changed to lopinavir 400 mg and ritonavir 100 mg tablets twice daily. Ursodeoxycholic acid was introduced at a dose of 15 mg/kg per day in November, 2009. His liver function tests improved considerably once antiretroviral therapy was introduced (fi gure). In May, 2010, after 13 months of treatment with anti-retroviral therapy, and 6 months of ursodeoxycholic acid, his liver function tests were normal. His antimitochondrial antibodies decreased to 1:250. Using a branched chain hybridisation assay (Quanti-Gene Aff ymetrix, California, USA) we found that serum from our patient was strongly positive for human betaretrovirus RNA. He was last seen in June, 2010, and was asymptomatic, with no clinical or biochemical evidence of cirrhosis. His HIV virus was completely suppressed and his CD4 count increased to 580 cells per μL. In 2003, a human betaretrovirus closely related to mouse mammary tumour virus was cloned from the biliary epithelium from patients with primary biliary cirrhosis. Viral infection of cholangiocytes with human betaretrovirus results in the aberrant expression of the mitochondrial E2 component of the pyruvate dehydrogenase complex. This protein, normally located on the inner mitochondrial membrane, appears on the cell surface in patients with primary biliary cirrhosis, and is thought to trigger the appearance of antimitochondrial antibodies. The relation between betaretrovirus infection and primary biliary cirrhosis is controversial. It has been suggested that randomised controlled trials with antiviral therapy may provide supportive evidence for a causal role of viral infection. Randomised controlled trials using combination lamivudine 150 mg and zidovudine 300 mg twice a day, have shown biochemical improvements in patients with primary biliary cirrhosis, but failed to achieve signifi cant endpoints, possibly because of the development of viral resistance to therapy. Other antiretrovirals that have proven eff ective against betaretrovirus in vitro, include: adefovir, tenofovir, and lopinavir. Here, we report that the combination of tenofovir, emtricitabine, lopinavir, and ritonavir used to manage HIV infection, coincided with marked reduction of cholestatic liver function tests, before the institution of ursodeoxycholic acid. If an association between primary biliary cirrhosis and human betaretrovirus infection can be established, the effi cacy of this highly active antiviral regimen can be tested in future controlled trials in patients with primary biliary cirrhosis unresponsive to ursodeoxycholic acid.

Bilateral facial nerve palsy associated with HIV seroconversion illness

Bilateral facial nerve palsy is a rare but recognised manifestation of HIV seroconversion illness. The pathophysiology of this clinical presentation is thought to be associated with the immune response of...

HIV seroconversion complicated by Mycobacterium kansasii infection

HIV seroconversion can be associated with opportunistic infections when the CD4 cell count is low. Mycobacterium kansasii infection has been described in established HIV infection, often advanced, but not previously in seroconversion. We present a patient in whom seroconversion to HIV was complicated by M. kansasii infection. A 30-year-old Zambian man presented to our department in February 2004 with fevers, sweats, weight loss, and shortness of breath. A chest X-ray showed a right pleural effusion that was found to be an exudate. No organism was isolated on pleural biopsy. Given his symptoms and background, he was treated empirically for pleural tuberculosis. Testing for HIV antibodies at this time was negative. He responded well to 6 months of standard antituberculosis treatment, and was discharged from follow-up in July 2004. He re-presented to us at the end of April 2006 with a flu-like illness. He had a marked sore throat and also complained of fevers, diarrhoea, rash and a cough productive of sputum. On examination he had a macular rash over his torso, oral macular lesions and oral thrush. He was also noted to have lymphadenopathy in both groins and crackles at the right lung base. His chest X-ray was normal but he continued to have a cough productive of sputum. On direct questioning it transpired that his wife had just returned from a long period in Zambia, the patient denying any new sexual contacts. Initial blood tests showed a total lymphocyte count of 0.42 × 109 cells/l. His initial HIV serology was equivocal, with a reference laboratory report showing the absence of HIV antibodies, but the presence of p24 antigen. He subsequently became HIV antibody positive 6 days later. His HIV viral load was 694 843 copies/ml, with an initial CD4 T-cell count of 0.194 × 109 cells/l. Sputum microscopy at this time showed moderate numbers of acid fast bacilli. These samples were sent for testing by polymerase chain reaction for Mycobacterium tuberculosis. In the interim he was started on conventional antituberculosis treatment, with rifampicin, isoniazid, pyrazinamide and ethambutol. He made a good response to treatment, with resolution of his fevers and cough, his rash and diarrhoea having already settled. His polymerase chain reaction test, however, came back negative for M. tuberculosis. At this point we added clarithromycin to provide additional cover against atypical mycobacteria. His sputum subsequently grew M. kansasii sensitive to rifampicin, ethambutol and clarithromycin. At follow-up at 2 months he felt well with only a slight cough still present but no sputum production. He had no further fevers or sweats and his repeat CD4 T-cell count was 0.461 × 109 cells/l, with his viral load having reduced to 51 416 copies/ml. M. kansasii infection has been well reported in advanced HIV disease [1–6], but to the best of our knowledge this is the first reported case occurring in seroconversion. Given that our patient has been treated previously for tuberculosis, without microbiological confirmation, it is possible that he had M. kansasii infection originally, which became active again during seroconversion. The response to treatment, with resolution of his fevers and cough, led us to believe he was actively infected rather than merely colonized. He clearly had a seroconversion illness, as demonstrated by his previous negative HIV test and his high HIV viral load and low CD4 cell count at presentation followed by spontaneous improvement without antiretroviral therapy. Other opportunistic infections and complications of advanced HIV disease have previously been reported during seroconversion [7–9], and our case adds to this literature. Seroconversion is associated with a rapid temporary drop in the CD4 cell count and a reversal in the CD4/CD8 cell ratio, during which time opportunistic infections may occur [7,10]. M. kansasii infection in the context of HIV has been described in patients who tend to be moderately to severely immunosuppressed [1–4]. The introduction of antiretroviral therapy has reduced both the incidence and the mortality from M. kansasii infection [11]. It has also been noted that those with disseminated diseases do worse than patients only suffering from pulmonary disease [2,7]. As has been shown before, HIV patients respond well to standard treatment against M. kansasii[4]. Although the British Thoracic Society guidelines recommend lifelong treatment in HIV/M. kansasii co-infection [12], given that our patient has regained a good CD4 cell count, had local disease, and has responded well to treatment, we are intending to treat him for 9 months in the first instance (as is the practice for non-HIV-infected individuals) especially as his immune recovery has been marked. In summary, we have described a patient in whom an HIV seroconversion illness was complicated by M. kansasii infection. Clinicians should be aware that atypical mycobacteria can present during seroconversion and may require treatment.

Profiling of HIV clinic patients to determine the prevalence and characteristics of recent infections

Patients newly attending the government HIV clinic in Hong Kong were studied for the prevalence and characteristics of recent HIV infection, which was defined as having a negative HIV antibody test and/or seroconversion illness within one year of a first positive antibody result. Fifty-nine (12.0%) of 492 HIV-positive patients first seen from 2001 to 2004 were determined to be recently infected. This likely represented the lower bound of the real situation. Compared with non-recent infections on univariate analysis, recent cases were more likely to be men who have sex with men (OR 2.23; 95%CI, 1.23–4.05), never married (OR 1.96; 95%CI, 1.03–3.89), had tertiary or above education (OR 3.93; 95%CI, 1.65–10.09) and with a baseline CD4>=500 cells/ul (OR 3.65; 95%CI, 1.87–6.93). Upon multivariate analysis, tertiary or above education (adjusted OR 4.23; 95%CI, 1.76–10.16) and CD4>=500 cells/ul at diagnosis (adjusted OR 3.58; 95%CI, 1.88–6.84) remained independent variables. HIV clinics are feasible settings for collecting epidemiological information of on-going infection. Differences in the profile between recent and non-recent cases may shed light on targeting efforts to prevent new HIV infections.

Haemorrhagic acute disseminated encephalomyelitis: an unusual case of blindness in an HIV-infected patient

Acute disseminated encephalomyelitis (ADEM) is a monophasic, polysymptomatic, immune-mediated demyelinating disorder involving central nervous system (CNS) white matter. It is usually seen in association with exanthematous viral illnesses, systemic infections or vaccinations. The haemorrhagic form of ADEM is rarer and follows a more fulminant course. We describe a case of haemorrhagic ADEM in an HIV-infected patient presenting solely with acute onset bilateral blindness and normal retina. ADEM was diagnosed from clinical, laboratory and radiological findings. Although ADEM has been seen with HIV seroconversion illness and in chronic infection, the haemorrhagic form has never been reported in association with HIV. Acute onset blindness is extremely rare in HIV-positive patients. A Medline search revealed very few reports. The importance of considering haemorrhagic ADEM as aetiology of blindness in such a scenario is discussed.

The relationship between HIV seroconversion illness, HIV test interval and time to AIDS in a seroconverter cohort.

Seroconversion illness is known to be associated with more rapid HIV disease progression. However, symptoms are often subjective and prone to recall bias. We describe symptoms reported as seroconversion illness and examine the relationship between illness, HIV test interval (time between antibody-negative and anibody-positive test dates) and the effect of both on time to AIDS from seroconversion. We used a Cox model, adjusting for age, sex, exposure group and year of estimated seroconversion. Of 1820 individuals, information on seroconversion illness was available for 1244 of whom 423 (34%) reported symptomatic seroconversion. Persons with a short test interval (< or = 2 months) were significantly more likely to report an illness than people with a longer interval (OR 6.76, 95% CI 4.75-9.62). Time to AIDS was significantly faster (P = 0.01) in those with a short test interval. The HIV test interval is a useful replacement for information on seroconversion illness in studies of HIV disease progression.

Atypical presentation of HIV seroconversion illness in a young woman

Early detection and counselling of HIV-infected individuals can have an impact on prevention of HIV transmission. We describe an atypical presentation of an HIV seroconversion illness in a woman.

The relationships between the HIV test interval, demographic factors and HIV disease progression.

Individuals developing an HIV seroconversion illness may experience rapid disease progression. Information on seroconversion illness is rarely collected in most cohort studies, thus the aim of this study was to assess the value of the HIV test interval (the time between last negative and first positive HIV tests) as a proxy for seroconversion illness. Among 8229 seroconverters, test intervals ranged from 0-5282 days, and varied by gender, risk group, age and calendar year of seroconversion. Those with intervals < or = 31 days had an increased hazard of AIDS (RH 1.42, P = 0.07), which was reduced slightly after adjusting for baseline factors, calendar year of follow-up, treatment and the declining CD4 count, but there was no effect on survival. Thus, it appears that if information on acute seroconversion illness is not available, then analyses of progression to AIDS in seroconverter studies could use a short test interval as a proxy measure.

P48 How reliable are data on HIV seroconversion illness? Is HIV test interval an adequate substitute?

P48 How reliable are data on HIV seroconversion illness? Is HIV test interval an adequate substitute?

Paediatric special interest group in medicine Haematometra and haematocolpus in a teenage girl Lies, damned lies and EDIS data: Statistics built on sand Lies, damned lies and EDIS data: Statistics built on sand: Reply Emergency sedation intubation Emergency sedation intubation: Reply Emergency physicians roles in managing HIV seroconversion illness: Take stock or take HAART? Emergency physicians roles in managing HIV

Emergency MedicineVolume 11, Issue 3 p. 196-204 Paediatric special interest group in medicineHaematometra and haematocolpus in a teenage girlLies, damned lies and EDIS data: Statistics built on sandLies, damned lies and EDIS data: Statistics built on sand: ReplyEmergency sedation intubationEmergency sedation intubation: ReplyEmergency physicians roles in managing HIV seroconversion illness: Take stock or take HAART?Emergency physicians roles in managing HIV seroconversion illness: Take stock or take HAART? Reply First published: 27 February 2002 https://doi.org/10.1046/j.1442-2026.1999.00046.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume11, Issue3September 1999Pages 196-204 RelatedInformation

Acute HIV seroconversion illness presenting as African viral haemorrhagic fever

Background: Both human immunodeficiency virus type 1 (HIV-1) and African viral haemorrhagic fever (VHF) viruses cause similar symptoms in acutely infected individuals and must be included in the differential diagnosis in areas where HIV-1 and VHF viruses both occur. Objectives: To determine the cause of an acute illness in a patient at risk of exposure to both HIV-1 and African VHF viruses. Results: Serological examination revealed the presence of high levels of the p24 core antigen of HIV-1 in the absence of antibodies to HIV-1 in a specimen collected during the acute stage of the infection. On follow-up, the antigen enzyme-linked immunosorbent assay (ELISA) became negative while the antibody ELISA and confirmatory Western blot for HIV-1 became positive. Conclusions: Acute HIV seroconversion illness may have protean manifestations and, in the more severe forms, may cause diagnostic dilemmas, particularly in regions where African VHFs occur.

Laboratory indicators for monitoring HIV disease.

Immunological monitoring of disease progression following HIV infection and seroconversion illness, latency and AIDS, not only helps in the basic investigation of the natural history of the viral infection in man, but also can assist in prognosis and treatment of AIDS-defining illnesses. However, outside clinical trials, these tests should be selected and used in clinical practice only if they are validated as relevant and effective. The absolute CD4+ T-helper lymphocyte count, measured by flow cytometry, has emerged as the best available investigation, but needs care in sampling due to diurnal and circadian rhythms, effects of age, pregnancy, therapy, intercurrent infections and technique. Sampling should provide a baseline and trends-monthly intervals initially, then quarterly in uncomplicated cases. Thresholds may be given for counts (e.g. 200/microliter) below which prophylaxis against pneumocystis pneumonia should be administered, and repeating persistently low counts (e.g. below 50/microliter) is seldom helpful in practice. Serum levels of beta-2 microglobulin, neopterin and immunoglobulins rarely add information. Physicians and laboratories should have testing guidelines based on clinical audit of best practice, based in turn on scientific understanding of the immunological processes involved.

Color Atlas of AIDS and HIV Disease

Part 1 The AIDS epidemic: epidemiology immunology virology the definition of AIDS the antibody response to HIV the HIV antibody test the origin of HIV the clinical spectrum and classification of HIV disease. Part 2 Clinical manifestation of HIV disease: HIV seroconversion illness, or acute HIV lymphadenopathy weight loss oral cavity disease skin disease ENT problems Kaposi's sarcoma pulmonary disease diseases of the nervous system gastrointestinal disease lymphoma paediatric HIV disease. Part 3: Other sexually transmitted diseases in HIV positive patients. Part 4: Counselling of patients with HIV disease. Part 5: Tranmsmission and prevention of HIV disease. Appendices: 1 - the full definition of AIDS 2 - AIDS in Africa, M.Rolfe.