Acute HIV Infections

by Dr. Earl H. Eye, M.D.
7/18/98


Symptoms
The initial infection with the HIV type B virus is associated with symptoms in 50-90% of cases. Most patient with symptoms seek medical attention, but are rarely diagnosed.

The time from initial exposure to onset of symptoms is usually 2-4 weeks, but can rarely be up to 10 months. Typical symptoms at presentation are fever (96%), enlarged lymph nodes (74%), sore throat (70%), rash on face and trunk and occasionally hands and feet with ulcers in mouth, esophagus, and genitals (70%), muscle aches and pains (54%), diarrhea (54%), headache (32%), nausea and vomiting (27%), liver and spleen enlarged (14%), and oral fungal infection (12%).

Neurological complaints includes meningoencephalitis (confusion, headache - 8%), peripheral neuropathy (pains in hands and feet) (8%), and less commonly Guillain-Barre' syndrome (paralysis from feet toward head), Bell's palsy (paralysis of one side of the face), brachial neuritis (pains localized in shoulder with arm weakness), cognitive impairment (trouble focusing and thinking), and psychosis (delusional states).

Another study showed that weight loss and aseptic meningitis (headache with stiff neck) were frequently noted.

Laboratory Tests
Laboratory tests will show low lymphocytes with atypical forms, depletion of the CD4 cells, elevated CD8 cells. Liver enzyme elevation can be seen.

Diagnostic tests usually used are of no help. The ELISA screening test usually becomes positive at 3-12 weeks with most around 5 weeks. Studies which help are viral load, and p24 antigen, with the viral load the best test. A single positive test is considered diagnostic. Levels are usually very high in the 100,000 to 100,000,000 viral copies per ml. range. 

Transmission
Transmission is most commonly by sexual intercourse, followed by injection drug use, blood transfusions, transmission to baby by infected mother, and rarely by organ transplant, needle stick or blood splash, household contact, and deep kissing???(one case). A small number have no discernable risk factors.

The best estimate is that there are 400,000 to 650,000 HIV infected persons living in the USA. Today the fastest growing risk category is heterosexual sex, with the risk to the female from an infected male eight times higher than the reverse.

The importance of early Diagnosis and Treatment
Diagnosis is very important at this stage as early treatment with multiple drugs (HAART) can radically alter the course and prognosis of this disease.

When those infected have persistent symptoms for more that 14 days, they have more rapid progression to AIDS without treatment. The risk for developing AIDS (without early treatment) was as high as 78% vs. only 10% in those whose symptoms were shorter than 10 days.

Data have not yet confirmed what the treatment effect will be, but data shows that treating those who have been infected for even long time periods has reduced the mortality by 44% in 1997.

Early treatment would likely prevent the develop of immune suppression, reduce the viral load, and possibly convert the acute HIV infected to a long-term disease free survival status ("long-term non-progressors") which is seen in 4-7% of those currently infected. (defined as HIV infection for greater than or equal to 13 years, no drug treatment, CD4 counts over 600, no decrease in CD4 for 5 years, and viral load less than 5000.)

Treatment
Treatment usually begins with at least three drugs, usually AZT, 3TC, and a protease inhibitor, commonly Crixivan, Saquinavir, Norvir, or Viracept.

Other combinations are possible and effective. Viral loads and CD4 counts should be followed for treatment response, and other labs may be needed to monitor drug side effects.

Occasionally these drugs may be used to prevent infection in those health care workers who have had needle sticks or blood splash exposure, others with a known acute exposure such as rape victims, and for the baby in pregnant HIV infected mothers, especially when combined with C-section (reduces risk to 1% or less of infected baby.)

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