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1–34 | Clinical Manual for Management of the HIV-Infected Adult/2006
A: Assessment and Plan
Patients with primary HIV infection will need
additional medical evaluation, baseline laboratory testing,
and intensive support, counseling, and education about
HIV infection. See chapters Initial History, Initial
Physical Examination, and Initial and Interim Laboratory
and Other Tests for detailed information on the initial
evaluation of HIV-infected patients.
Laboratory
The initial laboratory work should include the
following:
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The CD4 count and HIV viral load should be
checked on 2 occasions within several weeks.
A baseline HIV genotype test should be obtained for
all patients with primary HIV infection, even those
who do not choose to start antiretroviral treatment
(ART). In some cities in the United States and
Europe, up to 15-20% of individuals infected in
recent years have acquired HIV virus strains with
mutations that confer resistance to antiretroviral
medications. These resistance mutations may be
identified by early resistance testing, but later may
not be detectable. (See chapter Resistance Testing.)
The HIV antibody test should be repeated in 4-6
weeks to document the HIV status of patients who
are presumed to have primary HIV infection.
Treatment
It is reasonable to consider starting combination ART in
patients with acute HIV infection, because some limited
evidence suggests that treatment initiated during primary
HIV infection may preserve HIV-specific immune
function that would otherwise be lost as the infection
progresses. However, it is not yet clear whether initiating
early treatment yields long-term immunologic, virologic,
or clinical benefits. The potential advantages of ART for
primary infection must be weighed against the possibility
of short- and long-term toxicities, the possibility of
developing drug resistance, and the adherence challenges
associated with starting antiretrovirals quickly in newly
diagnosed patients. These issues are complex, and consultation
with an HIV expert or referral to a clinical trial is
recommended.
For patients who choose to start therapy during
primary HIV infection, the choice of agents and the
monitoring of patients on treatment are similar to those
in the treatment of chronic HIV infection (see chapter
Antiretroviral Therapy). The initial goal of therapy in
primary HIV infection is to suppress the HIV viral load
to undetectable levels.
Clinical trials across the country currently are recruiting
individuals to evaluate both the natural history of
primary HIV infection and the possible benefits of
treatment of acute HIV infection. Information on
clinical studies of primary HIV may be obtained
through the AIDS Clinical Trials Information Service
(ACTIS) on its Web site at http://www.aidsinfo.nih.
gov/clinicaltrials or by telephone at 800-HIV-0440.
Issues concerning the possible treatment of primary
HIV infection also are reviewed in the U.S. Department
of Health and Human Services Guidelines for the Use
of Antiretroviral Agents in HIV-1-Infected Adults and
Adolescents.
Patient Education
Patients with primary HIV infection need support and
counseling, as do all newly diagnosed patients. Intensive
education about HIV infection, the course of disease,
prognosis, and the risks and benefits of ART must
be undertaken. Counseling about safer sex and drug
injection techniques, as indicated, is especially important
for these patients because they may have ongoing highrisk
behaviors for HIV transmission and because they
may be highly infectious during the primary infection
period. (See chapter Preventing HIV Transmission /
Prevention with Positives for more information about
patient support and counseling in these areas.)
References
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Daar ES, Little, S, et al. Diagnosis of primary HIV-
1 infection. Los Angeles County Primary HIV
Infection Recruitment Network. Ann Intern Med.
2001 Jan 2;134(1):25-9.
Schacker T, Collier AC, Hughes J, et al. Clinical and
epidemiologic features of primary HIV infection. Ann
Intern Med. 1996 Aug 15;125(4):257-64.
Smith DE, Walker BD, Cooper DA, et al. Is
antiretroviral treatment of primary HIV infection
clinically justified on the basis of current evidence?
AIDS. 2004 Mar 26;18(5):709-18.
U.S. Department of Health and Human Services.
Guidelines for the Use of Antiretroviral Agents in HIV-
1-Infected Adults and Adolescents. October 10, 2006.
Available online at aidsinfo.nih.gov/Guidelines/
GuidelineDetail.aspx?GuidelineID=7. Accessed July
7, 2007.