Acute HIV Seroconversion Illness

Acute HIV seroconversion illness is the flu like or glandular fever like syndrome that develops 2 to 4 weeks after HIV acquisition, as plasma viraemia peaks and antibodies appear. It occurs in about 50 to 90 percent of newly infected people.

• Most unrecognised because features are non specific.
• Viral load is very high, so transmission risk per exposure is greatest at this time.

Fever, sore throat, malaise, myalgia, arthralgia, headache, lymphadenopathy, maculopapular rash on the trunk and face, mouth and genital ulcers, diarrhoea, nausea and weight loss, lasting 1 to 3 weeks.

• Neurological: aseptic meningitis, facial palsy, Guillain Barre syndrome, encephalopathy; transient immunosuppression allows oral candidiasis or pneumocystis pneumonia.
• Differential diagnosis: malaria, dengue, chikungunya, infectious mononucleosis, CMV, secondary syphilis, typhoid, influenza, viral hepatitis, measles, rubella, toxoplasmosis, drug reaction, sepsis.
• Complications: opportunistic infection, neurological disease, high infectiousness, early reservoir seeding, rapid progression in some people, transmitted resistant virus.

Antibody tests may be negative, so use antigen and RNA tests.

• Fourth generation HIV antigen and antibody assay; HIV RNA PCR (viral load) if antibody negative, indeterminate or fourth generation reactive with a negative antibody; repeat antibody test at 4 weeks and at 3 months.
• Baseline CD4 count, viral load, resistance genotype if available, full blood count, creatinine, liver enzymes, hepatitis B surface antigen, hepatitis C antibody, syphilis serology, tuberculosis symptom screen, pregnancy test, STI screen, malaria test in fever.
• Lumbar puncture for meningism.

Start antiretroviral therapy at once without waiting for follow up tests.

• Supportive: counselling and psychological support, paracetamol 1 g four times daily for fever and myalgia, hydration, safer sex, partner notification and testing, offering pre exposure prophylaxis to partners, adherence preparation, avoid donating blood.
• Pharmacological: tenofovir disoproxil fumarate 300 mg with lamivudine 300 mg and dolutegravir 50 mg once daily, starting on the day of diagnosis or within 7 days. If rifampicin based tuberculosis treatment is needed, give dolutegravir 50 mg twice daily during rifampicin and for 2 weeks after it stops. Cotrimoxazole 960 mg daily if CD4 is under 350 or symptomatic. Hepatitis B coinfection: tenofovir with lamivudine treats both infections; do not interrupt. Infant of an infected mother: nevirapine 2 mg/kg daily for 6 to 12 weeks.
• Procedures: lumbar puncture if meningism or confusion.
• Special groups: pregnancy, give tenofovir, lamivudine and dolutegravir at once; children, weight based dosing; renal impairment, substitute abacavir 600 mg daily for tenofovir when creatinine clearance is under 50 mL/min (after HLA B5701 testing where available); adolescents, youth friendly services.
• Red flags: severe headache or confusion, persistent vomiting, severe mucosal ulceration, dysphagia, pregnancy, CD4 under 200.
• Follow-up: viral load at 3 months then 6 months then yearly once suppressed; creatinine at 3 months; adherence support.