Page 117 - HIV/AIDS Guidelines

Considerations for Antiretroviral Use in Special Patient
Populations

Acute HIV Infection (Last updated January 10, 2011; last reviewed January 10, 2011)

Panel’s Recommendations

• It is unknown if treatment of acute HIV infection results in long-term virologic, immunologic, or clinical benefit;
treatment should be considered optional at this time (CIII).

• Therapy should also be considered optional for patients with HIV seroconversion in the previous 6 months (CIII).
• All pregnant women with acute or recent HIV infection should start a combination antiretroviral (ARV) regimen as
soon as possible to prevent mother-to-child transmission (MTCT) of HIV (AI).

• If the clinician and patient elect to treat acute HIV infection, treatment should be implemented with the goal of
suppressing plasma HIV RNA to below detectable levels (AIII).
• For patients with acute HIV infection in whom therapy is initiated, testing for plasma HIV RNA levels and CD4 count
and toxicity monitoring should be performed as described for patients with established, chronic HIV infection (AII).
• If the decision is made to initiate therapy in a person with acute HIV infection, genotypic resistance testing at baseline
will be helpful in guiding the selection of an ARV regimen that can provide the optimal virologic response; this strategy
is therefore recommended (AIII). If therapy is deferred, genotypic resistance testing should still be performed because
the result may be useful in optimizing the virologic response when therapy is ultimately initiated (AIII).
• Because clinically significant resistance to protease inhibitors (PIs) is less common than resistance to non-
nucleoside reverse transcriptase inhibitors (NNRTIs) in antiretroviral therapy (ART)-naive persons who harbor
drug-resistant virus, a ritonavir (RTV)-boosted PI-based regimen should be used if therapy is initiated before drug-
resistance test results are available (AIII).

Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational
cohort studies with long-term clinical outcomes; III = expert opinion

An estimated 40%–90% of patients acutely infected with HIV will experience symptoms of acute retroviral
syndrome characterized by fever, lymphadenopathy, pharyngitis, skin rash, myalgias/arthralgias, and other
symptoms. 1-6 However, acute HIV infection is often not recognized by primary care clinicians because
symptoms are similar to those for influenza, infectious mononucleosis, or other illnesses. Additionally, acute
infection can occur asymptomatically. Table 10 provides practitioners with guidance on the recognition,
diagnosis, and management of acute HIV infection.

Diagnosis of Acute HIV Infection
Health care providers should maintain a high level of suspicion of acute HIV infection in patients who have a
7
compatible clinical syndrome and who report recent high-risk behavior. However, in some settings, patients
may not always disclose or admit to high-risk behaviors or might not perceive their behaviors as high risk.
Thus, symptoms and signs consistent with acute retroviral syndrome should motivate consideration of this
diagnosis even in the absence of reported high-risk behaviors.

When acute retroviral syndrome is suspected, a plasma HIV RNA test is typically used in conjunction with
an HIV antibody test to diagnose acute infection (BII). Acute HIV infection is often defined by detectable
HIV RNA in plasma in the setting of a negative or indeterminate HIV antibody test. A low-positive HIV
RNA level (<10,000 copies/mL) may represent a false-positive test because values in acute infection are

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-1

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