New HIV Diagnosis

Olga Vujovic : Infectious Diseases Unit, The Alfred Hospital, Melbourne VIC
David Baker : East Sydney Doctors, Darlinghurst, Sydney NSW

Evaluation of the newly diagnosed person with human immunodeficiency virus (HIV) infection presents a challenge to clinicians, even those highly experienced in the area of HIV medicine. Assessment and initial management involve careful evaluation of clinical status, with a focus on psychological issues, mode of infection and health promotion. While clinical practice guidelines for the management of newly diagnosed HIV infection exist, the rapidity of change in this area is such that published guidelines are not always up-to-date or relevant to the local context. Web-based resources which are updated regularly may be more useful and a list of these and commentary may be found on the ASHM website.[1]   Note that many guidelines are based on expert opinion with varying levels of evidence to support recommendations.

Following the publication of results of the (Strategic Timing of AntiRetroviral Treatment (START) trial, guidelines now recommend that all people living with HIV should be treated regardless of immune function.[2]   Individual benefits of early treatment now align with the public health benefit of reduced risk of HIV transmission. In a practical sense, this recommendation means that the assessment of the newly diagnosed person also means assessing him or her for antiretroviral therapy (ART). As treatment will be long term, a thorough assessment of the patient will need to be performed in order to offer him or her the most appropriate treatment.

Management can be considered under the following headings (a detailed check list is provided in Table 1)

  • Clinical assessment (history and examination), with a particular focus on identification of clinical indicators of the stage of HIV disease and associated infections, including sexually transmissible infections (STIs) and bloodborne viruses
  • Assessment of the social context of the infection, including drug and alcohol risk factors
  • Assessment of the psychological impact of the diagnosis
  • Laboratory evaluation, including the stage of HIV infection, baseline serological testing
  • Investigation of comorbidities and co-infections
  • Health maintenance, including prevention of comorbidities and STIs
  • Education and support
  • Risk assessment and prevention
  • Public health measures.

 

 Table 1 

Checklist of important points in initial assessment and management of HIV infection [3] [4] [5] [6]

Clinical assessment Complete history and examination
Assessment of duration of HIV infection if possible
Assessment of social context Risk factors for transmission, including sexual history, injecting drug use, prior surgery or blood transfusion, occupation
Level of understanding of HIV infection and its consequences
Community situation – occupation, family/social networks, cultural/religious context
Assessment of psychological  impact Factors leading to increased risk of suicide, depression or adjustment disorder following diagnosis – past psychiatric morbidity, injecting (and other) drug use, alcohol dependence, prior maladaptive illness behaviour, cultural/religious factors
Disclosure of diagnosis to others
Laboratory investigation Confirmation of HIV with enzyme-linked immunosorbent assay and Western Blot
CD4 cell count and plasma HIV RNA
Baseline HIV genotype
Baseline urea, electrolytes, creatinine, liver function tests, fasting lipids, fasting glucose, full blood examination, urine dipstick or urinary protein creatinine ratio (UP/C) for proteinuria
HLA B*5701 (screening for predisposition to abacavir hypersensitivity)
Baseline serology – Cytomegalovirus, toxoplasma, HAV IgG, HBV (hepatitis B surface antigen, hepatitis B surface antibody and hepatitis B core antibody), HCV (HCV antibody and HCV RNA if antibody test is positive), serum cryptococcal Ag (if CD4<100)
Investigation of co-morbidities and co-infections Screening for depression and other psychiatric morbidity
Screening for sexually transmitted infections (gonorrhoea, chlamydia, syphilis, and herpes simplex virus)
Evaluation of viral hepatitis co-infection
Chest X-ray, interferon-gamma release assays or Mantoux test if at risk for TB
Evaluation and recording of cardiovascular risk factors, calculation of 5 year cardiovascular disease risk
Neurocognitive assessment as indicated
Bone health review, risk assessment, vitamin D if indicated
 Health maintenance Nutritional assessment and intervention
Smoking cessation
Vaccination – HAV, HBV, pneumococcal and influenza vaccination, consider HPV, others as indicated[7]
Regular STI screening in men who have sex with men, as per current guidelines
Regular cervical cytology (12 monthly)
Cancer screening as per guidelines (colon, skin, breast)[8]

Prophylaxis – any CD4 cell count:

  • Herpes simplex virus (recurrent) – valaciclovir 500 mg twice a day or famciclovir 500 mg twice a day
  • Tuberculosis – refer to chapter on management of tuberculosis
    Prophylaxis – CD4 cell count <200 cells/μL:
  • Pneumocystis jirovecii pneumonia and Toxoplasma gondi encephalitis – trimethoprim-sulphamethoxazole (cotrimoxazole) 160 mg-800 mg daily or three times per week. Alternatives see references[9], [10]
  • Candidiasis (recurrent) fluconazole 50-200 mg daily for oral/oesophageal candidiasis, 200 mg weekly for vaginal candidiasis
    Prophylaxis – CD4 cell count <50 cells/μL:
  • Mycobacterium avium complex – azithromycin 1200 mg/week. Alternatives see references[11], [12]
  • Cytomegalovirus retinitis – review by ophthalmologist every six months
Education and support HIV transmission, natural history, treatment.
Counselling, including partners where this is requested.
Reproductive/contraceptive advice and counselling for women and discordant couples
Referral to other disciplines as required e.g. dietician, social worker, drug and alcohol counsellors
Referral to peer support agencies
Risk assessment and prevention Education, counselling and interventions regarding safer sexual practices and injecting techniques
Discuss treatment as prevention (TASP), pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)
detailed risk assessment, at least annually (including sexual practices and alcohol and drug use) Regular STI screening as indicated by risk assessment and local guidelines
Public health measures Notification of new HIV diagnosis (de-identified)
Partner notification/contact tracing – can be done by patient or clinician or by local public health officers
Notification of other notifiable infections eg syphilis, HBV, HCV
Advice to patient regarding legal obligations around disclosure of HIV status to sexual partners (refer to state public health legislation, differs between states)
Occupational advice e.g. HCW and exposure-prone procedures, sex work – refer to state legislation and policies
HIV RNA = human immunodeficiency virus ribonucleic acid; HCV = hepatitis C virus; HBV = hepatitis B virus; HAV= hepatitis A virus; STI = sexually transmitted infection; HCW = health care worker; G-6-PD = glucose-6-phosphate dehydrogenase; HCV RNA =  hepatitis C virus ribonucleic acid; HLA = human lymphocyte antigen; IgG = immunoglobulin G. HPV = human papilloma virus

 

Following diagnosis patients need frequent reviews including regular clinical assessment, in addition to a focus on psychosocial issues and provision of ongoing education, care and support. Often clinical review includes both the care of the person with HIV infection and others closely involved with him or her (e.g. partners, family members, contacts). With all patients it is important to discuss and document advice around public health issues (transmission risk, contact tracing and legal issues as per state guidelines).

In 2014 the  number of new HIV diagnoses was 1081 cases with 16.6 % presenting with a CD4+ of less than 200 cells/μl.[13]  Patients with advanced disease need consideration of prophylaxis for opportunistic infectious(OI).[14] This group should also be carefully examined to exclude the presence of an OI.  In general ART should be started as soon as possible even in the presence of an OI, the exception being potential infections of the central nervous system such as cryptococcal and tuberculous meningitis for which immediate therapy may cause the immune reconstitution inflammatory syndrome (IRIS).[15]  Tuberculosis (TB) and cryptococcal infection should be screened for and treated before initiating ART.

Case studies of newly diagnosed HIV infection

These case vignettes are intended to highlight the range of issues that need to be addressed in the care of a person presenting with a new HIV diagnosis.  Detailed management advice is offered in other sections. Note that these clinical steps may be performed over one or more consultations.

Case 1

Paul is a 34-year-old man with recently diagnosed thrombocytopenia who has requested HIV testing because of his illness and recent knowledge of a past male sexual partner with HIV infection. He is currently living alone, between jobs, depressed and isolated. Physical examination reveals oral candidiasis, generalised lymphadenopathy, and his platelet count is 20 x 109/L. Baseline investigation reveals hepatitis C virus (HCV) infection, plasma HIV RNA of 150,000 copies/mL and CD4 cell count of 35 cells/μL.

Important factors in this man’s management include:

  • Establishment of a supportive relationship with health-care providers including community agencies if appropriate
  • Commencement of ART, in accordance with baseline drug resistance testing, HLA typing and ASHM antiretroviral guidelines as soon as possible after diagnosis given his severe immunodeficiency.
  • Assessment of depression, with exclusion of organic contributing factors, and commencement of antidepressant therapy as indicated
  • Provide treatment for oral candidiasis
  • Prophylaxis for Pneumocystis jirovecii pneumonia and toxoplasmosis (with trimethoprim/sulfamethoxazole), Mycobacterium avium complex (with azithromycin), ophthalmological review for cytomegalovirus (CMV) retinitis, Cryptococcal antigen and TB screening (if at risk)
  • Sexual health assessment and STI screening
  • Education concerning goals of therapy for HIV, importance of adherence, discussion of adverse effects of therapy, frequent monitoring of platelet count until a response is noted
  • Assessment and referral for HCV treatment with direct acting antivirals. Note that choice of ART may be influenced by planned hepatitis C treatment. See http://hep-druginteractions.org/ for possible drug-drug interactions. HCV treatment would usually be deferred until HIV is stable.  
  • Vaccinations (e.g. hepatitis B) may be delayed until the person with HIV infection is more immune competent

Case 2

Kit is a 28-year-old Thai national who is visiting his Australian male partner. He presents at your practice with his partner for an HIV test and sexual health screen.  On examination he is in good health.   He requests a rapid HIV test which is reactive and subsequent testing confirms that he is HIV positive with a CD4 count of 210 cells/μL and an HIV viral load of 480,000 copies/mL.

Important factors in this man’s management include:

  • Referral to the local sexual health clinic that has a Thai counsellor for detailed supportive counselling
  • Review hepatitis serology and vaccination history
  • Screening for TB with CXR and interferon-gamma release assay or Mantoux testing
  • Commencement of ART, in accordance with baseline drug resistance testing, HLA typing and ASHM antiretroviral guidelines with medication provided by a local pharmaceutical company under a compassionate access program
  • Discussion regarding longer-term treatment access and possible immigration issues as they relate to HIV infection
  • HIV and STI screening of current partner.

Case 3

Claire is a 32-year-old single unemployed factory worker who is currently being treated on an opioid substitution program with methadone 60 mg daily.   She continues to inject amphetamines and morphine tablets. Claire present with concerns that she may have shared a needle with a friend who she knows is HIV positive.  She has previously tested HCV antibody positive but HCV RNA negative. You order an HIV antibody test and HCV RNA.  HIV antibody and Western blot results are positive.  Her CD4 count is 678 cells/μL with an HIV viral load of 88,000 copies/mL.  HCV RNA remains negative.

Important factors in this women’s management include:

  • Establishment of a supportive relationship with health-care providers including community agencies if appropriate
  • Detailed discussion regarding future plans regarding pregnancy and the provision of appropriate contraception
  • Commencement of ART, in accordance with baseline drug resistance testing, HLA typing and ASHM antiretroviral guidelines
  • Review of possible drug interactions between methadone and antiretroviral ;see http://www.hiv-druginteractions.org/
  • Discussion and possible referral regarding ongoing drug use and needle sharing.

Case 4

Paul is a 57-year-old hospitality worker who presents for an HIV and STI screening.   He has recently left a 14-year gay relationship and is back on the scene.  Paul has hypertension which is well controlled on amlodipine.  He smokes 15 cigarettes daily. His last HIV test was about 5 years ago and was reported to be negative.  Results are HIV Ab positive, Western blot positive with a CD4 count of 512 cells/μL and an HIV viral load of 98,000 copies/mL.

Important factors in this man’s management include:

  • Establishment of a supportive relationship with health-care providers including community agencies if appropriate
  • Commencement of ART, in accordance with baseline drug resistance testing, HLA typing and ASHM antiretroviral guidelines
  • Detailed discussion regarding increased cardiovascular risk associated with HIV infection and smoking
  • Consider drug-drug interactions between antiretrovirals and antihypertensive medication see http://www.hiv-druginteractions.org/
1.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Incorporating Australian commentary of 18 May 2012. Available at: http://arv.ashm.org.au/pdf/ARV_Guidelines_AustCommentary_March28.pdf (last accessed 21 July 2016). 
2.
Insight Start Study Group. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. N Engl J Med. 2015. 
3.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Incorporating Australian commentary of 18 May 2012. Available at: http://arv.ashm.org.au/pdf/ARV_Guidelines_AustCommentary_March28.pdf (last accessed 21 July 2016). 
4.
European AIDS Clinical Society (EACS). EACS Guidelines 8.0. 2015. 
5.
STIGMA. Australian Sexually Transmitted Infection & HIV Testing Guidelines 2014 for Asymptomatic Men Who Have Sex with Men 2014 [cited 2016 10 January 2016]. Available from: http://stipu.nsw.gov.au/stigma/sti-testing-guidelines-for-msm 
6.
Australian Technical Advisory Group on Immunisation. The Australian immunisation handbook. 10 th ed. Canberra: NHMRC; 2013 2013. 
7.
Australian Technical Advisory Group on Immunisation. The Australian immunisation handbook. 10 th ed. Canberra: NHMRC; 2013 2013. 
8.
Ackermann E, Harris M, Alexander K, Bailey L, Bennett J, Del Mar C, et al. Guidelines for Preventive Activities in General Practice. 2013. 
9.
Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H; Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  MMWR Recomm Rep 2009;58(RR-4):1-207 
10.
European AIDS Clinical Society (EACS). EACS Guidelines 8.0. 2015. 
11.
Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H; Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  MMWR Recomm Rep 2009;58(RR-4):1-207 
12.
European AIDS Clinical Society (EACS). EACS Guidelines 8.0. 2015. 
13.
The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia, Annual Surveillance Report 2015. . The Kirby Institute, UNSW Australia, Sydney NSW 2052: 2015. 
14.
Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H; Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  MMWR Recomm Rep 2009;58(RR-4):1-207 
15.
Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H; Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.  MMWR Recomm Rep 2009;58(RR-4):1-207