diagnosing primary HIV infection in primary care
The clinical diagnosis of HIV-related conditions in primary care is not always easy. The opportunity to diagnose primary HIV infection is limited by the short duration of the symptoms and their non-specific nature (1,2).
- GP should be have an idea regarding the current HIV transmission patterns in their communities (e.g., men who have sex with men, persons who share needles, prevalence of heterosexual transmission) and should have low threshold to consider the acute infection in patients who present with suggestive symptoms (3)
There are two main clinical opportunities for diagnosing HIV infection in primary care:
- when the patient presents with symptoms or medical conditions possibly associated with HIV
- offering an HIV test to an asymptomatic patient because they are or may be at risk of HIV infection (1)
When raising the possibility of HIV in suspected patients, GPs should:
- be open about the clinical reasoning behind the questions
- first explain the clinical grounds for asking the question in order to make the patient comfortable in revealing the complete history
- be non-judgemental
- be direct but sensitive during questioning
- the more accessible and understanding the clinician appear, the more trusting the patient will be, and the more accurate the replies
- reassure the patient about confidentiality of the information provided by them (1)
Hints and tips which should be considered when thinking about primary HIV infection:
- if a diagnosis of infectious mononucleosis is considered, think about primary HIV infection as well
- take a history and conduct an examination to look for further evidence of PHI (primary HIV infection)
- inquire specifically about all activities that potentially involve HIV exposure, including heterosexual intercourse with a long-term partner
- has the person had a rash? Or sores or ulcers in the mouth or genital area? (even if the person has PHI, there may be no additional features)
- less common presentations may include - headache, meningism and diarrhoea
- acute conditions associated with immunosuppression may be present at this stage due to a drop in CD4 count
- if the patient has clinical features of PHI, or if they have an identified risk, then recommend the test and offer safer sex advice at this point.
- if the result is positive - arrange referral to HIV specialist services
- if negative, but still a high probability of PHI - refer to the local HIV services for further assessment (1,2,3).
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