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INTRODUCTION
The prevalence of HIV in the United States is less than 1%, which is much less than many African nations. However, the prevalence in some US populations does compare to the African epidemic. A recent study estimated the prevalence of HIV in Washington, DC to be at least 3% among all persons aged over 12 years, and 6.5% in Black men.1 Previously, the incidence of new HIV infections in the United States was thought to be approximately 40,000 per year, with little change over the last several years. However, new assays allowing the differentiation of recent versus long standing HIV infections have led to the revised estimate that approximately 56,300 persons became infected with HIV in 2006.2
Traditionally, prevention strategies have focused on preventing HIV negative persons from acquiring the virus. With the increasing prevalence and incidence of HIV, public health personnel have been focusing on prevention with positives or secondary prevention to decrease the transmission of HIV.
| 50% of infections are transmitted in the first
two to four weeks following infection. |
BACKGROUND
- The Centers for Disease Control and Prevention (CDC) has estimated that 21%of people living with HIV infection have not yet been diagnosed.3
- The first step in prevention with positives is to identify all those who have HIV.
- The CDC recently recommended routine yearly HIV screening of all persons ages 13 to 64 in all healthcare settings.4
- According to the CDC,HIV testing based on risk behavior fails to identify many persons infected with HIV who are unaware they are at risk for infection or who do not report risk behavior.
- The expanded screening protocol is also an effort to destigmatize the act of requesting an HIV test.
- People are more likely to be cautious and use protection if they realize that there is a risk of transmitting the virus to others. Those who are HIV positivemust know their status.
- Previously, HIV testing required returning to the testing center a week or two after the test to receive the results, and approximately 31% of those who were positive never returned to obtain the results.5
- Now with the advent of rapid HIV testing, a definitive negative and a preliminary positive result can be obtained within minutes of test taking.
- In New Jersey, the percentage of clients receiving their result in publicly funded sites has risen to 98.91%since the state began funding rapid testing.6 Hopefully, these efforts will uncover previously unknown HIV positive persons.
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Source: www.hivguidelines.org
ACUTE HIV INFECTION
It is also important to recognize the SIGNS and SYMPTOMS of Acute HIV Infection (AHI), also known as Primary HIV infection, which occurs in the first two to four weeks following infection. Some estimate that as many as 50% of infections are transmitted during this period. This is because initial viral loads are usually very high, sometimes greater than 750,000 copies/ml.7
HIGHER SERUM VIRAL LOADS correlate to increased transmission of HIV. A study of serodiscordant couples in Uganda noted a significantly higher serum viral load among HIV positive subjects whose partners seroconverted than those who did not seroconvert, and there were no seroconversions among partners of subjects with HIV RNA levels less than 1,500 copies/ml.8
People rarely realize they are HIV positive during Acute HIV Infection and may not be as likely to use clean needles or to wear condoms. Health care workers need to be cognizant of the signs and symptoms of AHI including fever, chills, myalgias, sore throat, rash, headache, and swollen glands. These symptoms are quite common and can masquerade as the common cold, influenza or Group A streptococcal pharyngitis. Please see Table 1. The astute provider will obtain an HIV antibody test along with a test that can diagnose the virus during the window period, such as an HIV viral load.
Antiretroviral Therapy (ART) and Prevention
Over the years the RECOMMENDATIONS HAVE CHANGED regarding when to start antiretroviral therapy. The most recent recommendations state that treatment of asymptomatic patients should be initiated when the CD4+ cell count is <350 cells/mm3.9 However, the pendulum seems to be swinging back to starting antiretroviral therapy earlier for many reasons including simpler drug regimens, fewer medication adverse effects, and most recently improved survival.10 Starting antiretroviral treatment earlier can also impact secondary prevention efforts. If patients are started on antiretroviral treatment earlier, then they may have lower levels of the virus in their serum and genital secretions, which would lead to fewer transmissions.
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