Acute retroviral syndrome - UCLA Program in Global Health
+ Acute Retroviral Syndrome Dr. Jennifer Veltman + Acute Retroviral Syndrome (ARS) Definitions Epidemiology Basic course of Primary HIV Symptoms Diagnosis Treatment + What is Acute Retroviral Syndrome??? + Definitions: Acute HIV Infection: Phase of HIV disease immediately after infection during which the initial burst of viremia in newly infected patients occurs: anti-HIV antibodies are undetectable at this time, while HIV RNA or p24 antigen are present. Recent Infection: considered the phase up to 6 months after infected during which anti-HIV antibodies are detectable. Early HIV: either acute or recent HIV infection Acute retroviral syndrome: patient w/ acute HIV infection w/ symptoms. + Epidemiology 1/2 -2/3 of people infected with HIV develop ARS Reported more in those infected via sexual exposure or health care related (needle stick) compared to IVDU Onset 1-6 weeks after exposure. Peak onset is 3 weeks after exposure. + Day 0 Day 8 exposed to HIV, and infection begins. virus is detectable in blood using (PCR) antibody test are negative. amount of virus in the blood more than doubles every day. The CD4 cell count (and total white blood cell count) begins to drop Weeks 2-9 viral load peaks and begins to decline as the immune system begins to battle the virus highly infectious!!! Weeks 10-24 HIV viral load drops to its lowest point, also known as the set point, which is different in each person. antibody tests become positive for HIV. Seroconversion is now complete, and chronic HIV infection begins. + Window period + What are the symptoms of Acute Retroviral Syndrome? + Symptoms Symptom # w/ finding (n=209) Frequency % Fever 200 96 Enlarged lymph nodes 154 74 Sore throat 146 70 Rash 146 70 Sore muscles or joints 112 54 Low platelets 94 45 Low WBC 80 38 Diarrhea 67 32 Headache 66 32 Nausea/vomiting 56 27 Elevated liver enzymes 38 21 Enlarged liver/spleen 30 14 Thrush 24 12 Neuropathy 13 6 Encephalopathy 12 6 + What are some other diseases that can cause similar signs/symptoms? “MONO” (EBV or CMV infection) Influenza Fever, fatigue, sore throat, headache, rash, sore muscles, enlarged glands near ulcer Secondary Syphilis Muscle aches, fevers, nausea, vomiting, diarrhea, fatigue Acute HSV (Primary Herpes Infection) Sore throat, fatigue, enlarged glands, fever, muscle or joint aches, rash, enlarged liver/spleen, elevated liver enzymes, low platelets Fatigue, headache, poor appetite, nausea, joint aches, fever, (rarely) meningitis and liver inflammation Acute Hepatitis Fever, fatigue, elevated liver enzymes, enlarged liver + Symptoms resolve 10-15 days Acute opportunistic infections have been reported Examples: P. jirovecii pneumonia, Cryptococci meningitis, and Candida esophagitis. Likely caused by the depression of the CD4+cell count generally seen in acute HIV infection. + Diagnosis: high-level HIV RNA viral load in the absence of anti-HIV antibodies. (+)viral load. (–)ELISA ELISA remains negative for an average of 2 to 6 weeks after the onset of symptoms, despite the appearance of specific antibodies on a Western blot of the patient’s serum. If VL <10,000, may be false positive b/c usually VL >100,000 copies/mL Pt should have elisa repeated over next 3-6 months to document seroconversion + + Should your patient get on treatment? + Pros of starting treatment during Acute Retroviral Syndrome Pros: evidence treatment initiated during acute retroviral syndrome may lower the viral set point, which can affect disease progression rates in the event therapy is stopped Decreases mortality Reduce viral reservoir Decrease rate of viral mutation by suppressing viral replication Prevent immune destruction Symptom relief Public health, reduces transmission to serodiscordant sexual partners + Cons of starting treatment during Acute Retroviral Syndrome Cons: Toxicity of medications Risk of developing drug resistance Development of drug resistance Quality of life w/ daily medication in which strict adherence is necessary Cost + + Guidelines say… Treatment optional , unless pregnant, then recommended + Now, how much do you remember? Definitions Epidemiology Basic course of Primary HIV Symptoms Diagnosis Treatment + references DHHS guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents; considerations for antiretroviral use in special patient populations. Acute and recent HIV infection. Last updated 2/12/13. http://aidsinfo.nih.gov/guidelines/html/1/adult-andadolescent-arv-guidelines/20/acute-and-recent--early---hivinfection Mendel's http://www.thebody.com/content/art16805.html Emedicine accessed 8/10/13 + Family Feud What are the most common signs/ symptoms in Acute Retroviral Syndrome? + Symptoms Symptom # w/ finding (n=209) Frequency % Fever 200 96 Enlarged lymph nodes 154 74 Sore throat 146 70 Rash 146 70 Sore muscles or joints 112 54 Low platelets 94 45 Low WBC 80 38 Diarrhea 67 32 Headache 66 32 Nausea/vomiting 56 27 Elevated liver enzymes 38 21 Enlarged liver/spleen 30 14 Thrush 24 12 Neuropathy 13 6 Encephalopathy 12 6 + Family Feud What are the Pros of treating patients during Acute Antiretroviral Syndrome? + Pros of starting treatment during Acute Retroviral Syndrome Pros: evidence treatment initiated during acute retroviral syndrome may lower the viral set point, which can affect disease progression rates in the event therapy is stopped Decreases mortality Reduce viral reservoir Decrease rate of viral mutation by suppressing viral replication Prevent immune destruction Symptom relief Public health, reduces transmission to serodiscordant sexual partners + Family Feud What are the Cons of treating patients during Acute Antiretroviral Syndrome? + Cons of starting treatment during Acute Retroviral Syndrome Cons: Toxicity of medications Risk of developing drug resistance Development of drug resistance Quality of life w/ daily medication in which strict adherence is necessary Cost + Family Feud How do you diagnosis Acute Retroviral Syndrome? + Diagnosis: high-level HIV RNA viral load in the absence of anti-HIV antibodies. (+)viral load. (–)ELISA ELISA remains negative for an average of 2 to 6 weeks after the onset of symptoms, despite the appearance of specific antibodies on a Western blot of the patient’s serum. If VL <10,000, may be false positive b/c usually VL >100,000 copies/mL Pt should have elisa repeated over next 3-6 months to document seroconversion + Family Feud When are HIV patients the most infectious? + Day 0 Day 8 exposed to HIV, and infection begins. virus is detectable in blood using (PCR) antibody test are negative. amount of virus in the blood more than doubles every day. The CD4 cell count (and total white blood cell count) begins to drop Weeks 2-9 viral load peaks and begins to decline as the immune system begins to battle the virus highly infectious!!! Weeks 10-24 HIV viral load drops to its lowest point, also known as the set point, which is different in each person. antibody tests become positive for HIV. Seroconversion is now complete, and chronic HIV infection begins. + Family Feud What is the window period? + Window period + Thank you!
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