HIV infection in adults

Consult the most recent HIV Guidelines from the National Department of Health.
https://www.knowledgehub.org.za/elibrary/2019-art-clinical-guidelines-management-hiv-adults-pregnancy-adolescents-children-infants

DESCRIPTION

HIV replicates in CD4 lymphocytes and monocytes, leading to progressive destruction of CD4 lymphocytes and impaired immunity.

Primary infection is characterised by:

  • glandular fever-type illness
  • maculopapular rash
  • small orogenital ulcers

After primary infection, patients may have generalised lymphadenopathy and are usually asymptomatic for several years. Subsequently inflammatory skin conditions and an increased frequency of minor infections occur, followed by more severe infections (especially tuberculosis), weight loss or chronic diarrhoea. Eventually severe opportunistic infections, HIV-associated cancers or other severe HIV manifestations develop, known as the Acquired Immune Deficiency Syndrome (AIDS).

DIAGNOSIS

  • Adequate pre- and post-test counselling must be provided.
  • Ensure patient confidentiality.
  • HIV in adults must be confirmed with a 2nd rapid test from a different manufacturer. If the screening and confirmation rapid test results differ, repeat the tests. If the repeated test series differ, a laboratory test would be required (usually ELISA).
  • HIV antibodies are not detected during the 1st few weeks in primary infection. This is known as the window period.

PROGNOSIS

  • Progression of HIV diseases is variable. The CD4 lymphocyte count and clinical features of immune suppression (see WHO staging below) both provide independent information on prognosis. Patients may be asymptomatic with very low CD4 counts or have severe clinical features with well-preserved CD4 counts. CD4 counts < 200 cells/mm³ indicate severe immune suppression. All HIV-infected patients must have a CD4 count requested and WHO clinical staging done.
  • All HIV-infected patients are eligible for ART, irrespective of CD4 count or WHO stage. Patients should be counselled about the benefits and risks of early ART initiation and encouraged to initiate ART as soon as feasible. However, should a patient elect to defer ART, the CD4 count should be repeated every 6 months until ART can be initiated.

South African modified WHO staging of HIV/AIDS for adults and adolescents

Clinical stage 1

  • Asymptomatic.
  • Persistent generalised lymphadenopathy.

Clinical stage 2

  • Unexplained moderate weight loss (< 10% of presumed or measured body weight).
  • Recurrent respiratory tract infections (sinusitis, otitis media and pharyngitis).
  • Herpes zoster (shingles).
  • Angular stomatitis.
  • Recurrent oral ulceration.
  • Papular pruritic eruption.
  • Seborrhoeic dermatitis.
  • Fungal nail infections.

Clinical stage 3

  • Unexplained severe weight loss (> 10% of presumed or measured body weight).
  • Unexplained chronic diarrhoea for > 1 month.
  • Unexplained persistent fever (> 37.5ºC intermittent or constant for > 1 month).
  • Persistent oral candidiasis (thrush).
  • Oral hairy leukoplakia.
  • Pulmonary TB.
  • Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis or bacteraemia).
  • Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis.
  • Unexplained anaemia (< 8 g/dL), neutropaenia (<0.5 × 10⁹/L) and/or chronic thrombocytopaenia (<50 × 10⁹/L).

Clinical stage 4

  • HIV wasting syndrome.
  • Extrapulmonary tuberculosis.
  • Pneumocystis pneumonia.
  • Recurrent severe bacterial pneumonia.
  • Chronic herpes simplex infection (orolabial, genital or anorectal of > 1 month duration or visceral at any site).
  • Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs).
  • Kaposi’s sarcoma.
  • Cytomegalovirus infection (retinitis or infection of other organs).
  • Central nervous system toxoplasmosis.
  • HIV encephalopathy.
  • Extrapulmonary cryptococcosis including meningitis.
  • Disseminated non-tuberculous mycobacterial infection.
  • Progressive multifocal leukoencephalopathy.
  • Chronic cryptosporidiosis.
  • Chronic isosporiasis.
  • Disseminated mycosis (extrapulmonary histoplasmosis or coccidiomycosis).
  • Recurrent septicaemia (including non-typhoidal Salmonella).
  • Lymphoma (cerebral or B cell non-Hodgkin).
  • Invasive cervical carcinoma.
  • Atypical disseminated leishmaniasis.
  • Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy.

GENERAL MEASURES

  • Patients and their families must be supported and encouraged to join support or peer groups.
  • Counsel patients on preventive methods of reducing the spread of HIV:
    • use condoms during sexual intercourse
    • ART in HIV-infected
    • PrEP where indicated
    • seek early treatment for sexually transmitted infections
    • safe handling of blood spills.