Acute retroviral syndrome - UCLA Program in Global Health

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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.
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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
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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!