eMedicine Specialties > Infectious Diseases > HIV

Early Symptomatic HIV Infection: Treatment & Medication

Author: Robert J Carpenter, DO, Fellow in Infectious Diseases, Infectious Diseases Clinic, Naval Medical Center San Diego
Coauthor(s): Braden R Hale, MD, MPH, Assistant Clinical Professor, Department of Internal Medicine, University of California at San Diego; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Naval Medical Center at San Diego; Kirk M Chan-Tack, MD, Fellow, Division of Infectious Disease, University of Maryland School of Medicine; John Bartlett, MD, Chief of Division of Infectious Diseases, Chief of HIV Care Service, Professor, Department of Internal Medicine, Johns Hopkins University School of Medicine
Contributor Information and Disclosures

Updated: Jun 9, 2009

Treatment

Medical Care

Antiretroviral treatment of acute human immunodeficiency virus (HIV) infection is controversial. However, treating acute HIV infection has several theoretical advantages, as follows:1

  • To treat some symptomatic patients
  • To halt viral evolution at a time of minimal viral diversity, prior to viral adaptations to specific host immune responses
  • To protect developing immune responses from the deleterious effects of sustained HIV viremia
  • To reduce the viral set-point
  • To limit the latent pool of infection

Several studies have shown no benefit for short-term combination antiretroviral therapy during acute infection.7 However, a 2006 retrospective study found that an initiation of combination therapy within 2 weeks of HIV seroconversion was associated with sustained viral load and CD4 cell count benefits for up to 72 weeks after termination of therapy.8 In 2007, another group found that the CD4 cell count decline over 3 years was slower after cessation of 3 months of antiretroviral therapy started during acute infection when compared with those who did not receive acute therapy.9 CD4 counts appear to deplete very rapidly during acute HIV infection. Thus, treatment to prevent early loss of cells may be impractical in most circumstances.

In 2008, a subset analysis of the Strategic Management of Antiretroviral Therapy (SMART) study found that initiation of combined antiretroviral therapy at higher CD4 counts (>350 cells/µL) was associated with decreased morbidity and mortality in HIV disease.10

Evidence from the NIH Comprehensive International Program of Research on AIDS (CIPRA) HT 001 clinical study showed that starting antiretroviral therapy at CD4+ T-cell counts between 200-350 cells/µL improves survival compared with deferring treatment until the CD4+ T-cell count drops to less than 200 cells/µL (the current standard of care). CIPRA HT 001 is a randomized, controlled, open-label clinical trial that was conducted in a resource-limited setting where the standard of care to initiate therapy was when CD4+ T cells were less than 200 cells/µL or when the patient had a clinical diagnosis of AIDS.11

HIV-infected adults (n=816) with early HIV disease were randomly assigned to either begin antiretroviral therapy within 2 weeks of enrollment or when they were diagnosed with clinical AIDS or when their CD4+ T-cell count fell to below 200 cells/µL. Six participants in the early treatment group had died, while 23 participants in the standard-of-care group had died. Also, among participants who began the study without tuberculosis infection, 18 individuals in the early treatment group developed tuberculosis, while 36 people in the standard-of-care group developed tuberculosis. These interim results were statistically significant and led to ending the trial early to offer antiretroviral therapy to all participants in the standard-of-care group with a CD4+ T-cell count of less than 350 cells/µL.

Given the heterogeneity of medical evidence regarding treatment of acute HIV infection, the current Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents, published by US Department of Health and Human Services, consider treatment of acute infection optional and recommend enrollment in a clinical trial.

Surgical Care

  • Idiopathic thrombocytopenic purpura: Splenectomy is an option in patients whose conditions are refractory to medical treatment. Most patients with HIV-associated thrombocytopenia respond to this surgical treatment. Because of the risk of infections with encapsulated organisms, all patients infected with HIV, especially those who are about to undergo splenectomy, must be immunized with pneumococcal polysaccharide vaccine.
  • Thrombotic thrombocytopenic purpura: Splenectomy is also an option in refractory cases of TTP, but the response rate is highly variable. Because of the risk of infections with encapsulated organisms, all patients infected with HIV, especially those who are about to undergo splenectomy, must be immunized with pneumococcal polysaccharide vaccine.

Consultations

Close collaboration with consultants (eg, infectious diseases specialists, dermatologists, gastroenterologists, hematologists, neurologists) is important and is directed by the constellation of HIV manifestations.

Medication

Many drugs are used to treat human immunodeficiency virus (HIV) infection, and new drugs are in development. See the article HIV Disease in eMedicine’s Infectious Diseases volume for a discussion of current treatment options. The most up-to-date list of FDA-approved drugs can be found at AIDSinfo Drug Database.

More on Early Symptomatic HIV Infection

Overview: Early Symptomatic HIV Infection
Differential Diagnoses & Workup: Early Symptomatic HIV Infection
Treatment & Medication: Early Symptomatic HIV Infection
Follow-up: Early Symptomatic HIV Infection
References
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References

  1. Pilcher CD, Eron JJ Jr, Galvin S, Gay C, Cohen MS. Acute HIV revisited: new opportunities for treatment and prevention. J Clin Invest. Apr 2004;113(7):937-45. [Medline].

  2. Zetola NM, Pilcher CD. Diagnosis and management of acute HIV infection. Infect Dis Clin North Am. Mar 2007;21(1):19-48, vii. [Medline].

  3. Truong HM, Grant RM, McFarland W, Kellogg T, Kent C, Louie B. Routine surveillance for the detection of acute and recent HIV infections and transmission of antiretroviral resistance. AIDS. Nov 14 2006;20(17):2193-7. [Medline].

  4. Pilcher CD, Fiscus SA, Nguyen TQ, Foust E, Wolf L, Williams D. Detection of acute infections during HIV testing in North Carolina. N Engl J Med. May 5 2005;352(18):1873-83. [Medline].

  5. Bettaieb A, Fromont P, Louache F, et al. Presence of cross-reactive antibody between human immunodeficiency virus (HIV) and platelet glycoproteins in HIV-related immune thrombocytopenic purpura. Blood. Jul 1 1992;80(1):162-9. [Medline].

  6. Mylonakis E, Paliou M, Lally M, et al. Laboratory testing for infection with the human immunodeficiency virus: established and novel approaches. Am J Med. Nov 2000;109(7):568-76. [Medline].

  7. Streeck H, Jessen H, Alter G, Teigen N, Waring MT, Jessen A. Immunological and virological impact of highly active antiretroviral therapy initiated during acute HIV-1 infection. J Infect Dis. Sep 15 2006;194(6):734-9. [Medline].

  8. Hecht FM, Wang L, Collier A, Little S, Markowitz M, Margolick J. A multicenter observational study of the potential benefits of initiating combination antiretroviral therapy during acute HIV infection. J Infect Dis. Sep 15 2006;194(6):725-33. [Medline].

  9. Fidler S, Fox J, Touloumi G, Pantazis N, Porter K, Babiker A. Slower CD4 cell decline following cessation of a 3 month course of HAART in primary HIV infection: findings from an observational cohort. AIDS. Jun 19 2007;21(10):1283-91. [Medline].

  10. Strategies for Management of Antiretroviral Therapy (SMART) Study Group, Emery S, Neuhaus JA, Phillips AN, Babiker A, Cohen CJ, et al. Major clinical outcomes in antiretroviral therapy (ART)-naive participants and in those not receiving ART at baseline in the SMART study. J Infect Dis. Apr 15 2008;197(8):1133-44. [Medline].

  11. US Department of Health and Human Services. National Institutes of Health. NIH News. Starting Antiretroviral Therapy Earlier Yields Better Clinical Outcomes. June 8, 2009. [Full Text].

  12. Aberg JA, Gallant JE, Anderson J, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. Sep 1 2004;39(5):609-29. [Medline].

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Further Reading

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Keywords

early symptomatic HIV infection, acute HIV infection, acute retroviral syndrome, HIV seroconversion illness, HIV seroconversion syndrome, immune reconstitution inflammatory syndrome, human immunodeficiency virus, HIV, viral infection, immunologic impairment, immunocompromise, pre-acquired immune deficiency syndrome, pre-AIDS, thrush, oral hairy leukoplakia, herpes simplex virus, HSV, varicella-zoster virus, VZV, shingles, herpes zoster, thrombocytopenia, acute inflammatory demyelinating polyneuropathy, mononeuritis multiplex, myopathy, persistent generalized lymphadenopathy, PGL, oral lesions, anemia, aseptic meningitis, aphthous ulcers

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Contributor Information and Disclosures

Author

Robert J Carpenter, DO, Fellow in Infectious Diseases, Infectious Diseases Clinic, Naval Medical Center San Diego
Robert J Carpenter, DO is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Osteopathic Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Braden R Hale, MD, MPH, Assistant Clinical Professor, Department of Internal Medicine, University of California at San Diego; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Naval Medical Center at San Diego
Braden R Hale, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Kirk M Chan-Tack, MD, Fellow, Division of Infectious Disease, University of Maryland School of Medicine
Kirk M Chan-Tack, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Christian Medical & Dental Society, Physicians for Social Responsibility, and Southern Medical Association
Disclosure: Nothing to disclose.

John Bartlett, MD, Chief of Division of Infectious Diseases, Chief of HIV Care Service, Professor, Department of Internal Medicine, Johns Hopkins University School of Medicine
John Bartlett, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Clinical Pharmacology, American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, American Thoracic Society, American Venereal Disease Association, Association of American Physicians, Infectious Diseases Society of America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Fred A Lopez, MD, Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine
Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

 
 
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