Sections

Presentation

History

The history should be carefully taken to elicit possible exposures to human immunodeficiency virus (HIV). Risk factors include the following:

Unprotected sexual intercourse, especially receptive anal intercourse (8-fold higher risk for transmission)
A large number of sexual partners
Prior or current sexually transmitted diseases (STDs): Gonorrhea and chlamydia infections increase the HIV transmission risk 3-fold, syphilis raises the transmission risk 7-fold, and herpes genitalis raises the transmission risk up to 25-fold during an outbreak
Sharing of intravenous drug paraphernalia
Receipt of blood products (before 1985 in the United States)
Mucosal contact with infected blood or needle-stick injuries
Maternal HIV infection (for newborns, infants, and children): Steps taken to reduce the risk of transmission at birth include cesarean delivery and prenatal antiretroviral therapy in the mother and antiretroviral therapy in the newborn immediately after birth.

The patient may present with signs and symptoms of any of the stages of HIV infection. Acute seroconversion manifests as a flulike illness, consisting of fever, malaise, and a generalized rash. The asymptomatic phase generally is benign. Generalized lymphadenopathy is common and may be a presenting symptom.

AIDS manifests as recurrent, severe, and occasionally life-threatening infections and/or opportunistic malignancies. The signs and symptoms are those of the presenting illness, meaning that HIV infection should be suspected as an underlying illness when unusual infections present in apparently healthy individuals.

HIV infection itself does cause some sequelae, including AIDS-associated dementia/encephalopathy and HIV wasting syndrome (chronic diarrhea and weight loss with no identifiable cause).

Physical Examination

No physical findings are specific to HIV infection. The physical findings are those of the presenting infection or illness. Generalized lymphadenopathy is common. Weight loss may be apparent.

Evidence for risk factors or minor concurrent opportunistic infections (eg, herpetic lesions on the groin, widespread oral candidiasis) may be clues to HIV infection.

Differential Diagnoses

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Media Gallery

Electron microscopy of human immunodeficiency virus (HIV)–1 virions. Courtesy of CDC (Dr Edwin P Ewing, Jr).
Genome layout of human immunodeficiency virus (HIV)–1 and HIV-2.
Timeline of CD4 T-cell and viral-load changes over time in untreated human immunodeficiency virus (HIV) infection. Courtesy of Wikipedia (based on an original from Pantaleo et al (1993)).
Incidence of HIV infection by risk group. Courtesy of CDC (derived from the revised 2006 estimated figures).
Changes in survival of people infected with HIV. As therapies have become more aggressive, they have been more effective, although survival with HIV infection is not yet equivalent to that in uninfected people. Modified from Lohse N et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Ann Intern Med. 2007;146(2):87-95.

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Table 1. Antiretroviral Drug Classes and Agents

Nucleoside reverse transcriptase inhibitors (NRTIs)	Abacavir (Ziagen, ABC) Didanosine (Videx, Videx EC, ddI) Emtricitabine (Emtriva, FTC) Lamivudine (Epivir, 3TC) Stavudine (Zerit, Zerit XR, d4T) Tenofovir DF (Viread, TDF) Tenofovir AF (TAF) Zalcitabine (Hivid, ddC)* Zidovudine (Retrovir, ZDV, AZT)
Protease inhibitors (PIs)	Amprenavir (Agenerase, AVP)* Atazanavir (Reyataz , ATV) Darunavir (Prezista, DRV) Fosamprenavir (Lexiva, f-APV) Indinavir (Crixivan, IDV) Lopinavir and ritonavir (Kaletra, LPV/r) Nelfinavir (Viracept, NFV) Ritonavir (Norvir, RTV) Saquinavir (Invirase [hard gel] capsule, SQV) Tipranavir (Aptivus, TPV)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)	Delavirdine (Rescriptor, DLV) Efavirenz (Sustiva, EFV) Etravirine (Intelence, ETR) Nevirapine (Viramune, NVP) Rilpivirine (Edurant) Doravirine (Pifeltro, DOR) Cabotegravir (CAB)
Fusion inhibitors	Enfuvirtide (Fuzeon, T-20)
Cellular chemokine receptor (CCR5) antagonists	Maraviroc (Selzentry, MVC)
Integrase inhibitors	Raltegravir (Isentress, RAL) Dolutegravir (Tivicay, DTG) Elvitegravir (Vitekta, EVG)
Entry inhibitors (CD4 post-attachment inhibitors)	Ibalizumab (Trogarzo, IBA)
gp120 Attachment inhibitors	Fostemsavir (Rukobia, FTR)
Capsid inhibitors	Lenacapavir (Sunlenca, LEN)
*No longer available on market

Table 2. Antiretroviral Combination Products

Drug Content per Tablet/Capsule*	Brand Name	Adult Dose (≥40 kg)
Darunavir 800 mg Cobicistat 150 mg Emtricitabine 200 mg Tenofovir AF 10 mg	Symtuza^#	1 tab PO qd with food
Bictegravir 50 mg Emtricitabine 200 mg Tenofovir AF 25 mg	Biktarvy^#	1 tab PO qd
Efavirenz 400 mg Lamivudine 300 mg Tenofovir DF 300 mg	Symfi Lo^#	1 tab PO qHS on an empty stomach
Efavirenz 600 mg Lamivudine 300 mg Tenofovir DF 300 mg	Symfi^#	1 tab PO qHS on an empty stomach
Dolutegravir 50 mg Rilpivirine 25 mg	Juluca^#	1 tab PO qd with a meal Note: This is a complete once-daily regimen in adults who are virologically suppressed (HIV-1 RNA < 50 copies/mL) on a stable ART regimen for ≥6 months with no history of treatment failure and no known substitutions associated with resistance
Dolutegravir 50 mg Lamivudine 300 mg	Dovato^#	1 tab PO qd with or without food Note: This a complete once-daily regimen in treatment-naïve adults with no known substitutions associated with resistance to dolutegravir or lamivudine
Elvitegravir 150 mg Cobicistat 150 mg Emtricitabine 200 mg Tenofovir AF 10 mg	Genvoya^#	1 tab PO qd
Elvitegravir 150 mg Cobicistat 150 mg Emtricitabine 200 mg Tenofovir DF 300 mg	Stribild^#	1 tab PO qd
Cabotegravir IM copackaged with Rilpivirine IM	Cabenuva^#	One-time initiating injection (on last day of oral lead-in dosing): Cabotegravir 600 mg IM plus rilpivirine 900 mg IM, THEN Once-monthly continuation injections: Cabotegravir 400 mg IM plus rilpivirine 600 mg IM
Abacavir 600 mg Lamivudine 300 mg	Epzicom	1 tab PO qd
Abacavir 600 mg Dolutegravir 50 mg Lamivudine 300 mg	Triumeq	1 tab PO qd
Abacavir 300 mg Lamivudine 150 mg Zidovudine 300 mg	Trizivir	1 tab PO bid
Efavirenz 600 mg Emtricitabine 200 mg Tenofovir DF 300 mg	Atripla^#	1 tab PO qd on empty stomach Note: May be used alone as a complete regimen or in combination with other ARTs
Emtricitabine 200 mg Rilpivirine 25 mg Tenofovir DF 300 mg	Complera^#	1 tab PO qd with a meal
Emtricitabine 200 mg Rilpivirine 25 mg Tenofovir AF 25 mg	Odefsey^#	1 tab PO qd with a meal
Emtricitabine 200 mg Tenofovir DF 300 mg	Truvada	1 tab PO qd CrCl 30-49 mL/min: 1 tab PO q48h CrCl < 30 mL/min: Do not administer
Emtricitabine 200 mg Tenofovir AF 300 mg	Descovy	1 tab PO qd CrCl < 30 mL/min: Do not administer
Lamivudine 150 mg Zidovudine 300 mg	Combivir	1 tab PO bid
Lamivudine 300 mg Tenofovir DF 300 mg	Cimduo	1 tab PO qd
Doravirine 100 mg Lamivudine 300 mg Tenofovir DF 300 mg	Delstrigo^#	1 tab PO qd with or without food
*Not indicated for patients requiring dosage adjustments (eg, weight < 40 kg, renal impairment, hepatic impairment, dose-limiting adverse effects) unless otherwise stated. ^#Complete once-daily regimen

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Author

Shelley A Gilroy, MD, FACP, FIDSA Associate Professor of Medicine, Infectious Disease and HIV Medicine, Albany Medical College; Associate Chief of Staff for Education/DEO, Lead Physician for HIV Medicine, Division of Infectious Diseases, Albany Stratton VA Medical Center

Shelley A Gilroy, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

John J Faragon, PharmD, BCPS, AAHIVP Pharmacist, HIV/HCV Medicine, Division of HIV Medicine and Department of Pharmacy, Albany Medical Center; Regional Pharmacy Director, Northeast Caribbean AIDS Education and Training Center; HIV and HCV Education Consultant, VirologyEd Consultants

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Gilead; Janssen; Merck.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Nicholas John Bennett, MBBCh, PhD, FAAP, MA(Cantab) Assistant Professor of Pediatrics, Co-Director of Antimicrobial Stewardship, Medical Director, Division of Pediatric Infectious Diseases and Immunology, Connecticut Children's Medical Center

Nicholas John Bennett, MBBCh, PhD, FAAP, MA(Cantab) is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Received research grant from: Cubist<br/>Received income in an amount equal to or greater than $250 from: Horizon Pharmaceuticals, Shire<br/>Medico legal consulting for: Various.

Acknowledgements

Aaron Glatt, MD Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, St Joseph Hospital (formerly New Island Hospital)

Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society forHealthcare Epidemiology of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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