Acute and Recent (Early) HIV Infection

• Signs, symptoms, or laboratory findings of acute HIV infection may include but are not limited to one or more of the following: fever, lymphadenopathy, skin rash, myalgia, arthralgia, headache, diarrhea, oral ulcers, leucopenia, thrombocytopenia, and transaminase elevation.
• High-risk exposures include sexual contact with a person who has HIV or a person at risk of HIV infection; sharing needles and syringes to inject drugs, as well as equipment used to prepare drugs for injection; or any exposure in which an individual’s mucous membranes or any breaks in the skin come in contact with bodily fluid that potentially carries HIV.

Differential Diagnosis:

• The differential diagnosis of acute HIV infection may include but is not limited to viral illnesses such as EBV and non-EBV (e.g., CMV) infectious mononucleosis syndromes, influenza, viral hepatitis, streptococcal infection, or syphilis. Diagnosis of any STI should prompt HIV testing and consideration of acute or early HIV infection.

^a In some settings, behaviors that increase the risk of HIV infection may not be recognized or perceived as risky by the health care provider or the patient, or both. Thus, even in the absence of reported high-risk behaviors, symptoms and signs consistent with acute retroviral syndrome should motivate practitioners to consider a diagnosis of acute HIV infection.

Key: 3TC = lamivudine; Ag/Ab = antigen/antibody; ART = antiretroviral therapy; ARV = antiretroviral; BIC = bictegravir; CMV = cytomegalovirus; DRV = darunavir; DTG = dolutegravir; EBV = Epstein-Barr virus; FTC = emtricitabine; INSTI = integrase strand transfer inhibitor; NTD = neural tube defect; STI = sexually transmitted infection; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TFV = tenofovir

• Acute HIV infection is defined as detectable HIV RNA or p24 antigen (the specific antigen used in currently available HIV-1/2 Ag/Ab combination assays) in the setting of a negative or indeterminate HIV antibody test result.
• A reactive HIV antibody test result or Ag/Ab combination test result must be followed by supplemental confirmatory testing.
• A negative or indeterminate HIV antibody test result in a person with a reactive Ag/Ab test result or in whom acute HIV infection is suspected requires plasma HIV RNA testing to diagnose acute HIV infection.
• A positive result on a quantitative or qualitative plasma HIV RNA test in the setting of a negative or indeterminate antibody test result indicates that acute HIV infection is highly likely. In this case, the diagnosis of HIV infection should be later confirmed by subsequent documentation of HIV antibody seroconversion.

Key: 3TC = lamivudine; Ag/Ab = antigen/antibody; ART = antiretroviral therapy; ARV = antiretroviral; BIC = bictegravir; CMV = cytomegalovirus; DRV = darunavir; DTG = dolutegravir; EBV = Epstein-Barr virus; FTC = emtricitabine; INSTI = integrase strand transfer inhibitor; NTD = neural tube defect; STI = sexually transmitted infection; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TFV = tenofovir

• ART is recommended for all individuals with HIV, including those with early^a HIV infection (AI). ART should be initiated as soon as possible after HIV diagnosis (AII).
• Once initiated, the goals of ART are to achieve sustained plasma virologic suppression and to prevent HIV transmission (AII).
• All individuals of childbearing potential who receive a diagnosis of early HIV infection should have a pregnancy test (AIII).
• Pregnant individuals with early HIV infection should begin ART as soon as possible for their own health and to prevent perinatal transmission of HIV (AI).
• A blood sample for genotypic drug resistance testing should be obtained before initiation of ART to guide the selection of the regimen (AII), but ART should be initiated as soon as possible, often before resistance test results are available. If resistance is subsequently identified, treatment should be modified as needed.
• ART can be initiated before the results of drug resistance testing are known. In this setting, one of the following ART regimens is recommended (AIII):
  • DTG with (TAF or TDF)^b plus (FTC or 3TC)
  • BIC/TAF/FTC
  • Boosted DRV with (TAF or TDF)^b plus (FTC or 3TC)
• Pregnancy testing should be performed in individuals of childbearing potential before initiation of ART (AIII).
• Preliminary data from Botswana suggested that there is an increased risk of NTDs (0.9%) in infants born to women who were receiving DTG at the time of conception.⁴⁵ Follow-up data, however, showed that the prevalence of NTDs in association with DTG exposure at conception is lower (0.3%), but still slightly higher than with non-DTG containing ARV regimens (0.1%).^46,47 Before initiating an INSTI-based regimen in a person of childbearing potential, clinicians should review Table 6b for information to consider when choosing an ART regimen.

^a In some settings, behaviors that increase the risk of HIV infection may not be recognized or perceived as risky by the health care provider or the patient, or both. Thus, even in the absence of reported high-risk behaviors, symptoms and signs consistent with acute retroviral syndrome should motivate practitioners to consider a diagnosis of acute HIV infection.
^b TAF and TDF are two forms of TFV that are approved in the United States. TAF has fewer bone and kidney toxicities than TDF, while TDF is associated with lower lipid levels. Safety, cost, and accessibility are among the factors to consider when choosing between these drugs.

Key: 3TC = lamivudine; Ag/Ab = antigen/antibody; ART = antiretroviral therapy; ARV = antiretroviral; BIC = bictegravir; CMV = cytomegalovirus; DRV = darunavir; DTG = dolutegravir; EBV = Epstein-Barr virus; FTC = emtricitabine; INSTI = integrase strand transfer inhibitor; NTD = neural tube defect; STI = sexually transmitted infection; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TFV = tenofovir