Key Points

Early HIV diagnosis increases access to care and decreases transmission.

Approximately half of patients are diagnosed with AIDS within the first year of HIV diagnosis.

Routine HIV testing using blood (or less often saliva or urine) helps reduce stigma and decrease anxiety.

Infection is diagnosed by detection of HIV antigen in a two-step process, a preliminary EIA and a confirmatory Western blot. Rapid HIV testing removes the barrier of a return visit because results are available in 20 minutes.

1200 -1100 -1000 -900 -800 -700 -600 -500 -400 -300 -200

Primary infection

+ Acute HIV syndrome Wide dissemination of virus Seeding of lymphoid organs

Death

Opportunistic diseases

r 107

+ Acute HIV syndrome Wide dissemination of virus Seeding of lymphoid organs

Opportunistic diseases r 107

Weeks Years

Figure 17-1 Typical course of HIV infection showing the relationship between the levels of HIV (viral load) and CD4+ T-cell counts over the average course of untreated HIV infection. NIAID publication showing clinical progression of HIV.

(Modified from Fauci AS et al. immunopathogenic mechanisms of HIV infection. Ann intern Med i996;i24:654-663.)

Weeks Years

Figure 17-1 Typical course of HIV infection showing the relationship between the levels of HIV (viral load) and CD4+ T-cell counts over the average course of untreated HIV infection. NIAID publication showing clinical progression of HIV.

(Modified from Fauci AS et al. immunopathogenic mechanisms of HIV infection. Ann intern Med i996;i24:654-663.)

• The Oraquick and Multispot tests detect both HIV-1 and HIV-2; Reveal and Uni-Gold Recombigen tests detect HIV-1 only.

• As of September 2006, the CDC recommends voluntary testing in all health care settings after informing patients and allowing them to "opt out" if they choose.

Early diagnosis increases access to treatment and helps reduce HIV transmission, but it remains a challenge. Approximately half of HIV-positive patients are diagnosed with AIDS within the first year of HIV diagnosis (Klein et al., 2003; Samet et al., 2001). Many patients ignore the obvious link between sexual and drug use behavior. Taking a careful drug use and sexual history helps identify patients at high risk for HIV infection, and routine HIV testing helps remove the stigma of such identification (Box 17-3). Although blood tests are most common, tests using saliva or urine are also available.

Laboratory diagnosis of HIV that depends on the presence and detection of antibodies to HIV antigen is a two-step process. A specific test for the p24 antigen or HIV-1 RNA is also available but is not widely used. The highly sensitive enzyme immunoassay (EIA) constitutes the first step of the process; further testing is necessary only if the EIA is positive. If exposure occurred less than 3 months earlier and the test is negative, it is repeated in 3 months. EIA is repeated in duplicate if positive or indeterminate. A confirmatory Western blot test is done if the results of repeat testing are again positive or indeterminate. A positive Western blot is conclusive evidence for seropositivity. Indeterminate tests are repeated in a month. A Western blot discordant with EIA raises the possibility of HIV-2 infection.

The CDC estimates that 31% of people tested for HIV did not return for results in 2001 (CDC, 2003). Rapid HIV testing further removes the often-neglected barrier of repeat visits because results are available in about 20 minutes.

Box 17-3 Recommendations for HIV Screening

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