INTRODUCTION — Human immunodeficiency virus (HIV) testing is used to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken.
WHAT IS HIV? — HIV is a virus that weakens the body's immune system, making it difficult to fight infections and cancers. A person who is infected with HIV may have no signs or symptoms of their illness, but can still pass the infection to other persons through sexual contact or through exposure to contaminated needles. If HIV is not treated, an infected person eventually becomes very ill and may die. The advanced stage of HIV infection is called AIDS (acquired immune deficiency syndrome).
RISK FACTORS FOR INFECTION — Patients can acquire HIV through sexual contact or through exposure to contaminated needles.
People at risk for sexual transmission of HIV include: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV.
People at risk for exposure to HIV through contaminated needles include: Injection drug users who share needles or "works" Health care workers with needlestick exposure.
Who should be tested — The United States Preventive Services Task Force (USPTF) recommends HIV testing for persons who have one or more of the above risk factors for HIV infection. In addition, the USPSTF and the CDC recommend testing for the following persons: Persons who request HIV testing Persons who consider themselves at risk for HIV Health care workers who are exposed to potentially infected blood or bodily fluids at work Donors of blood, semen, and organs (mandatory in all states) Persons who present with an AIDS-defining diagnosis (See "Patient information: Symptoms of HIV infection") Persons who received blood products from 1977 to May 1985 (before blood donations were routinely screened for HIV) Heterosexual persons with one or more sex partner(s) in past 12 months Pregnant women
Routine testing approach — In 2006, the CDC issued revised guidelines for HIV testing in adolescents and adults. These revised guidelines recommend routine voluntary HIV screening as a normal part of medical care, similar to screening for other treatable diseases such as diabetes or cholesterol. The rationale for this approach is that HIV can be detected by accurate and inexpensive testing, earlier identification and treatment can lead to decreased illness and death in those who are found to be HIV-positive, and early identification can prevent HIV transmission to other persons.
With these guidelines, the CDC also included a strategy that allows a person to "opt-out" of testing. The following would occur in this situation: A healthcare provider would explain the recommendation for HIV testing to the patient The patient would have the opportunity to ask questions. Testing would be performed unless the patient states that they do not wish to be tested.
The CDC also recommends against the use of a consent form for HIV testing. A consent form is currently required in some states to record the patient's desire to be tested,
The aim of this initiative is to minimize barriers to testing, including many people's fear of being stigmatized and health care providers' reluctance to test. Rapid HIV testing will play a key role in this new CDC strategy. (See "Rapid tests" below).
TESTING METHODS — There are several methods to test for HIV. The standard test for HIV infection requires a small sample of blood taken from a vein, and is greater than 99 percent accurate. All positive tests are confirmed with another test.
Anonymous testing — Anonymous testing allows a person to be tested without disclosing his or her identity, and is offered in some areas.
Home testing — Home test kits provide accurate and anonymous results and are available in most pharmacies. The kit requires either a small sample of blood, obtaining by pricking the finger, or a swab of the inside of the cheek.
Rapid tests — Rapid tests for HIV provide accurate results within 5 to 40 minutes. Rapid tests are useful because they do not require that a person return on another day for their results. In 2000, more than one-third of patients who were tested with standard testing did not return for a discussion of their results. In contrast, 80 percent of those patients who tested HIV-positive with rapid testing later sought medical care [1].
TESTING PROCEDURE
Frequency of testing — Initial testing for HIV can be done at any time, but may need to be repeated if a person is concerned about recent exposure. Repeat testing is usually recommended at 6, 12, and 24 weeks after a suspected exposure. (See "Patient information: Symptoms of HIV infection").
Periodic testing is recommended for persons who are at risk for infection. (See "Risk factors for infection" above). Most healthcare providers recommend repeat testing every 6 to 12 months for such persons.
In addition to testing, individuals should learn about ways to prevent infection with HIV. This includes encouraging sexual partners to be tested, use of a latex or polyurethane condom with every sexual encounter, avoiding drugs or alcohol that can affect judgment about sexual activities, and avoiding needles and syringes that have been used by other IV drug users and avoiding sexual intercourse (abstinence).
TEST RESULTS — Test results are reported as being positive, negative, or indeterminate. The chance of having a negative result despite being infected with HIV (false negative) or a positive result despite having no evidence of HIV infection (false positive) is very low. The most common cause of a false positive result is human error in performing the test or reporting the test result. All false positive results are easily resolved by getting other tests that confirm the positive result or prove that the person is not infected. The most common cause of a false negative result is being tested before HIV antibodies are made. A person should inform their health care provider if they may have been exposed recently; in this case a test for the presence of virus in the bloodstream may also be needed. Persons should be retested at 3 and 6 months after the possible exposure. An indeterminate result occurs when a person's result is not clearly positive or negative. The final result usually depends upon a person's risk of having HIV. In persons at low risk for HIV infection, approximately 1 in 5000 results (0.0002 percent) are indeterminate. This type of laboratory result requires additional counseling and diagnostic testing, as determined by an HIV specialist.
While awaiting the results of further testing, the person should take precautions to avoid transmitting their potential infection to others. This includes discussing the possibility of infection with any sexual partners and use of a condom with every sexual encounter. Sharing of razors, toothbrushes, and any injection drug equipment (needles, syringes) should also be avoided.
SUMMARY Most individuals who are at the highest risk for HIV have not been tested usually because they do not realize that they are at risk for HIV. Others avoid testing because of anxiety about the possibility of a positive test result. However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve long-term outcome. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others. HIV is a virus that weakens the body's immune system, making it difficult to fight infections and cancers. A person who is infected with HIV may have no signs or symptoms of their illness, but can still pass the infection to other persons through sexual contact or through exposure to contaminated needles. If HIV is not treated, an infected person eventually becomes very ill and may die. There are several methods to test for HIV. The standard test for HIV infection requires a small sample of blood taken from a vein, and is greater than 99 percent accurate. All positive tests are confirmed with another test. Anonymous, home, and rapid tests are also available. Initial testing for HIV can be done at any time, but may need to be repeated if a person is concerned about recent exposure. Repeat testing is usually recommended at 6, 12, and 24 weeks after a suspected exposure. The accuracy of HIV blood testing is high, greater than 99 percent. Test results are reported as being positive, negative, or indeterminate. The chances of having a negative result despite being infected with HIV (false negative) or a positive result despite having no evidence of HIV infection (false positive) are very low.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Wright, AA, Katz, IT. Home testing for HIV. N Engl J Med 2006; 354:437.
2. Greenwald, JL, Rich, CA, Bessega, S, et al. Evaluation of the Centers for Disease Control and Prevention's recommendations regarding routine testing for human immunodeficiency virus by an inpatient service: who are we missing?. Mayo Clin Proc 2006; 81:452.
3. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001; 50:1.
4. Chou, R, Smits, AK, Huffman, LH, et al. Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:38.
5. Chou, R, Huffman, LH, Fu, R, et al. Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:55.
Tuesday, October 16, 2007
Testing for HIV
INTRODUCTION — Human immunodeficiency virus (HIV) testing is used to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken.
WHAT IS HIV? — HIV is a virus that weakens the body's immune system, making it difficult to fight infections and cancers. A person who is infected with HIV may have no signs or symptoms of their illness, but can still pass the infection to other persons through sexual contact or through exposure to contaminated needles. If HIV is not treated, an infected person eventually becomes very ill and may die. The advanced stage of HIV infection is called AIDS (acquired immune deficiency syndrome).
RISK FACTORS FOR INFECTION — Patients can acquire HIV through sexual contact or through exposure to contaminated needles.
People at risk for sexual transmission of HIV include: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV.
People at risk for exposure to HIV through contaminated needles include: Injection drug users who share needles or "works" Health care workers with needlestick exposure.
Who should be tested — The United States Preventive Services Task Force (USPTF) recommends HIV testing for persons who have one or more of the above risk factors for HIV infection. In addition, the USPSTF and the CDC recommend testing for the following persons: Persons who request HIV testing Persons who consider themselves at risk for HIV Health care workers who are exposed to potentially infected blood or bodily fluids at work Donors of blood, semen, and organs (mandatory in all states) Persons who present with an AIDS-defining diagnosis (See "Patient information: Symptoms of HIV infection") Persons who received blood products from 1977 to May 1985 (before blood donations were routinely screened for HIV) Heterosexual persons with one or more sex partner(s) in past 12 months Pregnant women
Routine testing approach — In 2006, the CDC issued revised guidelines for HIV testing in adolescents and adults. These revised guidelines recommend routine voluntary HIV screening as a normal part of medical care, similar to screening for other treatable diseases such as diabetes or cholesterol. The rationale for this approach is that HIV can be detected by accurate and inexpensive testing, earlier identification and treatment can lead to decreased illness and death in those who are found to be HIV-positive, and early identification can prevent HIV transmission to other persons.
With these guidelines, the CDC also included a strategy that allows a person to "opt-out" of testing. The following would occur in this situation: A healthcare provider would explain the recommendation for HIV testing to the patient The patient would have the opportunity to ask questions. Testing would be performed unless the patient states that they do not wish to be tested.
The CDC also recommends against the use of a consent form for HIV testing. A consent form is currently required in some states to record the patient's desire to be tested,
The aim of this initiative is to minimize barriers to testing, including many people's fear of being stigmatized and health care providers' reluctance to test. Rapid HIV testing will play a key role in this new CDC strategy. (See "Rapid tests" below).
TESTING METHODS — There are several methods to test for HIV. The standard test for HIV infection requires a small sample of blood taken from a vein, and is greater than 99 percent accurate. All positive tests are confirmed with another test.
Anonymous testing — Anonymous testing allows a person to be tested without disclosing his or her identity, and is offered in some areas.
Home testing — Home test kits provide accurate and anonymous results and are available in most pharmacies. The kit requires either a small sample of blood, obtaining by pricking the finger, or a swab of the inside of the cheek.
Rapid tests — Rapid tests for HIV provide accurate results within 5 to 40 minutes. Rapid tests are useful because they do not require that a person return on another day for their results. In 2000, more than one-third of patients who were tested with standard testing did not return for a discussion of their results. In contrast, 80 percent of those patients who tested HIV-positive with rapid testing later sought medical care [1].
TESTING PROCEDURE
Frequency of testing — Initial testing for HIV can be done at any time, but may need to be repeated if a person is concerned about recent exposure. Repeat testing is usually recommended at 6, 12, and 24 weeks after a suspected exposure. (See "Patient information: Symptoms of HIV infection").
Periodic testing is recommended for persons who are at risk for infection. (See "Risk factors for infection" above). Most healthcare providers recommend repeat testing every 6 to 12 months for such persons.
In addition to testing, individuals should learn about ways to prevent infection with HIV. This includes encouraging sexual partners to be tested, use of a latex or polyurethane condom with every sexual encounter, avoiding drugs or alcohol that can affect judgment about sexual activities, and avoiding needles and syringes that have been used by other IV drug users and avoiding sexual intercourse (abstinence).
TEST RESULTS — Test results are reported as being positive, negative, or indeterminate. The chance of having a negative result despite being infected with HIV (false negative) or a positive result despite having no evidence of HIV infection (false positive) is very low. The most common cause of a false positive result is human error in performing the test or reporting the test result. All false positive results are easily resolved by getting other tests that confirm the positive result or prove that the person is not infected. The most common cause of a false negative result is being tested before HIV antibodies are made. A person should inform their health care provider if they may have been exposed recently; in this case a test for the presence of virus in the bloodstream may also be needed. Persons should be retested at 3 and 6 months after the possible exposure. An indeterminate result occurs when a person's result is not clearly positive or negative. The final result usually depends upon a person's risk of having HIV. In persons at low risk for HIV infection, approximately 1 in 5000 results (0.0002 percent) are indeterminate. This type of laboratory result requires additional counseling and diagnostic testing, as determined by an HIV specialist.
While awaiting the results of further testing, the person should take precautions to avoid transmitting their potential infection to others. This includes discussing the possibility of infection with any sexual partners and use of a condom with every sexual encounter. Sharing of razors, toothbrushes, and any injection drug equipment (needles, syringes) should also be avoided.
SUMMARY Most individuals who are at the highest risk for HIV have not been tested usually because they do not realize that they are at risk for HIV. Others avoid testing because of anxiety about the possibility of a positive test result. However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve long-term outcome. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others. HIV is a virus that weakens the body's immune system, making it difficult to fight infections and cancers. A person who is infected with HIV may have no signs or symptoms of their illness, but can still pass the infection to other persons through sexual contact or through exposure to contaminated needles. If HIV is not treated, an infected person eventually becomes very ill and may die. There are several methods to test for HIV. The standard test for HIV infection requires a small sample of blood taken from a vein, and is greater than 99 percent accurate. All positive tests are confirmed with another test. Anonymous, home, and rapid tests are also available. Initial testing for HIV can be done at any time, but may need to be repeated if a person is concerned about recent exposure. Repeat testing is usually recommended at 6, 12, and 24 weeks after a suspected exposure. The accuracy of HIV blood testing is high, greater than 99 percent. Test results are reported as being positive, negative, or indeterminate. The chances of having a negative result despite being infected with HIV (false negative) or a positive result despite having no evidence of HIV infection (false positive) are very low.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Wright, AA, Katz, IT. Home testing for HIV. N Engl J Med 2006; 354:437.
2. Greenwald, JL, Rich, CA, Bessega, S, et al. Evaluation of the Centers for Disease Control and Prevention's recommendations regarding routine testing for human immunodeficiency virus by an inpatient service: who are we missing?. Mayo Clin Proc 2006; 81:452.
3. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001; 50:1.
4. Chou, R, Smits, AK, Huffman, LH, et al. Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:38.
5. Chou, R, Huffman, LH, Fu, R, et al. Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:55.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken.
WHAT IS HIV? — HIV is a virus that weakens the body's immune system, making it difficult to fight infections and cancers. A person who is infected with HIV may have no signs or symptoms of their illness, but can still pass the infection to other persons through sexual contact or through exposure to contaminated needles. If HIV is not treated, an infected person eventually becomes very ill and may die. The advanced stage of HIV infection is called AIDS (acquired immune deficiency syndrome).
RISK FACTORS FOR INFECTION — Patients can acquire HIV through sexual contact or through exposure to contaminated needles.
People at risk for sexual transmission of HIV include: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV.
People at risk for exposure to HIV through contaminated needles include: Injection drug users who share needles or "works" Health care workers with needlestick exposure.
Who should be tested — The United States Preventive Services Task Force (USPTF) recommends HIV testing for persons who have one or more of the above risk factors for HIV infection. In addition, the USPSTF and the CDC recommend testing for the following persons: Persons who request HIV testing Persons who consider themselves at risk for HIV Health care workers who are exposed to potentially infected blood or bodily fluids at work Donors of blood, semen, and organs (mandatory in all states) Persons who present with an AIDS-defining diagnosis (See "Patient information: Symptoms of HIV infection") Persons who received blood products from 1977 to May 1985 (before blood donations were routinely screened for HIV) Heterosexual persons with one or more sex partner(s) in past 12 months Pregnant women
Routine testing approach — In 2006, the CDC issued revised guidelines for HIV testing in adolescents and adults. These revised guidelines recommend routine voluntary HIV screening as a normal part of medical care, similar to screening for other treatable diseases such as diabetes or cholesterol. The rationale for this approach is that HIV can be detected by accurate and inexpensive testing, earlier identification and treatment can lead to decreased illness and death in those who are found to be HIV-positive, and early identification can prevent HIV transmission to other persons.
With these guidelines, the CDC also included a strategy that allows a person to "opt-out" of testing. The following would occur in this situation: A healthcare provider would explain the recommendation for HIV testing to the patient The patient would have the opportunity to ask questions. Testing would be performed unless the patient states that they do not wish to be tested.
The CDC also recommends against the use of a consent form for HIV testing. A consent form is currently required in some states to record the patient's desire to be tested,
The aim of this initiative is to minimize barriers to testing, including many people's fear of being stigmatized and health care providers' reluctance to test. Rapid HIV testing will play a key role in this new CDC strategy. (See "Rapid tests" below).
TESTING METHODS — There are several methods to test for HIV. The standard test for HIV infection requires a small sample of blood taken from a vein, and is greater than 99 percent accurate. All positive tests are confirmed with another test.
Anonymous testing — Anonymous testing allows a person to be tested without disclosing his or her identity, and is offered in some areas.
Home testing — Home test kits provide accurate and anonymous results and are available in most pharmacies. The kit requires either a small sample of blood, obtaining by pricking the finger, or a swab of the inside of the cheek.
Rapid tests — Rapid tests for HIV provide accurate results within 5 to 40 minutes. Rapid tests are useful because they do not require that a person return on another day for their results. In 2000, more than one-third of patients who were tested with standard testing did not return for a discussion of their results. In contrast, 80 percent of those patients who tested HIV-positive with rapid testing later sought medical care [1].
TESTING PROCEDURE
Frequency of testing — Initial testing for HIV can be done at any time, but may need to be repeated if a person is concerned about recent exposure. Repeat testing is usually recommended at 6, 12, and 24 weeks after a suspected exposure. (See "Patient information: Symptoms of HIV infection").
Periodic testing is recommended for persons who are at risk for infection. (See "Risk factors for infection" above). Most healthcare providers recommend repeat testing every 6 to 12 months for such persons.
In addition to testing, individuals should learn about ways to prevent infection with HIV. This includes encouraging sexual partners to be tested, use of a latex or polyurethane condom with every sexual encounter, avoiding drugs or alcohol that can affect judgment about sexual activities, and avoiding needles and syringes that have been used by other IV drug users and avoiding sexual intercourse (abstinence).
TEST RESULTS — Test results are reported as being positive, negative, or indeterminate. The chance of having a negative result despite being infected with HIV (false negative) or a positive result despite having no evidence of HIV infection (false positive) is very low. The most common cause of a false positive result is human error in performing the test or reporting the test result. All false positive results are easily resolved by getting other tests that confirm the positive result or prove that the person is not infected. The most common cause of a false negative result is being tested before HIV antibodies are made. A person should inform their health care provider if they may have been exposed recently; in this case a test for the presence of virus in the bloodstream may also be needed. Persons should be retested at 3 and 6 months after the possible exposure. An indeterminate result occurs when a person's result is not clearly positive or negative. The final result usually depends upon a person's risk of having HIV. In persons at low risk for HIV infection, approximately 1 in 5000 results (0.0002 percent) are indeterminate. This type of laboratory result requires additional counseling and diagnostic testing, as determined by an HIV specialist.
While awaiting the results of further testing, the person should take precautions to avoid transmitting their potential infection to others. This includes discussing the possibility of infection with any sexual partners and use of a condom with every sexual encounter. Sharing of razors, toothbrushes, and any injection drug equipment (needles, syringes) should also be avoided.
SUMMARY Most individuals who are at the highest risk for HIV have not been tested usually because they do not realize that they are at risk for HIV. Others avoid testing because of anxiety about the possibility of a positive test result. However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve long-term outcome. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others. HIV is a virus that weakens the body's immune system, making it difficult to fight infections and cancers. A person who is infected with HIV may have no signs or symptoms of their illness, but can still pass the infection to other persons through sexual contact or through exposure to contaminated needles. If HIV is not treated, an infected person eventually becomes very ill and may die. There are several methods to test for HIV. The standard test for HIV infection requires a small sample of blood taken from a vein, and is greater than 99 percent accurate. All positive tests are confirmed with another test. Anonymous, home, and rapid tests are also available. Initial testing for HIV can be done at any time, but may need to be repeated if a person is concerned about recent exposure. Repeat testing is usually recommended at 6, 12, and 24 weeks after a suspected exposure. The accuracy of HIV blood testing is high, greater than 99 percent. Test results are reported as being positive, negative, or indeterminate. The chances of having a negative result despite being infected with HIV (false negative) or a positive result despite having no evidence of HIV infection (false positive) are very low.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Wright, AA, Katz, IT. Home testing for HIV. N Engl J Med 2006; 354:437.
2. Greenwald, JL, Rich, CA, Bessega, S, et al. Evaluation of the Centers for Disease Control and Prevention's recommendations regarding routine testing for human immunodeficiency virus by an inpatient service: who are we missing?. Mayo Clin Proc 2006; 81:452.
3. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001; 50:1.
4. Chou, R, Smits, AK, Huffman, LH, et al. Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:38.
5. Chou, R, Huffman, LH, Fu, R, et al. Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:55.
Tips for taking HIV protease inhibitors
INTRODUCTION — Protease inhibitors are antiretroviral medications that commonly used in the treatment of HIV. Proteases are enzymes that the virus requires to copy itself. Thus, protease inhibitors can prevent or limit the virus's ability to copy itself. When proteases are blocked, HIV makes copies of itself that cannot infect new cells. This can reduce the amount of virus in the blood and increase the number of CD4 cells.
Protease inhibitors are generally combined with at least two other anti-HIV medications; this combination is called highly active antiretroviral therapy (HAART). The combination treatment reduces the risk of the virus becoming resistant to treatment.
IMPORTANT GENERAL ADVICE — To help assure that the protease inhibitor keeps working and to avoid drug interactions and resistance, keep the following in mind: Take protease inhibitors consistently, uninterrupted, along with your other antiretroviral medicines for HIV. Take the prescribed dosage and correct number of capsules per day. Review this with your health care provider at each visit. Protease inhibitors can interact with many other medicines. Report any other medications you are taking or have stopped taking to your clinician and pharmacist. This includes nonprescription drugs and herbal medicines from health food stores.
For example, garlic supplements and St. John's wort substantially reduce concentrations of the some protease inhibitors. Ask your pharmacist or clinician to check if there are any interactions between your protease inhibitor and any other medications or herbal medications you are taking. Call your healthcare provider's office immediately if you have difficulty getting any of your antiretroviral prescriptions filled. It is important to take all of the medications in your combination regimen each and every day. Taking only a portion of the combination of HIV medications can lead to resistance. When resistance occurs, that drug is no longer effective against HIV. Check with the pharmacist and your healthcare provider's office immediately if the medicines you get from your pharmacy look different from how they looked before, or if it seems that the dosage is different from what you recall. When you need refills, call your pharmacy several days in advance to make sure they have your HIV medicines in stock. Consider using a pharmacy that specializes in HIV medicines and/or one that will call you each month to see if you need refills. If you have to go to the hospital, it is helpful to bring a list of your medications, or even the medications themselves to be certain that there is no interruption in your dosing. You should give the medications to your physician, and not take them on your own, once you are in the hospital. If you are taking ritonavir (Norvir®) or tipranavir (Aptivus®), take only a one day supply since these medications need to be kept cool. Never change the number of pills you are taking without speaking with your clinician. Never stop any of your antiretroviral HIV medicines without checking with your clinician. It is generally better to use one pharmacy for all of your medication needs. If you have to use more than one pharmacy, make sure each pharmacy is aware of all of the medications you are taking.
ADVICE ON SPECIFIC PROTEASE INHIBITORS — The following information will serve as a guide on how best to take the particular protease inhibitor medication that you have been prescribed.
Atazanavir (Reyataz®) — Take with food. Certain medications, called proton pump inhibitors, have an effect on stomach acid and interact badly with atazanavir. For this reason, it is important not to take omeprazole (Prilosec®), esomeprozole (Nexium®), or lansoprazole (Prevacid®) while you are taking atazanavir because the atazanavir may not work. Talk to your health care provider and pharmacist before you take other medicines that decrease acid in your stomach like calcium (Tums®), ranitidine (Zantac®), or cimetidine (Tagamet®); these should be taken at a different time of the day than the atazanavir.
Fosamprenavir (Lexiva®) — Take with or without food. Tell your health care provider if you are allergic to sulfonamide medicines.
Indinavir (Crixivan®) — Take with plenty of water (at least 48 ounces or 1.5 liters per day) to decrease the risk of developing kidney stones. Store indinavir (Crixivan®) in a dry place.
The way you need to take indinavir will depend on whether or not to you are taking ritonavir (Norvir®) also. Take indinavir (Crixivan®) on an empty stomach (one hour before a meal or two hours after a meal) or with a low-fat snack. Check with your pharmacist or physician for a list of acceptable low fat snacks. If you are also taking ritonavir (Norvir®), you do not have to take the indinavir on an empty stomach.
Lopinavir/ritonavir (Kaletra®) — Take with food.
Nelfinavir (Viracept®) — Take with food. Call your health care provider right away if you develop diarrhea, which is a common side effect.
Ritonavir (Norvir®) — Take with meals. Store in the refrigerator or at room temperature (less than 77) for 30 days or less.
Saquinavir (Invirase®) — Take with meals or within two hours of a meal. If you are currently taking Invirase in the 200 mg strength, ask your health care provider about the invirase 500 mg tablets.
Tipranavir (Aptivus) — Take tipranavir (Aptivus 500 mg) with ritonavir (Norvir 200 mg) twice daily with meals. There are several drug interactions between tipranavir and drugs from six classes of medications as well as St John's wort. You should discuss your full medication list, including herbal medications, with your physician or pharmacist before initiating tipranavir.
Darunavir (Prezista®, TMC 114) — Take darunavir (Prezista®) with ritonavir (Norvir®) twice a day with food. Tell your healthcare provider if you are allergic to sulfonamide (sulfa) medications.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Piscitelli, SC, Burstein, AH, Welden, N, et al. The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin Infect Dis 2002; 34:234.
Protease inhibitors are generally combined with at least two other anti-HIV medications; this combination is called highly active antiretroviral therapy (HAART). The combination treatment reduces the risk of the virus becoming resistant to treatment.
IMPORTANT GENERAL ADVICE — To help assure that the protease inhibitor keeps working and to avoid drug interactions and resistance, keep the following in mind: Take protease inhibitors consistently, uninterrupted, along with your other antiretroviral medicines for HIV. Take the prescribed dosage and correct number of capsules per day. Review this with your health care provider at each visit. Protease inhibitors can interact with many other medicines. Report any other medications you are taking or have stopped taking to your clinician and pharmacist. This includes nonprescription drugs and herbal medicines from health food stores.
For example, garlic supplements and St. John's wort substantially reduce concentrations of the some protease inhibitors. Ask your pharmacist or clinician to check if there are any interactions between your protease inhibitor and any other medications or herbal medications you are taking. Call your healthcare provider's office immediately if you have difficulty getting any of your antiretroviral prescriptions filled. It is important to take all of the medications in your combination regimen each and every day. Taking only a portion of the combination of HIV medications can lead to resistance. When resistance occurs, that drug is no longer effective against HIV. Check with the pharmacist and your healthcare provider's office immediately if the medicines you get from your pharmacy look different from how they looked before, or if it seems that the dosage is different from what you recall. When you need refills, call your pharmacy several days in advance to make sure they have your HIV medicines in stock. Consider using a pharmacy that specializes in HIV medicines and/or one that will call you each month to see if you need refills. If you have to go to the hospital, it is helpful to bring a list of your medications, or even the medications themselves to be certain that there is no interruption in your dosing. You should give the medications to your physician, and not take them on your own, once you are in the hospital. If you are taking ritonavir (Norvir®) or tipranavir (Aptivus®), take only a one day supply since these medications need to be kept cool. Never change the number of pills you are taking without speaking with your clinician. Never stop any of your antiretroviral HIV medicines without checking with your clinician. It is generally better to use one pharmacy for all of your medication needs. If you have to use more than one pharmacy, make sure each pharmacy is aware of all of the medications you are taking.
ADVICE ON SPECIFIC PROTEASE INHIBITORS — The following information will serve as a guide on how best to take the particular protease inhibitor medication that you have been prescribed.
Atazanavir (Reyataz®) — Take with food. Certain medications, called proton pump inhibitors, have an effect on stomach acid and interact badly with atazanavir. For this reason, it is important not to take omeprazole (Prilosec®), esomeprozole (Nexium®), or lansoprazole (Prevacid®) while you are taking atazanavir because the atazanavir may not work. Talk to your health care provider and pharmacist before you take other medicines that decrease acid in your stomach like calcium (Tums®), ranitidine (Zantac®), or cimetidine (Tagamet®); these should be taken at a different time of the day than the atazanavir.
Fosamprenavir (Lexiva®) — Take with or without food. Tell your health care provider if you are allergic to sulfonamide medicines.
Indinavir (Crixivan®) — Take with plenty of water (at least 48 ounces or 1.5 liters per day) to decrease the risk of developing kidney stones. Store indinavir (Crixivan®) in a dry place.
The way you need to take indinavir will depend on whether or not to you are taking ritonavir (Norvir®) also. Take indinavir (Crixivan®) on an empty stomach (one hour before a meal or two hours after a meal) or with a low-fat snack. Check with your pharmacist or physician for a list of acceptable low fat snacks. If you are also taking ritonavir (Norvir®), you do not have to take the indinavir on an empty stomach.
Lopinavir/ritonavir (Kaletra®) — Take with food.
Nelfinavir (Viracept®) — Take with food. Call your health care provider right away if you develop diarrhea, which is a common side effect.
Ritonavir (Norvir®) — Take with meals. Store in the refrigerator or at room temperature (less than 77) for 30 days or less.
Saquinavir (Invirase®) — Take with meals or within two hours of a meal. If you are currently taking Invirase in the 200 mg strength, ask your health care provider about the invirase 500 mg tablets.
Tipranavir (Aptivus) — Take tipranavir (Aptivus 500 mg) with ritonavir (Norvir 200 mg) twice daily with meals. There are several drug interactions between tipranavir and drugs from six classes of medications as well as St John's wort. You should discuss your full medication list, including herbal medications, with your physician or pharmacist before initiating tipranavir.
Darunavir (Prezista®, TMC 114) — Take darunavir (Prezista®) with ritonavir (Norvir®) twice a day with food. Tell your healthcare provider if you are allergic to sulfonamide (sulfa) medications.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Piscitelli, SC, Burstein, AH, Welden, N, et al. The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin Infect Dis 2002; 34:234.
Tips for taking HIV protease inhibitors
INTRODUCTION — Protease inhibitors are antiretroviral medications that commonly used in the treatment of HIV. Proteases are enzymes that the virus requires to copy itself. Thus, protease inhibitors can prevent or limit the virus's ability to copy itself. When proteases are blocked, HIV makes copies of itself that cannot infect new cells. This can reduce the amount of virus in the blood and increase the number of CD4 cells.
Protease inhibitors are generally combined with at least two other anti-HIV medications; this combination is called highly active antiretroviral therapy (HAART). The combination treatment reduces the risk of the virus becoming resistant to treatment.
IMPORTANT GENERAL ADVICE — To help assure that the protease inhibitor keeps working and to avoid drug interactions and resistance, keep the following in mind: Take protease inhibitors consistently, uninterrupted, along with your other antiretroviral medicines for HIV. Take the prescribed dosage and correct number of capsules per day. Review this with your health care provider at each visit. Protease inhibitors can interact with many other medicines. Report any other medications you are taking or have stopped taking to your clinician and pharmacist. This includes nonprescription drugs and herbal medicines from health food stores.
For example, garlic supplements and St. John's wort substantially reduce concentrations of the some protease inhibitors. Ask your pharmacist or clinician to check if there are any interactions between your protease inhibitor and any other medications or herbal medications you are taking. Call your healthcare provider's office immediately if you have difficulty getting any of your antiretroviral prescriptions filled. It is important to take all of the medications in your combination regimen each and every day. Taking only a portion of the combination of HIV medications can lead to resistance. When resistance occurs, that drug is no longer effective against HIV. Check with the pharmacist and your healthcare provider's office immediately if the medicines you get from your pharmacy look different from how they looked before, or if it seems that the dosage is different from what you recall. When you need refills, call your pharmacy several days in advance to make sure they have your HIV medicines in stock. Consider using a pharmacy that specializes in HIV medicines and/or one that will call you each month to see if you need refills. If you have to go to the hospital, it is helpful to bring a list of your medications, or even the medications themselves to be certain that there is no interruption in your dosing. You should give the medications to your physician, and not take them on your own, once you are in the hospital. If you are taking ritonavir (Norvir®) or tipranavir (Aptivus®), take only a one day supply since these medications need to be kept cool. Never change the number of pills you are taking without speaking with your clinician. Never stop any of your antiretroviral HIV medicines without checking with your clinician. It is generally better to use one pharmacy for all of your medication needs. If you have to use more than one pharmacy, make sure each pharmacy is aware of all of the medications you are taking.
ADVICE ON SPECIFIC PROTEASE INHIBITORS — The following information will serve as a guide on how best to take the particular protease inhibitor medication that you have been prescribed.
Atazanavir (Reyataz®) — Take with food. Certain medications, called proton pump inhibitors, have an effect on stomach acid and interact badly with atazanavir. For this reason, it is important not to take omeprazole (Prilosec®), esomeprozole (Nexium®), or lansoprazole (Prevacid®) while you are taking atazanavir because the atazanavir may not work. Talk to your health care provider and pharmacist before you take other medicines that decrease acid in your stomach like calcium (Tums®), ranitidine (Zantac®), or cimetidine (Tagamet®); these should be taken at a different time of the day than the atazanavir.
Fosamprenavir (Lexiva®) — Take with or without food. Tell your health care provider if you are allergic to sulfonamide medicines.
Indinavir (Crixivan®) — Take with plenty of water (at least 48 ounces or 1.5 liters per day) to decrease the risk of developing kidney stones. Store indinavir (Crixivan®) in a dry place.
The way you need to take indinavir will depend on whether or not to you are taking ritonavir (Norvir®) also. Take indinavir (Crixivan®) on an empty stomach (one hour before a meal or two hours after a meal) or with a low-fat snack. Check with your pharmacist or physician for a list of acceptable low fat snacks. If you are also taking ritonavir (Norvir®), you do not have to take the indinavir on an empty stomach.
Lopinavir/ritonavir (Kaletra®) — Take with food.
Nelfinavir (Viracept®) — Take with food. Call your health care provider right away if you develop diarrhea, which is a common side effect.
Ritonavir (Norvir®) — Take with meals. Store in the refrigerator or at room temperature (less than 77) for 30 days or less.
Saquinavir (Invirase®) — Take with meals or within two hours of a meal. If you are currently taking Invirase in the 200 mg strength, ask your health care provider about the invirase 500 mg tablets.
Tipranavir (Aptivus) — Take tipranavir (Aptivus 500 mg) with ritonavir (Norvir 200 mg) twice daily with meals. There are several drug interactions between tipranavir and drugs from six classes of medications as well as St John's wort. You should discuss your full medication list, including herbal medications, with your physician or pharmacist before initiating tipranavir.
Darunavir (Prezista®, TMC 114) — Take darunavir (Prezista®) with ritonavir (Norvir®) twice a day with food. Tell your healthcare provider if you are allergic to sulfonamide (sulfa) medications.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Piscitelli, SC, Burstein, AH, Welden, N, et al. The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin Infect Dis 2002; 34:234.
Protease inhibitors are generally combined with at least two other anti-HIV medications; this combination is called highly active antiretroviral therapy (HAART). The combination treatment reduces the risk of the virus becoming resistant to treatment.
IMPORTANT GENERAL ADVICE — To help assure that the protease inhibitor keeps working and to avoid drug interactions and resistance, keep the following in mind: Take protease inhibitors consistently, uninterrupted, along with your other antiretroviral medicines for HIV. Take the prescribed dosage and correct number of capsules per day. Review this with your health care provider at each visit. Protease inhibitors can interact with many other medicines. Report any other medications you are taking or have stopped taking to your clinician and pharmacist. This includes nonprescription drugs and herbal medicines from health food stores.
For example, garlic supplements and St. John's wort substantially reduce concentrations of the some protease inhibitors. Ask your pharmacist or clinician to check if there are any interactions between your protease inhibitor and any other medications or herbal medications you are taking. Call your healthcare provider's office immediately if you have difficulty getting any of your antiretroviral prescriptions filled. It is important to take all of the medications in your combination regimen each and every day. Taking only a portion of the combination of HIV medications can lead to resistance. When resistance occurs, that drug is no longer effective against HIV. Check with the pharmacist and your healthcare provider's office immediately if the medicines you get from your pharmacy look different from how they looked before, or if it seems that the dosage is different from what you recall. When you need refills, call your pharmacy several days in advance to make sure they have your HIV medicines in stock. Consider using a pharmacy that specializes in HIV medicines and/or one that will call you each month to see if you need refills. If you have to go to the hospital, it is helpful to bring a list of your medications, or even the medications themselves to be certain that there is no interruption in your dosing. You should give the medications to your physician, and not take them on your own, once you are in the hospital. If you are taking ritonavir (Norvir®) or tipranavir (Aptivus®), take only a one day supply since these medications need to be kept cool. Never change the number of pills you are taking without speaking with your clinician. Never stop any of your antiretroviral HIV medicines without checking with your clinician. It is generally better to use one pharmacy for all of your medication needs. If you have to use more than one pharmacy, make sure each pharmacy is aware of all of the medications you are taking.
ADVICE ON SPECIFIC PROTEASE INHIBITORS — The following information will serve as a guide on how best to take the particular protease inhibitor medication that you have been prescribed.
Atazanavir (Reyataz®) — Take with food. Certain medications, called proton pump inhibitors, have an effect on stomach acid and interact badly with atazanavir. For this reason, it is important not to take omeprazole (Prilosec®), esomeprozole (Nexium®), or lansoprazole (Prevacid®) while you are taking atazanavir because the atazanavir may not work. Talk to your health care provider and pharmacist before you take other medicines that decrease acid in your stomach like calcium (Tums®), ranitidine (Zantac®), or cimetidine (Tagamet®); these should be taken at a different time of the day than the atazanavir.
Fosamprenavir (Lexiva®) — Take with or without food. Tell your health care provider if you are allergic to sulfonamide medicines.
Indinavir (Crixivan®) — Take with plenty of water (at least 48 ounces or 1.5 liters per day) to decrease the risk of developing kidney stones. Store indinavir (Crixivan®) in a dry place.
The way you need to take indinavir will depend on whether or not to you are taking ritonavir (Norvir®) also. Take indinavir (Crixivan®) on an empty stomach (one hour before a meal or two hours after a meal) or with a low-fat snack. Check with your pharmacist or physician for a list of acceptable low fat snacks. If you are also taking ritonavir (Norvir®), you do not have to take the indinavir on an empty stomach.
Lopinavir/ritonavir (Kaletra®) — Take with food.
Nelfinavir (Viracept®) — Take with food. Call your health care provider right away if you develop diarrhea, which is a common side effect.
Ritonavir (Norvir®) — Take with meals. Store in the refrigerator or at room temperature (less than 77) for 30 days or less.
Saquinavir (Invirase®) — Take with meals or within two hours of a meal. If you are currently taking Invirase in the 200 mg strength, ask your health care provider about the invirase 500 mg tablets.
Tipranavir (Aptivus) — Take tipranavir (Aptivus 500 mg) with ritonavir (Norvir 200 mg) twice daily with meals. There are several drug interactions between tipranavir and drugs from six classes of medications as well as St John's wort. You should discuss your full medication list, including herbal medications, with your physician or pharmacist before initiating tipranavir.
Darunavir (Prezista®, TMC 114) — Take darunavir (Prezista®) with ritonavir (Norvir®) twice a day with food. Tell your healthcare provider if you are allergic to sulfonamide (sulfa) medications.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.hivatis.org)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Piscitelli, SC, Burstein, AH, Welden, N, et al. The effect of garlic supplements on the pharmacokinetics of saquinavir. Clin Infect Dis 2002; 34:234.
Symptoms of HIV infection
INTRODUCTION — Recognizing symptoms of HIV is important since starting treatment quickly may improve the immune system's response to HIV. This topic review discusses the early signs and symptoms of HIV and the groups that are at risk for becoming infected with HIV. A separate topic is available that discusses testing for HIV. (See "Patient information: Testing for HIV").
AT-RISK GROUPS — HIV infection is usually acquired through sexual intercourse, exposure to contaminated blood or body fluids, or transmission from an affected woman to her baby during pregnancy, birth, or breast-feeding. In other words, HIV infection is not spread by casual contact but rather through direct exposure to contaminated body fluids. (See "Patient information: Blood and body fluid exposure").
Certain individuals may have an increased risk of HIV infection, including the following: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV Injection drug users who share needles or "works" Health care workers with needlestick exposure.
SYMPTOMS — Human immunodeficiency virus (HIV) infection is infection with a virus that gradually destroys cells in the immune system. Symptoms of HIV infection develop in 50 to 90 percent of infected patients. A few days or weeks after being exposed to HIV, many individuals develop a characteristic, flu-like illness that lasts approximately two weeks. This is referred to as primary (or acute) HIV infection.
HIV infection is highly contagious at this stage because there are large amounts of the virus in the blood and other bodily fluids. As an example, a man could potentially infect 7 to 24 percent of susceptible female partners during the first two months of HIV infection [1]. Recognizing symptoms early, being tested for HIV, and starting treatment as soon as possible could help to decrease the risk of transmitting HIV to another person.
The initial signs and symptoms of HIV include problems like fever, muscle and joint pain, and swollen lymph nodes. Because these signs and symptoms may be caused by other common illnesses like the flu, most people do not initially realize that they have HIV.
In most patients, symptoms of HIV begin about two to four weeks after exposure. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection.
The symptoms typically have an abrupt onset, beginning with a fever between 100.4ºF (38ºC) to 104ºF (40ºC). Most patients tend to develop the "full-blown" syndrome within one to two days. During the second week of the illness, most patients also have painless swelling of certain lymph nodes, including those under the arms and in the neck. Although the lymph nodes decrease in size after the first few weeks, some moderate swelling remains. Some patients develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located to the left of the stomach.
On average, these symptoms last for about two weeks. However, some patients experience lingering fatigue, listlessness, or depression that lasts for weeks to months.
Skin, mouth, genital symptoms — A characteristic feature of acute HIV infection is open sores or ulcers involving the mucous membranes and skin in certain areas of the body. They may be located in the mouth; the esophagus (throat, which extends from the mouth to the stomach); the anus; or the penis. Ulceration involving the esophagus often causes pain during swallowing. The ulcers tend to be shallow, with sharply defined edges, and are typically swollen and painful.
Many patients also develop a rash or reddish inflammation of the skin about two to three days after the onset of fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving skin of the scalp, the arms and legs, and the palms and soles. The inflammation is usually pink to deep red spots and/or small, solid, slightly raised areas of the skin. Itching is rare and tends to be mild.
Digestive symptoms — Many patients with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and associated weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.
Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with acute HIV infection. A few rare cases have been reported in which patients developed inflammation of the lungs, resulting in difficulty breathing, coughing, and insufficient supply of oxygen to tissues.
Neurologic symptoms — Headaches are common in persons with primary HIV infection. Patients often describe pain behind the eyes that worsens with eye movement. Rarely, more severe neurologic features have been reported, including: Inflammation of the protective membranes that cover the brain and spinal cord (meningitis), with associated fever, severe headache, skin rash, abnormal sensitivity to light, or other signs Inflammation of the brain (encephalitis), sometimes with meningitis. Symptoms can vary and may include fever, headache, confusion, personality disturbances, and episodes of uncontrolled electrical activity in the brain (seizures). Impairment of certain "peripheral nerves" or motor and sensory nerves outside the brain and spinal cord. For example, following acute HIV infection, some patients develop facial nerve paralysis; paralysis and muscle wasting (shrinking of muscle) of the arm; or Guillain-Barré syndrome.
Guillain-Barré syndrome causes weakness, tingling, and numbness that begins in the legs and progresses upward to the chest, arms, and facial area. Weakness is rapidly progressive and can sometimes lead to paralysis.
Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from organisms that do not usually cause disease. These organisms cause infections known as "opportunistic infections".
Opportunistic infections may include yeast infections in the mouth or esophagus. Yeast infections are caused by Candida, a yeast-like fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals. Candidiasis of the mouth, also known as thrush, causes cream-colored, slightly raised patches in the mouth, soreness, and easy bleeding (show picture 1). Candidiasis of the esophagus may cause difficulty swallowing. Candidiasis of the vagina is known as a yeast infection (show picture 2). Candidiasis does occur in people without HIV, although people with HIV are at a higher risk for this and other types of opportunistic infection. (See "Patient information: Vaginal yeast infection").
TESTING FOR HIV — Human immunodeficiency virus (HIV) testing is the only way to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken. (See "Patient information: Testing for HIV").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.aidsinfo.nih.gov)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Pilcher, CD, Tien, HC, Eron, JJ Jr, et al. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004; 189:1785.
2. Walensky, RP, Goldie, SJ, Sax, PE, et al. Treatment for primary HIV infection: projecting outcomes of immediate, interrupted, or delayed therapy. J Acquir Immune Defic Syndr 2002; 31:27.
3. Quinn, TC. Acute primary HIV infection. JAMA 1997; 278:58.
4. Pao, D, Fisher, M, Hue, S, et al. Transmission of HIV-1 during primary infection: relationship to sexual risk and sexually transmitted infections. AIDS 2005; 19:85.
5. Schacker, T, Collier, AC, Hughes, J, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257.
AT-RISK GROUPS — HIV infection is usually acquired through sexual intercourse, exposure to contaminated blood or body fluids, or transmission from an affected woman to her baby during pregnancy, birth, or breast-feeding. In other words, HIV infection is not spread by casual contact but rather through direct exposure to contaminated body fluids. (See "Patient information: Blood and body fluid exposure").
Certain individuals may have an increased risk of HIV infection, including the following: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV Injection drug users who share needles or "works" Health care workers with needlestick exposure.
SYMPTOMS — Human immunodeficiency virus (HIV) infection is infection with a virus that gradually destroys cells in the immune system. Symptoms of HIV infection develop in 50 to 90 percent of infected patients. A few days or weeks after being exposed to HIV, many individuals develop a characteristic, flu-like illness that lasts approximately two weeks. This is referred to as primary (or acute) HIV infection.
HIV infection is highly contagious at this stage because there are large amounts of the virus in the blood and other bodily fluids. As an example, a man could potentially infect 7 to 24 percent of susceptible female partners during the first two months of HIV infection [1]. Recognizing symptoms early, being tested for HIV, and starting treatment as soon as possible could help to decrease the risk of transmitting HIV to another person.
The initial signs and symptoms of HIV include problems like fever, muscle and joint pain, and swollen lymph nodes. Because these signs and symptoms may be caused by other common illnesses like the flu, most people do not initially realize that they have HIV.
In most patients, symptoms of HIV begin about two to four weeks after exposure. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection.
The symptoms typically have an abrupt onset, beginning with a fever between 100.4ºF (38ºC) to 104ºF (40ºC). Most patients tend to develop the "full-blown" syndrome within one to two days. During the second week of the illness, most patients also have painless swelling of certain lymph nodes, including those under the arms and in the neck. Although the lymph nodes decrease in size after the first few weeks, some moderate swelling remains. Some patients develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located to the left of the stomach.
On average, these symptoms last for about two weeks. However, some patients experience lingering fatigue, listlessness, or depression that lasts for weeks to months.
Skin, mouth, genital symptoms — A characteristic feature of acute HIV infection is open sores or ulcers involving the mucous membranes and skin in certain areas of the body. They may be located in the mouth; the esophagus (throat, which extends from the mouth to the stomach); the anus; or the penis. Ulceration involving the esophagus often causes pain during swallowing. The ulcers tend to be shallow, with sharply defined edges, and are typically swollen and painful.
Many patients also develop a rash or reddish inflammation of the skin about two to three days after the onset of fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving skin of the scalp, the arms and legs, and the palms and soles. The inflammation is usually pink to deep red spots and/or small, solid, slightly raised areas of the skin. Itching is rare and tends to be mild.
Digestive symptoms — Many patients with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and associated weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.
Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with acute HIV infection. A few rare cases have been reported in which patients developed inflammation of the lungs, resulting in difficulty breathing, coughing, and insufficient supply of oxygen to tissues.
Neurologic symptoms — Headaches are common in persons with primary HIV infection. Patients often describe pain behind the eyes that worsens with eye movement. Rarely, more severe neurologic features have been reported, including: Inflammation of the protective membranes that cover the brain and spinal cord (meningitis), with associated fever, severe headache, skin rash, abnormal sensitivity to light, or other signs Inflammation of the brain (encephalitis), sometimes with meningitis. Symptoms can vary and may include fever, headache, confusion, personality disturbances, and episodes of uncontrolled electrical activity in the brain (seizures). Impairment of certain "peripheral nerves" or motor and sensory nerves outside the brain and spinal cord. For example, following acute HIV infection, some patients develop facial nerve paralysis; paralysis and muscle wasting (shrinking of muscle) of the arm; or Guillain-Barré syndrome.
Guillain-Barré syndrome causes weakness, tingling, and numbness that begins in the legs and progresses upward to the chest, arms, and facial area. Weakness is rapidly progressive and can sometimes lead to paralysis.
Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from organisms that do not usually cause disease. These organisms cause infections known as "opportunistic infections".
Opportunistic infections may include yeast infections in the mouth or esophagus. Yeast infections are caused by Candida, a yeast-like fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals. Candidiasis of the mouth, also known as thrush, causes cream-colored, slightly raised patches in the mouth, soreness, and easy bleeding (show picture 1). Candidiasis of the esophagus may cause difficulty swallowing. Candidiasis of the vagina is known as a yeast infection (show picture 2). Candidiasis does occur in people without HIV, although people with HIV are at a higher risk for this and other types of opportunistic infection. (See "Patient information: Vaginal yeast infection").
TESTING FOR HIV — Human immunodeficiency virus (HIV) testing is the only way to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken. (See "Patient information: Testing for HIV").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.aidsinfo.nih.gov)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Pilcher, CD, Tien, HC, Eron, JJ Jr, et al. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004; 189:1785.
2. Walensky, RP, Goldie, SJ, Sax, PE, et al. Treatment for primary HIV infection: projecting outcomes of immediate, interrupted, or delayed therapy. J Acquir Immune Defic Syndr 2002; 31:27.
3. Quinn, TC. Acute primary HIV infection. JAMA 1997; 278:58.
4. Pao, D, Fisher, M, Hue, S, et al. Transmission of HIV-1 during primary infection: relationship to sexual risk and sexually transmitted infections. AIDS 2005; 19:85.
5. Schacker, T, Collier, AC, Hughes, J, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257.
Symptoms of HIV infection
INTRODUCTION — Recognizing symptoms of HIV is important since starting treatment quickly may improve the immune system's response to HIV. This topic review discusses the early signs and symptoms of HIV and the groups that are at risk for becoming infected with HIV. A separate topic is available that discusses testing for HIV. (See "Patient information: Testing for HIV").
AT-RISK GROUPS — HIV infection is usually acquired through sexual intercourse, exposure to contaminated blood or body fluids, or transmission from an affected woman to her baby during pregnancy, birth, or breast-feeding. In other words, HIV infection is not spread by casual contact but rather through direct exposure to contaminated body fluids. (See "Patient information: Blood and body fluid exposure").
Certain individuals may have an increased risk of HIV infection, including the following: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV Injection drug users who share needles or "works" Health care workers with needlestick exposure.
SYMPTOMS — Human immunodeficiency virus (HIV) infection is infection with a virus that gradually destroys cells in the immune system. Symptoms of HIV infection develop in 50 to 90 percent of infected patients. A few days or weeks after being exposed to HIV, many individuals develop a characteristic, flu-like illness that lasts approximately two weeks. This is referred to as primary (or acute) HIV infection.
HIV infection is highly contagious at this stage because there are large amounts of the virus in the blood and other bodily fluids. As an example, a man could potentially infect 7 to 24 percent of susceptible female partners during the first two months of HIV infection [1]. Recognizing symptoms early, being tested for HIV, and starting treatment as soon as possible could help to decrease the risk of transmitting HIV to another person.
The initial signs and symptoms of HIV include problems like fever, muscle and joint pain, and swollen lymph nodes. Because these signs and symptoms may be caused by other common illnesses like the flu, most people do not initially realize that they have HIV.
In most patients, symptoms of HIV begin about two to four weeks after exposure. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection.
The symptoms typically have an abrupt onset, beginning with a fever between 100.4ºF (38ºC) to 104ºF (40ºC). Most patients tend to develop the "full-blown" syndrome within one to two days. During the second week of the illness, most patients also have painless swelling of certain lymph nodes, including those under the arms and in the neck. Although the lymph nodes decrease in size after the first few weeks, some moderate swelling remains. Some patients develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located to the left of the stomach.
On average, these symptoms last for about two weeks. However, some patients experience lingering fatigue, listlessness, or depression that lasts for weeks to months.
Skin, mouth, genital symptoms — A characteristic feature of acute HIV infection is open sores or ulcers involving the mucous membranes and skin in certain areas of the body. They may be located in the mouth; the esophagus (throat, which extends from the mouth to the stomach); the anus; or the penis. Ulceration involving the esophagus often causes pain during swallowing. The ulcers tend to be shallow, with sharply defined edges, and are typically swollen and painful.
Many patients also develop a rash or reddish inflammation of the skin about two to three days after the onset of fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving skin of the scalp, the arms and legs, and the palms and soles. The inflammation is usually pink to deep red spots and/or small, solid, slightly raised areas of the skin. Itching is rare and tends to be mild.
Digestive symptoms — Many patients with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and associated weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.
Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with acute HIV infection. A few rare cases have been reported in which patients developed inflammation of the lungs, resulting in difficulty breathing, coughing, and insufficient supply of oxygen to tissues.
Neurologic symptoms — Headaches are common in persons with primary HIV infection. Patients often describe pain behind the eyes that worsens with eye movement. Rarely, more severe neurologic features have been reported, including: Inflammation of the protective membranes that cover the brain and spinal cord (meningitis), with associated fever, severe headache, skin rash, abnormal sensitivity to light, or other signs Inflammation of the brain (encephalitis), sometimes with meningitis. Symptoms can vary and may include fever, headache, confusion, personality disturbances, and episodes of uncontrolled electrical activity in the brain (seizures). Impairment of certain "peripheral nerves" or motor and sensory nerves outside the brain and spinal cord. For example, following acute HIV infection, some patients develop facial nerve paralysis; paralysis and muscle wasting (shrinking of muscle) of the arm; or Guillain-Barré syndrome.
Guillain-Barré syndrome causes weakness, tingling, and numbness that begins in the legs and progresses upward to the chest, arms, and facial area. Weakness is rapidly progressive and can sometimes lead to paralysis.
Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from organisms that do not usually cause disease. These organisms cause infections known as "opportunistic infections".
Opportunistic infections may include yeast infections in the mouth or esophagus. Yeast infections are caused by Candida, a yeast-like fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals. Candidiasis of the mouth, also known as thrush, causes cream-colored, slightly raised patches in the mouth, soreness, and easy bleeding (show picture 1). Candidiasis of the esophagus may cause difficulty swallowing. Candidiasis of the vagina is known as a yeast infection (show picture 2). Candidiasis does occur in people without HIV, although people with HIV are at a higher risk for this and other types of opportunistic infection. (See "Patient information: Vaginal yeast infection").
TESTING FOR HIV — Human immunodeficiency virus (HIV) testing is the only way to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken. (See "Patient information: Testing for HIV").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.aidsinfo.nih.gov)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Pilcher, CD, Tien, HC, Eron, JJ Jr, et al. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004; 189:1785.
2. Walensky, RP, Goldie, SJ, Sax, PE, et al. Treatment for primary HIV infection: projecting outcomes of immediate, interrupted, or delayed therapy. J Acquir Immune Defic Syndr 2002; 31:27.
3. Quinn, TC. Acute primary HIV infection. JAMA 1997; 278:58.
4. Pao, D, Fisher, M, Hue, S, et al. Transmission of HIV-1 during primary infection: relationship to sexual risk and sexually transmitted infections. AIDS 2005; 19:85.
5. Schacker, T, Collier, AC, Hughes, J, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257.
AT-RISK GROUPS — HIV infection is usually acquired through sexual intercourse, exposure to contaminated blood or body fluids, or transmission from an affected woman to her baby during pregnancy, birth, or breast-feeding. In other words, HIV infection is not spread by casual contact but rather through direct exposure to contaminated body fluids. (See "Patient information: Blood and body fluid exposure").
Certain individuals may have an increased risk of HIV infection, including the following: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV Injection drug users who share needles or "works" Health care workers with needlestick exposure.
SYMPTOMS — Human immunodeficiency virus (HIV) infection is infection with a virus that gradually destroys cells in the immune system. Symptoms of HIV infection develop in 50 to 90 percent of infected patients. A few days or weeks after being exposed to HIV, many individuals develop a characteristic, flu-like illness that lasts approximately two weeks. This is referred to as primary (or acute) HIV infection.
HIV infection is highly contagious at this stage because there are large amounts of the virus in the blood and other bodily fluids. As an example, a man could potentially infect 7 to 24 percent of susceptible female partners during the first two months of HIV infection [1]. Recognizing symptoms early, being tested for HIV, and starting treatment as soon as possible could help to decrease the risk of transmitting HIV to another person.
The initial signs and symptoms of HIV include problems like fever, muscle and joint pain, and swollen lymph nodes. Because these signs and symptoms may be caused by other common illnesses like the flu, most people do not initially realize that they have HIV.
In most patients, symptoms of HIV begin about two to four weeks after exposure. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection.
The symptoms typically have an abrupt onset, beginning with a fever between 100.4ºF (38ºC) to 104ºF (40ºC). Most patients tend to develop the "full-blown" syndrome within one to two days. During the second week of the illness, most patients also have painless swelling of certain lymph nodes, including those under the arms and in the neck. Although the lymph nodes decrease in size after the first few weeks, some moderate swelling remains. Some patients develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located to the left of the stomach.
On average, these symptoms last for about two weeks. However, some patients experience lingering fatigue, listlessness, or depression that lasts for weeks to months.
Skin, mouth, genital symptoms — A characteristic feature of acute HIV infection is open sores or ulcers involving the mucous membranes and skin in certain areas of the body. They may be located in the mouth; the esophagus (throat, which extends from the mouth to the stomach); the anus; or the penis. Ulceration involving the esophagus often causes pain during swallowing. The ulcers tend to be shallow, with sharply defined edges, and are typically swollen and painful.
Many patients also develop a rash or reddish inflammation of the skin about two to three days after the onset of fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving skin of the scalp, the arms and legs, and the palms and soles. The inflammation is usually pink to deep red spots and/or small, solid, slightly raised areas of the skin. Itching is rare and tends to be mild.
Digestive symptoms — Many patients with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and associated weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.
Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with acute HIV infection. A few rare cases have been reported in which patients developed inflammation of the lungs, resulting in difficulty breathing, coughing, and insufficient supply of oxygen to tissues.
Neurologic symptoms — Headaches are common in persons with primary HIV infection. Patients often describe pain behind the eyes that worsens with eye movement. Rarely, more severe neurologic features have been reported, including: Inflammation of the protective membranes that cover the brain and spinal cord (meningitis), with associated fever, severe headache, skin rash, abnormal sensitivity to light, or other signs Inflammation of the brain (encephalitis), sometimes with meningitis. Symptoms can vary and may include fever, headache, confusion, personality disturbances, and episodes of uncontrolled electrical activity in the brain (seizures). Impairment of certain "peripheral nerves" or motor and sensory nerves outside the brain and spinal cord. For example, following acute HIV infection, some patients develop facial nerve paralysis; paralysis and muscle wasting (shrinking of muscle) of the arm; or Guillain-Barré syndrome.
Guillain-Barré syndrome causes weakness, tingling, and numbness that begins in the legs and progresses upward to the chest, arms, and facial area. Weakness is rapidly progressive and can sometimes lead to paralysis.
Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from organisms that do not usually cause disease. These organisms cause infections known as "opportunistic infections".
Opportunistic infections may include yeast infections in the mouth or esophagus. Yeast infections are caused by Candida, a yeast-like fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals. Candidiasis of the mouth, also known as thrush, causes cream-colored, slightly raised patches in the mouth, soreness, and easy bleeding (show picture 1). Candidiasis of the esophagus may cause difficulty swallowing. Candidiasis of the vagina is known as a yeast infection (show picture 2). Candidiasis does occur in people without HIV, although people with HIV are at a higher risk for this and other types of opportunistic infection. (See "Patient information: Vaginal yeast infection").
TESTING FOR HIV — Human immunodeficiency virus (HIV) testing is the only way to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.
However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken. (See "Patient information: Testing for HIV").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline
English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)
Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)
(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service
Toll-free: (800) 448-0440
(www.aidsinfo.nih.gov)
AIDS Clinical Trials Information Service (ACTIS)
Toll-free: (800) 874-2572
(www.actis.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Pilcher, CD, Tien, HC, Eron, JJ Jr, et al. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004; 189:1785.
2. Walensky, RP, Goldie, SJ, Sax, PE, et al. Treatment for primary HIV infection: projecting outcomes of immediate, interrupted, or delayed therapy. J Acquir Immune Defic Syndr 2002; 31:27.
3. Quinn, TC. Acute primary HIV infection. JAMA 1997; 278:58.
4. Pao, D, Fisher, M, Hue, S, et al. Transmission of HIV-1 during primary infection: relationship to sexual risk and sexually transmitted infections. AIDS 2005; 19:85.
5. Schacker, T, Collier, AC, Hughes, J, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257.
Blood and body fluid exposure
INTRODUCTION — Exposure to blood or other bodily fluids can cause many serious infections, including the human immunodeficiency virus (HIV, the virus that causes AIDS). While most people are not exposed to these fluids, a number of situations can arise where exposures may occur, such as finding a syringe with needle, helping an injured person, or being the victim of an assault or rape.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
Experts have worked to determine the best advice for these situations. It is important to note that the guidelines are based on studies of exposures within the healthcare system, from needlestick and other exposures of healthcare workers.
Although more than 200 different diseases can be transmitted from exposure to blood, the most serious infections are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Fortunately, the risk of acquiring any of these infections is low. This topic review discusses the definition of exposure, the risk of infection, and treatment and follow up recommendations for non-healthcare workers.
DEFINITION OF EXPOSURE — In order to be exposed to a bloodborne pathogen, an individual must have contact with blood, a visibly bloody fluid (eg, phlegm or urine containing blood), or another bodily fluid (eg, semen or vaginal secretions) that contain a virus. The blood or fluid must come in direct contact with some part of the person's body. A virus can enter the body through the bloodstream or mucous membranes, which include the eye, mouth, or genitals. Contact with skin that is intact (without new cuts, scraps, or rashes) poses little to no risk of infection.
Thus, exposure to a bloodborne pathogen is possible after: A percutaneous (through the skin) injury such as a needlestick or cut with a sharp object Contact with a mucous membrane (including exposure through sexual intercourse, especially if an ulcer is present or trauma to vaginal tissues occurs) or non-intact skin
INFECTION AFTER EXPOSURE
Needlestick — Of the viruses that may be transmitted through the blood or bodily fluids, hepatitis B virus (HBV) is the most infectious. A healthcare worker who sustains a needlestick with blood from a known HBV-infected patient has between a 6 and 30 percent chance of developing HBV. The risk of HCV and HIV in the same situation is 1.8 and 0.3, respectively. Other factors influence the risk of becoming infected, including the amount of blood or bodily fluid involved, the depth of penetration, and the amount of virus in the source's blood or body fluid.
Mucous membrane — The risk of becoming infected from a mucous membrane exposure is more difficult to define. When healthcare workers were followed after mucous membrane exposure to HIV, no cases of HIV were identified among those who had been exposed. However, no other explanation for HIV has been found in a few cases where mucous membrane exposure occurred in a work setting. This has led most experts to believe that the risk of acquiring HIV following a mucous membrane exposure is far less than 0.3 percent, but the risk is not zero.
One versus multiple exposures — There is also a difference in terms of risk if the individual has a one-time exposure or has multiple exposures. Thus, the risk of infection for the victim of a single sexual assault is far less than that of a regular sexual partner of an infected person.
POST-EXPOSURE RECOMMENDATIONS — The first and most important measure to take following exposure to blood or bodily fluids is to wash the area well with soap and water. Crime victims are exceptions to this rule since washing may destroy important evidence for criminal prosecution. Recommendations to prevent infection after exposure depend upon the risk of a specific virus being present:
Hepatitis B — The risk of becoming infected with hepatitis B is greater than the risk of other infections. Fortunately, there is an effective vaccine that can help to prevent infection.
Hepatitis B vaccine — The vaccine may be administered to individuals who are exposed to blood, even if the blood is not known to carry HBV. The vaccine should be given at the time of exposure, and repeated one month and six months later to achieve full protection. (See "Patient information: Hepatitis B").
Many people have previously been given the series of three HBV vaccines. In this case, some experts recommend a single booster dose of the vaccine.
Hepatitis B immune globulin — If the source of the blood is known to be positive for HBV, treatment with hepatitis B immune globulin (HBIG) is recommended. HBIG contains antibodies that provide temporary protection against the infection. HBIG is an injection, which should be given as soon as possible after exposure, preferably within 24 hours. The first dose of hepatitis B vaccine should be given at the same time. HBIG is not needed if a person was previously vaccinated with HBV vaccine.
Hepatitis C — HCV can cause a form of hepatitis that leads to chronic liver disease. There is no known way to prevent this infection following exposure. Blood tests should be done immediately after exposure to measure liver function and test for the presence of hepatitis C; the tests should be repeated after four to six weeks and again after four to six months, or sooner if symptoms of hepatitis develop. Symptoms of hepatitis C include loss of appetite, nausea, abdominal pain, darkening of urine, light stools, or jaundice (yellowing of the skin or whites of the eye). (See "Patient information: Hepatitis C").
Human immunodeficiency virus (HIV) — Treatments are available to reduce the risk of becoming infected with HIV after exposure. One retrospective study suggested that the use of an anti-HIV medication, zidovudine (ZDV), reduced the already low risk of healthcare workers becoming infected with HIV by about 81 percent. The risk of becoming infected with HIV as a result of other types of exposure (eg, trauma, rape) is probably even lower than that of a healthcare worker.
However, unlike in healthcare settings, it is often difficult after a rape or trauma if the blood or bodily fluid contains HIV. If the source of the exposure is known, an attempt can be made to test the person for HIV. However, treatment is available even if the source's HIV status cannot be determined.
The benefits of post-exposure treatment (eg, reduced risk of infection) must be weighed against the risks (eg, side effects of treatment, interactions with other medications, cost of treatment). All women of childbearing age should be tested for pregnancy before beginning treatment. Anyone who was exposed to potentially infected blood or bodily fluids should be tested for HIV at the time of exposure (baseline) and at six weeks, three months, and six months postexposure (show table 1).
Recommendations — Experts from the United States Center for Disease Control recommend use of medications to reduce the risk of HIV infection if all of the following criteria are met: Exposure occurred less than 72 hours previously One or more of the following areas were exposed: the vagina, rectum, eye, mouth, or other mucous membrane, open skin, through the skin (eg, from a sharp or needle) One or more of the following bodily fluids was involved in the exposure: blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood
However, the CDC also recommends that each situation be considered on an individual basis; preventive treatment may be recommended to people who do not meet these criteria in some situations. In all situations, regardless of whether treatment is used, it is important to follow strategies to prevent further spread of the potential infection (see "Protecting others after exposure" below).
The CDC recommends NOT using preventive treatment when: the exposure occurred more than 72 hours prior; when the exposure is to intact skin; or when the exposure fluid is urine, nasal secretions, saliva, sweat, or tears, and is not visibly contaminated with blood.
Anyone who is exposed to blood or bodily fluids should consult with a healthcare provider if symptoms of fever, swollen lymph nodes (glands), sore throat, skin lesions, muscle or joint pain, diarrhea, headache, nausea/vomiting, or weight loss develop. The usual time from HIV exposure to the first symptoms of HIV is two to four weeks. (See "Patient information: Symptoms of HIV infection").
Treatment regimen — Postexposure prevention treatment should be started as soon as possible after exposure, within a few hours rather than days. Animal studies suggest that the longer treatment is delayed, the less effective it is. Preventive treatment should not be given if more than 72 hours have elapsed since exposure.
The Centers for Disease Control and Prevention (CDC) recommends a combination of two or three medications to prevent developing HIV after exposure; the best regimen should be determined by a healthcare provider who is experienced with HIV prevention and treatment regimens (show table 2). The optimal length of preventive treatment is unknown, although four weeks is generally recommended.
It is important to be aware of the potential side effects of these drugs, possible interactions with other medications, and the proper timing of doses. Because there are a variety of medications and combinations, it is best to discuss these issues with the person who prescribes them. In all cases, it is crucial to take all of the medication exactly as directed.
FOLLOW-UP
Testing — Follow-up testing for HBV, HCV, and HIV should be performed after possible exposure (see above for specific recommendations on frequency of testing). For people receiving HBV vaccine, return appointments to complete the vaccine series are crucial.
People exposed to a bloodborne pathogen via sexual intercourse are often tested for other sexually transmitted diseases (STDs). In particular, blood tests for syphilis and cultures for gonorrhea and chlamydia are usually performed immediately after exposure and four to six weeks later (show table 1).
Anxiety — It is common to feel anxious or scared after being exposed to blood or bodily fluids.
These fears are normal but may interfere with a person's ability to concentrate on normal day to day responsibilities.
However, the risk of becoming infected with hepatitis B, C, and HIV is small in most cases. Following the steps outlined here and the advice provided by healthcare personnel can further decrease this risk. Counseling may be helpful for people who have difficulty coping, especially during the first few weeks and months after exposure.
PROTECTING OTHERS AFTER EXPOSURE — Anyone exposed to a bloodborne pathogen should understand how to prevent spreading their potential infection to others (for example, family, sexual partner or breastfeeding child) during the follow-up period, especially during the first six months after exposure; this is when most people who are infected with HIV become antibody positive.
Precautions should include abstaining from sexual intercourse or using condoms every time. Condoms reduce, but do not completely eliminate, the chances of transmitting HBV, HCV, or HIV infection to others. Women who have been exposed to blood or body fluids from a person known to be infected should avoid becoming pregnant during this time. In addition, individuals who have been exposed to HIV-infected fluids should not donate blood, plasma, organs, tissue, or semen during the follow-up period. Women who are breastfeeding may consider stopping temporarily. To maintain a supply of breastmilk, it is acceptable to pump milk and then dump it.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Centers for Disease Control and Prevention (CDC)
Toll-free: (800) 311-3435
(www.cdc.gov)
[1-8]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Bamberger, JD, Waldo, CR, Gerberding, JL, Katz, MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
2. Beck-Sague, CM, Solomon, F. Sexually transmitted diseases in abused children and adolescent and adult victims of rape: review of selected literature. Clin Infect Dis 1999; 28 Suppl 1:S74.
3. Fong, C. Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?. Emerg Med J 2001; 18:242.
4. Lurie, P, Miller, S, Hecht, F, Chesney, M. Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations. JAMA 1998; 280:1769.
5. Tokars, JI, Marcus, R, Culver, DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood: The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
6. Wiebe, ER, Comay, SE, McGregor, M, Ducceschi, S. Offering HIV prophylaxis to people who have been sexually assaulted: 16 months' experience in a sexual assault service. CMAJ 2000; 162:641.
7. Workowski, KA, Berman, SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1.
8. Smith, DK, Grohskopf, LA, Black, RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005; 54:1.
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