The Bay Area Reporter - June 17, 1996
Bill Snow and Larry Hanbrook, ACT UP/Golden Gate Writers Pool

The period of time between initial infection and the immune system mounting an antibody response is called Primary HIV Infection, and it usually lasts from a few weeks to a few months. This period, when HIV infection is established in the body, is beginning to be the focus of intensive study, and there is some early evidence that treatment may be uniquely effective during Primary HIV. In order to understand the options available during Primary HIV Infection, let's look first at what happens right after someone is infected with the virus.

During Primary HIV Infection, growth and production of HIV is at its peak, and the virus spreads rapidly throughout the body. The viral load spikes, and reaches some of the highest levels that it will reach during the entire course of the disease. Eventually, as the immune system responds, the spike in the viral load drops to a relatively stable level for the duration of the asymptomatic period of the disease. This stable level of viral load is known as the "set point."

The fact that the virus replicates intensively for a period of time before the body produces an immune response means that standard HIV antibody tests will yield a negative result at the very time the virus is replicating most furiously - and when the person is likely to be highly infectious. However, there are symptoms of Primary HIV that can perhaps alert one to suspect infection. These symptoms, called Acute Retroviral Syndrome (ARS), are similar to the flu in some regards. The most common symptoms are fever, rash, sore throat, sweats, headache, and lymph node swelling - but not a runny nose or sneezing. As with the spike in viral load, these symptoms clear as the body mounts its immune response. Some people have no symptoms after infection.

While antibody tests remain negative during Primary HIV, viral load tests and p24 antigen tests can identify infection very early, and there are compelling reasons for finding out during primary HIV that infection has occurred. Since the level of virus in the blood is high and infectiousness is high as well, just knowing that you are infectious could affect your sexual decision-making and thereby help curb the spread of the virus. Also, treatment with antivirals at this time may be particularly effective.

Hit it hard

One suggested approach for dealing with Primary HIV is to "hit it early and hit it hard." Despite the fact that HIV replicates virtually unchecked early on, the virus hasn't had a chance to mutate a great deal and thereby to develop strains that are resistant to various antivirals. This means that the relative homogeneity of the virus could greatly increase the effectiveness of antiviral therapy (hitting it early); and effectiveness could be further increased by utilizing combination therapy to minimize the potential for resistant strains to emerge (hitting it hard). "Do you wait for any other kind of infection to get really bad before you treat it?" asks prominent AIDS researcher, David Ho, "Of course not."

The strongest component of the argument for early intervention involves the set point, the level the viral load drops to after the initial spike. Studies have shown that individuals with a lower set point stay healthy longer, while those with a higher set point develop AIDS-related symptoms more quickly. If the use of combination therapy during primary HIV can lower the set point, then it seems possible that the effects of short-term therapy might have long-lasting effects on the course of the infection. Scientists studying Primary HIV infection have no idea how long early antiviral treatment must last. Perhaps changing the set point will allow people to go off treatment until much later, when their disease progresses. Or one may have to stay on antivirals indefinitely.

Most of this is reasonable but theoretical speculation; studies need to be done to validate the best course of action in Primary HIV infection. Although there are legitimate reasons to believe that early intervention could have an effect on the course of HIV disease, many individuals may choose to do nothing at that time, since symptoms of immune dysfunction probably won't appear for years. They may be upset and confused when they learn they are infected, which may lead to denial or simply not wanting begin treatment in a time of great stress. Treatment or no treatment, there are certainly strong reasons to find out early if you've become infected to avoid a high risk of infecting others and to face these hard treatment decisions while you have these options.

Currently, a new study is beginning at UCSF called the Options Project. Its purpose is to study Primary HIV and do clinical trials of early treatment verses no treatment, a decision which is left up to each individual. The study does hope to take advantage of the window period of Primary HIV by offering those in Primary HIV early testing, information, and options and opportunities that may not be available to them at later stages of the infection. The Options Project and others like it around the country hope to answer important scientific questions that will help resolve what actions, if any will most help newly infected individuals and control the spread of HIV.

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Act now

If you think you may have been exposed to HIV and have some of the following symptoms: fever, swollen lymph nodes, sore throat, mouth sores, new body rash, nausea or vomiting, diarrhea, sore muscles or joints, headache, light-sensitive eyes, stiff neck, severe fatigue, you can call the UCSF Options Project. It provides free rapid and accurate testing, referrals for counseling, and information about treatment options. Remember that time is an important factor in dealing with Primary HIV, so you need to act right away!

You can call the Options Project at (415) 502-8100 if you think you may have been infected; or 476-4082 x 119 for more information.
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Always watch for outdated information. This article first appeared in 1996. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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