Being Alive Newsletter, Being Alive/Los Angeles - August 1993
Eric S. Daar, MD

It is a great disservice to our community when the health-care establishment fails to recognize this clinical entity. Most patients presenting to a physician with this syndrome are evaluated for common causes, such as streptococcal and Epstein-Barr Virus infection. Once these tests are found to be negative, the patient receives the dreaded "viral syndrome" diagnosis (i.e. I don't know what you have, but it will probably go away on its own) and is dismissed. If perceived by the physician to be at risk for HIV infection, a patient may be tested for HIV antibodies by standard ELISA. Unfortunately, at the time of primary infection, patients are typically antibody negative. The patient is discharged from medical care and usually improves with time, only to be found HIV-antibody positive in the future.

How is the diagnosis of primary infection made? The first step in making any diagnosis is to recognize the symptom complex. When a clinician is confronted by a patient at risk for HIV who complains of a nonspecific illness, such as fever, sore throat, and rash, diagnostic considerations must include primary HIV infection. At this point, the patient should be counseled and have blood drawn for HIV antibody and p24 antigen testing by ELISA. P24 antigen is only present in patients with relatively advanced HIV disease (who will also be HIV-antibody positive) and in patients with primary infection (who are typically HIV-antibody negative). Barring a rare false-positive p24 antigen, patients who are p24 antigen positive/HIV-antibody negative are essentially all in the process of seroconverting to HIV.

Why is it important to identify patients with primary HIV infection? Most importantly, it is the first opportunity to make an early diagnosis and provide appropriate counseling with regards to preventing the spread of HIV, as well as for early intervention. Secondly, this stage of disease represents a time when plasma viremia may exceed that seen in patients with end-stage disease. The good news is that the plasma viremia precipitously declines over the ensuing weeks in association with the patient entering the early stages of chronic asymptomatic HIV disease. The bad news is that recent studies demonstrated that early asymptomatic HIV disease is associated with large quantities of HIV present within lymphatic tissue. Together, these studies suggest that primary infection represents a time of massive dissemination of HIV, possibly setting the stage for what is to occur over the next 10 years of disease.

In light of the fact that primary HIV infection represents a brief illness associated with high levels of HIV viremia, the role of early therapy has been questioned. This stage of disease must be looked upon differently than that which immediately follows, i.e. early chronic HIV disease. Primary infection represents a very brief, once-in-a-lifetime opportunity to control the early dissemination of HIV throughout the body. The role of treatment for primary HIV infection is currently being addressed by a NIH funded study known as DATRI 002. This study is designed to establish if there are any short-term or long-term benefits derived from the treatment of patients with primary infection. If treatment is to be initiated, time is of the essence, as high level viremia and dissemination occur over days.

For more information regarding primary HIV infection, please contact the Research Coordinator for the Los Angeles site of this study, Jacqui Pitt ACRN, Harbor-UCLA Research and Education Institute, Division of HIV Medicine 310-222-3848

(Eric S. Daar, MD is the Director of HIV Medicine at Harbor-UCLA Research and Education Institute. He can be reached at 310-222-2159)
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