Being Alive; August 1996
Walt Senterfitt

The problem is: how do we find people when almost none of them realize they have HIV infection?

Primary or acute HIV infection (as opposed to chronic infection once HIV has become well established) refers to the period when one has been exposed and HIV is beginning to establish itself in the body. It's almost, though not quite, synonymous with the so-called "window period" of HIV testing parlance, because antibodies to HIV have not yet been made; thus the standard HIV antibody test or ELISA test will be negative. However, an inexpensive p24 antigen test will usually be positive during this period, indicating the presence of HIV in the bloodstream. PCR testing can be used to clear up questionable cases. Viral load goes up very high, before coming back down as the body mounts its immune response. CD4 cells similarly drop precipitously as HIV kills them off, then rebound to their original levels. So if someone who has been recently exposed, or thinks s/he may have been, comes in for the right kind of testing, acute infection can be detected and the person offered options of treatment.

More than half, maybe as many as 80%, of people have symptoms during acute infection. These symptoms include fever, sore throat, fatigue and often a skin rash, sores in the mouth and diarrhea. Problem is, this syndrome of symptoms is usually passed off as "the flu" or a "viral syndrome" by the person and the doctor, if indeed one even decides to visit a doctor. The syndrome seems to mimic "mono" in many cases. Two things can help a person or the provider to suspect acute HIV infection: recent risky activities should be inquired about and the skin rash or mouth sores that occur in about 75% of those with the flu-like syndrome are NOT typical of an ordinary flu.

As part of my work with the HIV Epidemiology Program of the LA County Health Department, and with the help of community physicians (especially Dr. Eric Daar of Cedars-Sinai and Dr. Charles Farthing of AHF) and a now-forming community advisory board, I have begun a new project to spread the word about acute HIV infection throughout Los Angeles County, among providers and communities where high-risk behaviors are concentrated (gay and bisexual men, drug injectors and the partners of either).

We are establishing a program for gradually-widening outreach to providers and communities; preparing snappy and colorful materials; and setting up a system for 24-hour telephone consultation. We will give referrals to a rapid-turnaround testing center, and to confidential or anonymous counseling. We also refer people to the various choices of treatment, clinical trial enrollment, and periodical follow-ups without treatment.

Research has shown that those who have the most severe symptoms during this phase tend to have the most rapidly developing HIV disease afterward. These are the people who tend to get AIDS in only a few years, and so there's good reason for them to know about and consider the possibility of early aggressive treatment to slow down or stop that rapid course.

We hope the project can help us to plan better prevention efforts, by knowing more about what caused these new infections. It can perhaps help prevent unknowing transmission, as primary infection is the period when one is likely to have the most infectious HIV particles spilling into semen or vaginal fluids. Studying blood specimens can help us know more about the level of drug-resistant viruses being transmitted in our community, as well as valuable information about how soon effective treatment can render someone noninfectious to others.

We realize that telling someone they are HIV+ and then, almost at the same time, suggesting they consider treatment right away is very stressful, to say the least. We're planning the most sensitive and unlimited counseling process we can conceive of. We plan to offer compensation as well for those who want to participate in the study. No one will ever be coerced into treatment, offered any placebo or asked to reveal their names if they do not wish to.

I invite your support and suggestions. The next meeting of the Community Advisory Board for the project will be at Being Alive, Thursday, August 15, at 6 PM. Spread the word among your partners, friends and care providers. While we are planning and implementing the full system, we already have in place a temporary system for rapid testing and access to treatment if desired. Call 213.351.8770 with referrals or for more information.

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