Human Immunodeficiency Virus (HIV)

🔍 When to Suspect

Flu-like seroconversion illness, persistent generalized lymphadenopathy, unexplained weight loss, opportunistic infections, or in any at-risk individual

From the full topic in The Ocean Library: Human Immunodeficiency Virus (HIV)

🧭 When to suspect (and when to offer a test)

Human immunodeficiency virus (HIV) is a retrovirus that progressively depletes CD4 T-lymphocytes; left untreated it advances over years to acquired immunodeficiency syndrome (AIDS). With modern antiretroviral therapy (ART) it is a manageable long-term condition with near-normal life expectancy, and a person with a sustained undetectable viral load cannot transmit HIV sexually – undetectable = untransmittable (U=U).

The central primary-care task is to test more, not less. Most missed diagnoses follow missed opportunities, so HIV testing should feel routine, with consent and the option to decline. Suspect acute seroconversion in any unexplained flu-like illness – fever, sore throat, maculopapular rash, lymphadenopathy, myalgia – 1–6 weeks after a possible exposure; this is a highly infectious phase that is easily mistaken for a viral upper respiratory illness. Later, suspect emerging immunodeficiency as the CD4 count falls: persistent generalised lymphadenopathy, weight loss, chronic diarrhoea, recurrent oral candidiasis, or shingles in a younger adult.

Test proactively in higher-risk groups and whenever an HIV indicator condition is diagnosed. In areas of high (2–5 per 1,000 aged 15–59) or extremely high (≥ 5 per 1,000) diagnosed prevalence, NICE recommends offering a test – ideally opt-out – on practice registration or with any blood test if none in the past 12 months, and to those attending the emergency department.

Offer a test – higher-risk groups	Offer a test – clinical clues / indicator conditions
• Men who have sex with men (MSM) and their partners	• Seroconversion illness – fever, rash, pharyngitis, lymphadenopathy after possible exposure
• People of Black African heritage, and people from high-prevalence countries	• AIDS-defining – Pneumocystis jirovecii pneumonia, Kaposi's sarcoma, oesophageal candidiasis, cerebral toxoplasmosis
• People who inject drugs (PWID) and those who share equipment	• Tuberculosis, lymphoma, anal or cervical cancer/dysplasia, hepatitis B or C
• Sexual partners of people living with HIV; trans women	• Unexplained weight loss, chronic diarrhoea, lymphadenopathy, oral candidiasis, or low white cell/platelet count
• Anyone diagnosed with another sexually transmitted infection (STI) or requesting an STI screen	• Shingles in a younger adult, severe or recalcitrant seborrhoeic dermatitis or psoriasis, community-acquired pneumonia

🧠 Clinical pearl – let the diagnosis in front of you prompt the test Each HIV indicator condition carries at least a 1 in 1,000 chance of undiagnosed HIV – the threshold at which testing is cost-effective. So the trigger is often a diagnosis a GP is already making: shingles in a young adult, recurrent thrush, unexplained cytopenias, a new STI, or community-acquired pneumonia. If you are coding one of these, offer the test in the same consultation.

Source: NICE NG60 · BHIVA/BASHH/BIA HIV Testing Guidelines · UK Health Security Agency

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