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, HIV advances over years to acquired immunodeficiency syndrome (AIDS).

• With modern antiretroviral therapy (ART), HIV is a manageable long-term condition with near-normal life expectancy.

• 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 1–6 weeks after a possible exposure:

• Fever

• Sore throat

• Maculopapular rash

• Lymphadenopathy

• Myalgia

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

• 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

• With any blood test if none in the past 12 months

• To those attending the emergency department

Offer a test – higher-risk groups
• Men who have sex with men (MSM) and their partners
• People of Black African heritage, and people from high-prevalence countries
• People who inject drugs (PWID) and those who share equipment
• Sexual partners of people living with HIV; trans women
• Anyone diagnosed with another sexually transmitted infection (STI) or requesting an STI screen

Offer a test – clinical clues or indicator conditions
• Seroconversion illness – fever, rash, pharyngitis, lymphadenopathy after possible exposure
• AIDS-defining – Pneumocystis jirovecii pneumonia, Kaposi's sarcoma, oesophageal candidiasis, cerebral toxoplasmosis
• Tuberculosis, lymphoma, anal or cervical cancer/dysplasia, hepatitis B or C
• Unexplained weight loss, chronic diarrhoea, lymphadenopathy, oral candidiasis, or low white cell/platelet count
• 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. • 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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