HIV Recognition in the ED

Martha I. Buitrago, MD
Infectious Diseases
Idaho State University
 HIV in the ED
• Changing Epidemiology
• HIV Infection
• Presentations in the ED
• History Taking
Adults and children estimated to be
living
with HIV as of end 2003
Eastern Europe
& Central Asia
Western Europe
North America 1.3 million
580 000 [860 000 –
1.0 million [460 000 – 730 000] 1.9 million] East Asia
[520 000 – 1.6 million] 900 000
Caribbean North Africa & Middle East
[450 000 – 1.5 million]
480 000 South
430 000 [200 000 – 1.4 million] & South-East Asia
[270 000 – 760 000]
6.5 million
Sub-Saharan Africa [4.1 – 9.6 million]
Latin America 25.0 million Oceania
1.6 million [23.1 – 27.9 million]
32 000
[1.2 – 2.1 million]
[21 000 – 46 000]

Total: 37.8 (34.6 – 42.3)

million
00003-E-3 – July 2004
Children (<15 years) estimated to be living
with HIV as of end 2003

Eastern Europe
Western Europe & Central Asia
North America 6 200 8 100
11 000 [4 900 – 7 900]
[6 600 – 12 000]
East Asia
[5 600 – 17 000]
North Africa & Middle 7 700
Caribbean South [2 700 – 22 000]
East
22 000 21 000 & South-East Asia
[11 000 – 48 000]
[6 300 – 72 000] 160 000
Sub-Saharan Africa [91 000 – 300 000]
Latin America 1.9 million Oceania
25 000 [1.7 – 2.2 million]
600
[20 000 – 41 000]
[< 2 000]

Total: 2.1 (1.9 – 2.5)

million
00003-E-4 – July 2004
 Estimated number of adults and
children
newly infected with HIV during 2003
Eastern Europe
Western Europe & Central Asia
North America
20 000 360 000
44 000 [13 000 – 37 000]
[160 000 – 900 000]
East Asia
[16 000 – 120 000]
North Africa & Middle East 200 000
Caribbean South [62 000 – 590 000]
52 000 75 000
[21 000 – 310 000] & South-East Asia
[26 000 – 140 000]
850 000
Sub-Saharan Africa [430 000 – 2.0 million]
Latin America 3.0 million Oceania
200 000 [2.6 – 3.7 million]
5 000
[140 000 – 340 000]
[2 100 – 13 000]

Total: 4.8 (4.2 – 6.3)

million
00003-E-5 – July 2004
Estimated number of children (<15 years)
newly infected with HIV during 2003

Eastern Europe
Western Europe & Central Asia
North America < 100 1 500
< 100 [< 200] [1 000 – 2 900] East Asia
[< 200]
North Africa & Middle East 3 300
Caribbean South [1 200 – 9 200]
6 000 8 400
[2 500 – 28 000] & South-East Asia
[3 000 – 13 000]
47 000
Sub-Saharan Africa [29 000 – 87 000]
Latin America 550 000 Oceania
6 400 [500 000 – 650 000]
< 300
[5 100 – 10 000]
[< 1 000]

Total: 630 000 (570 000 – 740 000)

00003-E-6 – July 2004
Estimated adult and child deaths
from AIDS during 2003

Eastern Europe
Western Europe & Central Asia
North America 6 000 49 000
[32 000 – 71 000]
16 000 [<8 000] East Asia
[8 300 – 25 000]
North Africa & Middle 44 000
Caribbean East South [22 000 – 75 000]
35 000 24 000 & South-East Asia
[23 000 – 59 000] [9 900 – 62 000] 460 000
Sub-Saharan Africa [290 000 – 700 000]
Latin America 2.2 million
84 000 [2.0 – 2.5 million]
Oceania
[65 000 – 110 000] 700
[<1 300]

Total: 2.9 (2.6 – 3.3) million

00003-E-7 – July 2004
About 14 000 new HIV infections a day in
2003
 More than 95% are in low and middle income
countries

 Almost 2000 are in children under 15 years of age

 About 12 000 are in persons aged 15 to 49 years,

of whom:
— almost 50% are women
— about 50% are 15–24 year olds

00003-E-8 – July 2004

Global estimates for adults and children
end 2003

 People living with HIV 37.8 million [34.6 – 42.3 million]

 New HIV infections in 2003 4.8 million [4.2 – 6.3 million]

 Deaths due to AIDS in 2003 2.9 million [2.6 – 3.3 million]

00003-E-9 – July 2004

13.2 Million Children have been Orphaned Since the start of the Epidemic
 Epidemiology
Changing demographics:

1998 2000
Women 21% 27% 
White 38% 36% 
Non-White 41% 47% 
MSM 45% 42% 
IVDU 20% 25% 
Heterosexuals 19% 26% 
 Idaho Cumulative HIV/AIDS 2003

-Cumulative statistics from April 1986 when HIV became a reportable disease in Idaho
-HIV (+): Total # of HIV (+) individuals excluding Idaho AIDS cases
 HIV in Idaho – Prevalence
HIV / AIDS
 District 1 95
 District 2 46
 District 3 101
 District 4 333
 District 5 76
 District 6 64
 District 7 46
• Total 761

(As of June 2004)

 Idaho Cumulative HIV/AIDS 2003

Exposure categories Idaho HIV(+) Idaho AIDS

(Adults) (N=565) (N= 552)
Men who have sex with men (MSM) 257 (45%) 308 (56%)

Injecting drug use (IDU) 95 (17%) 61 (11%)

MSM & IDU 44 (8%) 44 (8%)

Hemophilia/coagulation disorders 5 (1%) 18 (3%)

Heterosexual contact 73 (13%) 69 (13%)

Receipt of blood component or tissue 12 (2%) 12 (2%)

Other/risk not reported or identified 79 (14%) 40 (7%)

 Idaho Cumulative HIV/AIDS 2003

Exposure categories Idaho Idaho AIDS

Pediatric HIV(+) (N=3)
(N=8)
Hemophilia/coagulation disorder 0 (0%) 0 (0%)
Mother with/at risk for HIV 7 (88%) 1(33%)
infection
Receipt of blood, components, or 0 (0%) 2 (67%)
tissue
Other/risk not reported or 1 (13%) 0 (0%)
identified
 HIV Presentations
• Primary HIV Infection
• Asymptomatic Screening
• Chronic HIV Infection
• Late-Stage AIDS
Mayo Clin Proc 2002;77:1097-1102
HIV Presentation
 Case # 1
• Mr. John Corporate is a pleasant 30 y.o
male, captain of the baseball team. He
comes to the ER with complaints of fatigue,
sore throat, painful nodes on his neck, and
generalized body rash.
• All symptoms started 2 months after his last
business trip.
Case # 1

• What other questions

would you ask?
• What is your
differential diagnosis?
• What tests would you
order?
 Acute HIV Infection: opportunities
for diagnosis
• Physicians’ offices
• Emergency rooms
• Community health centers
• Dermatology clinics
• Sexually transmitted disease centers
• HIV clinics
Mayo Clin Proc 2002;77:1097-1102
 Acute HIV Infection
• Transient symptomatic illness in 40-90%
– nonspecific illness to severe manifestations
– occasionally can result in hospitalization
• No specific constellation of signs or symptoms
can differentiate acute HIV from other illnesses

Kahn JO, Walker BD. Acute human immunodeficiency virus

type 1 infection. N Engl J Med 1998;339:33-39
Schacker, T, et al. Clinical and epidemiologic features of primary
HIV infection. Ann Intern Med. 1996;125:257-264
HIV Infection
Acute Retroviral Syndrome
• Fever  96%
• Lymphadenopathy  74%
• Pharyngitis  70%
• Rash  70%
• Myalgia/arthralgia  54%
• Diarrhea  32%
• Headache  32%
• Nausea/Vomiting  27%
• Hepatosplenomegaly  14%
• Weight loss  13%
• Thrush  12%
• Neurologic symptoms  12%
 CDC. Guidelines for using antiretroviral agents…MMWR 2002;51(RR-7)
 Acute HIV Infection
• Symptoms present days to weeks after
initial exposure
• Most common presentation:
– fever, fatigue, headache, and rash
• Nonspecific symptoms overlap with
common viral illnesses
• High index of suspicion is CRITICAL
 Acute Retroviral Syndrome
• Rash (40-80%)
– erythematous maculopapular with lesion on
face and trunk (rarely extremities)
– mucocutaneous ulceration involving the mouth,
esophagus, or genitals
• Rash would help differentiate from infectious
mononucleosis
 Acute Retroviral Syndrome
• Neurologic symptoms (24%)
– meningoencephalitis or aseptic meningitis
– peripheral neuropathy or radiculopathy
– facial palsy
– Guillain-Barré syndrome
– brachial neuritis
– cognitive impairment
– psychosis
 Acute HIV DDX
• Influenza • Drug reaction
• Epstein-Barr virus • Viral hepatitis
mononucleosis • Primary HSV infection
• Severe (streptococcal) • Rubella
pharyngitis • Brucellosis
• Secondary syphilis • Malaria
• Primary CMV infection • West Nile Virus
• Toxoplasmosis
 Acute HIV: Diagnosis
 Question all patients about HIV risk behaviors
including sexual activity and injection drug use.
 Perform a thorough physical examination with
particular attention to the signs of primary HIV
infection such as rash, mucocutaneous ulcers, and
lymphadenopathy.
 Perform a baseline HIV antibody test.
– This serves two important purposes:
• it establishes whether chronic HIV infection is present
• the consent process initiates a discussion with the patient
about the implications of HIV testing
 Obtain an HIV viral load test, if the suspicion of acute
HIV is high (the HIV antibody is likely to be negative
in acute HIV infection)
 HIV Antibody Tests
• Serum antibody (EIA)
• Saliva and urine antibody tests (EIA)
• Rapid tests
– SUDS (microfiltration EIA)
• Laboratory-based
– OraQuick
• Point of care
• Western blot assay
– Confirmatory test
 Potential Benefits of Treatment
during PHI
• Suppress initial burst of viremia
• ? alter viral set-point
• Decrease viral evolution
• Preserve CD4 lymphocytes (both absolute
number and HIV-specific)
• Potentially decrease risk of transmission
• Possibly allow for future cessation of therapy
 Potential Risks of Treatment
during PHI
• Drug toxicity
• Costs of possible lifelong therapy
• Starting therapy in patients who may never
have needed it
• Early development of resistance
• Little evidence to date of clinical benefit
 Acute HIV - Treatment
• Goal: long-term viral suppression
• Evidence:
– Animal models (Macaques/SIV)
– Small case reports
• Berlin patient, New York pair, Caracas couple
 Acute Infection
6 No Therapy
• Control of SIV
viremia w/ 3

SIV RNA (log10), Median

wks on Rx & 3
5
wks off Rx

• Long term trial 4

of 3 wks on & 3
wks off in SIV+
STI-HAART
macaques 3

HAART
2
-3 -2 +2 +5 +8 +11 +14 +17 +20

Weeks
Lori et al. Science 2000
 The Berlin Patient
90,000
80,000
HIV RNA, copies/mL

= No treatment
70,000
60,000 s
iti s
A
50,000 ym
t i ti 7
did –22 pa –13
p i 5 e 1
40,000 E 1 H 12 176.......Permanently discontinued
30,000
20,000
10,000
<500 0
-10 30 70 110 150 190 230 270 310 350 390 727
Time, days

Lisziewicz et al. New Engl J Med. 1999.

Acute HIV: Missed Opportunity
• The symptoms — especially in mild cases — are
nonspecific and resolve spontaneously without
treatment.
• Clinicians may be uncomfortable raising the question of
sexual exposure or intravenous drug-use, especially with
patients whom they only see infrequently such as young,
previously healthy individuals.
• Primary care physicians may not be aware of high-risk
behavior even in patients they know well.
• Patients may not perceive themselves to be at risk.
 Case # 2
• MC is an 18 year old college student , who
presents with increased shortness of breath
for 3 weeks, fever, and non-productive
cough.
• On exam, he has an oxygen saturation of
85% after exercise, and clear lungs.
Case #2

• What other questions

would you ask?
• What is your
differential diagnosis?
• How would you treat?
 Sexual History Taking
• Ensure privacy
• Be non-judgmental and respectful
• Avoid making assumptions about people
• Make eye contact, have relaxed body language
• Provide patients with a context for the questions
that are to follow
 Asking Questions
• First question is the most difficult; start
with general, non-threatening
• Use open-ended questions
• Ask ‘how’, ‘what’, ‘where’
• Avoid asking ‘why’
• Ask about knowledge and use of barrier
methods
 Sample Questions
• Are you sexually active?
• How many sexual partners have you had in
the past year?
• Do you have sex with men, women, or
both?
• How are you protecting yourself from
pregnancy?
 Getting Started and the 5 “P”s
• Teens:
– Some of my patients your age have started having sex.
Have you?
– What are you doing to protect yourself from AIDS or
other STD’s?
• Adults:
– I ask these questions to all my patients regardless of
age or marital status….
 The 5 “P”s
1. Partners
2. Sexual Practices
3. Past STDs
4. Pregnancy History
5. Protection from STDs
 Importance of HIV Diagnosis
• Early Intervention services
– Improved quality of life
– Avoid complications
– Healthcare maintenance
• Prevent transmission
– Primary HIV infection
• Higher viral loads
• No antibody
– Chronic infection
• Asymptomatic
• High risk behaviors
 Chronic HIV Presentation
• Clinically latent
• Subtle clues
• Complicates other diseases
• Index of suspicion is CRITICAL
 Mucosal Clues
• Oral Lesions
– Thrush, hairy leukoplakia, gingivitis
• Genital
– Recurrent candidiasis, cervical or anal
dysplasia, STDs
• Gastrointestinal
– Esophageal candidiasis, diarrhea, anorectal
infections, cholangiopathy

Mayo Clin Proc 2002;77:1097-1102

Hairy Leukoplakia
 Oral Candidiasis

• Erythematous • Pseudomembranous
 Dermatologic Clues
• Infectious dermatitides
– Bacterial, fungal, viral
• Neoplastic
– Kaposi’s, basal-cell, squamous cell
• Inflammatory
– Psoriasis, seborrheic dermatitis

Mayo Clin Proc 2002;77:1097-1102

Seborrheic Dermatitis Kaposi’s Sarcoma
 Laboratory Clues
• Cytopenias
– Anemia, ITP, leukopenia
• Hypergammaglobulinemia
• False positive results
– RPR, ANA
• Elevated PTT
• Decreased cholesterol
• Renal insufficiency and protenuria
Mayo Clin Proc 2002;77:1097-1102
 Late-Stage Presentation
• Usually clinically obvious
• Should not be missed
• Opportunistic infections predominate
• Wasting common
 Missed Opportunities
• Women who do not receive prenatal care
• Pregnant women who seek prenatal care erratically
• Non-legal residents
• Injection drug users
• Homeless
• Women who receive prenatal care but are not offered
HIV testing

E Aaron, CRNP. Presented at Clinical Pathway, August 2002.

 Summary
• HIV/AIDS is an Idaho disease!
• Recognizing the presentation of HIV disease is
important for ALL clinicians
• Identifying HIV-infected individuals is important
for:
– The person living with HIV
– The spouse / partner
– Unborn children
– Society
• Referral specialty services ARE available