How Symptom Checking Can Place You at HIV Risk

Waiting for the Signs Can Increase the Risk of HIV Infection, Transmission

Man touching throat
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Without question, knowing the signs and symptoms of HIV is important, allowing a person to seek timely testing and treatment while preventing the spread of the virus to others.

But there's a conundrum. Given that the course of HIV infection can vary significantly from person to person, with different disease expressions (or a complete lack of it), can one really be assured of "spotting the signs" of HIV in time to prevent either an infection or transmission?

Ultimately, the signs of HIV are not enough to protect yourself or others if prevents a timely and informed response. To do so requires a clear understanding HIV symptomatology and the limitations of what they can actually tell us.

FACT #1: 60% of people will not have any symptoms during the early stages of HIV.

When an HIV infection occurs, 40% of people will develop flu-like symptoms, a condition commonly referred to as acute retroviral syndrome (ARS). Among the features of ARS are swollen lymph glands (usually around the neck, armpits and groin) and occasionally a morbilliform rash (i.e., a red, flat area covered with small, confluent bumps).

Certainly identifying these symptoms might alert an individual to seek appropriate testing and treatment, and that’s good. But most often, it's the symptoms coupled with already festering concerns about a sexual incident—either where condoms were not used or the sexual partner was of unknown status—that trigger the alert.

This is when waiting for symptoms can be a terrible mistake. By holding off until the signs appear, usually within 7-14 after exposure, a person will have lost the opportunity to take post-exposure prophylaxis (PEP), a 28-day course of drugs that can abort an infection if therapy is started, ideally, within 24-36 hours of exposure.

FACT #2: HIV symptoms, if there, are often so non-specific as to be missed by patients and doctors alike.

Currently in the U.S., there are about 1.2 million people infected with HIV, 20-25% of whom are undiagnosed. Many of the undiagnosed are, in fact, fully aware of their status, while others may suspect an infection but never act, either out of fear of stigma, discrimination or rejection, or misgivings about the treatment itself.

Their denial is often fuelled by either a lack of symptoms or symptoms that are so non-specific as to be easily dismissed as something else. Consider, for example, some of the more common symptoms of ARS:

  • Fever
  • Fatigue
  • Headache
  • Sore throat
  • Muscle and joint pain

And then consider the response when the symptoms eventually disappear, as they will. The resolution of symptoms during the so-called acute stage is often mistaken as a confirmation that an HIV infection has not occurred, allowing that individual to go untreated for years at a time and potentially infect others.

It’s a mistake and a very serious one.

FACT #3: The appearance of symptoms can often take years, by which time irretrievable damage to the body may have been done.

Opportunistic infections (OIs) are those that present themselves when a person's immune defenses are so depleted as to allow diseases, often harmless to healthy individuals, to suddenly manifest.

During the so-called latent stage of infection, when HIV progressively targets and kills defensive CD4+ T-cells, symptoms can often be minimal even when the immune function is considered to be low. There may appear skin infections, otherwise easily treated, or an overall tiredness that one may attribute to any number of things (e.g., work, family, age). 

But if an HIV infection is allowed to go untreated, with the CD4 count plummeting to below 200, the likelihood of a major acute event is high. And while such an event can likely be treated, the cost to your immune function can, in fact, be high.

There are a number of known consequences to the late initiation of antiretroviral therapy, particularly in patients with CD4 counts under 200. Among them:

  • Greater difficulty in reconstituting immune function to normal levels versus patients with higher baseline CD4 counts
     
  • Higher rates of treatment-related side effects and drug intolerance
     
  • Greater risk of non-HIV-related comorbidities (like heart disease, cancers, neurologic disorders, etc.) due to years of unchecked chronic inflammation associated with long-term HIV infection
     
  • A loss in life years (compared to a normal life span expected in those who start treatment early)

What Does This Actually Tell Us?

The message is clear: symptoms alone will never diagnose an HIV infection.  Never. Only HIV testing will. Here are a few rules you can follow to better ensure you make an informed choice, whether the signs are there or not:

  1. If you believe you have been exposed to HIV, do not wait to see if you have any of the tell-tale signs. Go immediately to your local clinic or emergency room and start a course of post-exposure prophylaxis (PEP), which most insurance plans will cover.
     
  2. You do not have wait until something has happened to get an HIV test. It is currently recommended that all American aged 15-65 be tested for HIV as part of a regular doctor's visit. Others, including younger men who have sex with men (MSM), should get tested more regularly. Confidential HIV testing is available, as well as commercially available, at-home saliva tests.
     
  3. Do not lose life years unnecessarily when modern therapy can ensure you a normal, healthy lifespan. Without a doubt, the benefits of early therapy far outweigh any possible risks, with newer generation drugs affording lower pill doses and minimal side effects. 
     
  4. If you do not have HIV but are at higher risk for infection (due either to inconsistent condom use, multiple sex partners, drug/alcohol use, HIV serodiscordancy), explore HIV pre-exposure prophylaxis (PrEP) to reduce your likelihood of HIV acquisition.

Sources:

Cohen, M.; Gay, C.; Busch, P.; and Hecht, F. "The Detection of Acute HIV Infection." The Journal of Infectious Diseases. 2010; 202(Supplement2):S270-S277.

Smith, D.; Grohskopf, L.; Black, R., et al. "Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States." Morbidity and Mortality Weekly Report. January 21, 2005; 55(RR02):1-20.

U.S. Centers for Disease Control and Prevention (CDC). "CDC Fact Sheet | HIV in the United States: The Stages of Care." Atlanta, Georgia; published July 2012.

Hasse, B,; Ledergerber, B.; Egger, M., et al. "Aging and (Non-HIV-associated) Co-morbidity in HIV-positive Persons: The Swiss Cohort Study (SHCS)." 18th Conference on Retroviruses and Opportunistic Infections (CROI). Boston, Massachusetts; February 27-March 2, 2011; abstract 792.

Moyer, V. "Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement." April 30, 2013. Annals of Internal Medicine. April 30, 2013; doi:10.7326/0003-4819-159-1-201307020-00645.

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