Question 1

What are the early signs of HIV?

Dr. Neha Rastogi · Accepted Answer

The early signs, known as acute HIV syndrome, look like a flu. They appear in the first month or two after infection, with on-and-off fever that can run for two to three months, fatigue or weakness, weight loss, loss of appetite, cough, cold, sore throat, swollen glands, a rash, and loose motions or diarrhoea. More frequent minor illnesses than usual can follow. This symptom complex in the first months after infection is what we call acute HIV syndrome.

Question 2

Why don't we use the urine LAM test and stool test for all patients?

Dr. Neha Rastogi · Accepted Answer

The urine lipoarabinomannan (LAM) test is reserved for tuberculosis diagnosis, and it has been described and validated only for patients with a CD4 count below 100. Urine LAM testing is now being adopted, much like cryptococcal antigen testing, but LAM is an antigen that reaches the urine only when there is a high burden of tuberculosis bacilli and the CD4 count is low. Its sensitivity and specificity rest on CD4 counts below 100, so extrapolating it to all patients is not supported. On stool testing for other opportunistic infections: in a treatment-naive patient with a high viral load, the stool shows a great deal of normal flora and candida, which makes interpretation for treatment decisions difficult, specifically in the HIV population.

Question 3

Are there any antiretrovirals that can have prolonged action for up to three or six months?

Dr. Neha Rastogi · Accepted Answer

Yes. Cabotegravir, a long-acting integrase inhibitor, combined with rilpivirine, has been shown in trials to maintain viral suppression with an intramuscular injection given once in three months. This has been a major step forward in maintenance therapy for patients who are already stable on antiretroviral therapy with a suppressed viral load. Longer-acting options are also emerging: subcutaneous lenacapavir, given every six months, is approved for people with multidrug-resistant HIV and for prevention.

Question 4

At what stage can we diagnose opportunistic infections, and how do we diagnose them?

Dr. Neha Rastogi · Accepted Answer

Opportunistic infections can be diagnosed at any stage. The WHO staging system, stages one to four, is built on the infection profile together with CD4-based staging. Many patients newly diagnosed with HIV arrive with oral thrush, which is usually stage two; others come with large lymph nodes that raise fears of tuberculosis or lymphoma but turn out to be reactive generalised lymphadenopathy, which is stage one. Sometimes the opportunistic infection is itself what reveals the HIV: a patient diagnosed with tuberculosis who is found to have HIV is already at WHO stage three, and a viral load in the lakhs with a CD4 count below about 200 to 250 further stratifies risk and prognosis. Diagnosis follows a three-part model: the clinical symptoms and signs, the organ involved, and targeted sampling. In the case I presented, a patient with fever, cough and bloody sputum had sputum tested by GeneXpert to diagnose tuberculosis. Oral thrush is diagnosed clinically. For cryptococcal meningitis, an AIDS-defining illness, we test the CSF, or serum cryptococcal antigen when CSF sampling is not possible.

Live Discussion with Dr. Neha Rastogi Panda

What are the early signs of HIV?

Why don't we use the urine LAM test and stool test for all patients?

Are there any antiretrovirals that can have prolonged action for up to three or six months?

At what stage can we diagnose opportunistic infections, and how do we diagnose them?

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In This Series: Tuberculosis & HIV - An Insight