Background:  The diagnosis of acute HIV infection is often missed because it requires a high degree of clinical suspicion as well as the correct use of specific laboratory tests. Patients with acute infection are likely to present at emergency departments, urgent care clinics, and sexually transmitted disease (STD) clinics as well as to their primary physician. Most providers working in these settings do not consider the diagnosis of acute HIV infection.

Methods:  North Carolina recently implemented the Screening and Tracing Active Transmission (STAT) program, a novel statewide system for identification, management and surveillance of incident HIV infections. STAT includes HIV RNA testing to detect acute infections among HIV antibody-negative specimens. We conducted qualitative interviews about risk behaviors, HIV testing, and illnesses before diagnosis in patients identified either through the STAT program or community providers as having acute HIV infection from January 1, 2003 to October 15, 2004.

Results:  To date, we have conducted 20 interviews (16 men and 4 women) with acutely infected individuals:  10 of the men (63%) were black, 4 (25%) white, and 2 (12%) Hispanic; of the 4 women, 2 were black and 2 white. The subjects reported a mean of 5.0 lifetime HIV tests (range 1 to 25, SD 6.2). The most common reasons cited for undergoing the current HIV test were following unprotected anal or vaginal intercourse (65%), wanting reassurance (55%), or symptoms of illness or STD (50%); 80% believed that, prior to their diagnosis, their chances of getting HIV were unlikely or very unlikely; 17 (85%) of the subjects reported having had an acute illness in the 3 months prior to testing for which 3 did not seek care, 7 presented to an emergency department, 3 to a walk-in or urgent care clinic, 2 to an STD clinic, and 2 to their private physician. The most common symptoms reported included fever (82%), anorexia or weight loss (71%), sore throat (65%), gastrointestinal complaints (nausea, vomiting, diarrhea) (53%), and skin rash (47%). The diagnosis of acute HIV infection was considered at 2 (14%) of these initial evaluations.

Conclusions:  This study offers unique insight into HIV testing behaviors and illnesses prior to the diagnosis of acute HIV infection. Symptoms of the acute HIV infection were extremely common, but few patients presented to their primary physician and the diagnosis of acute infection was rarely considered. There is a great need to educate clinicians at emergency departments, urgent care and STD clinics to recognize symptoms suggestive of acute HIV infection and consider this diagnosis.

Keywords: Acute HIV Infection; HIV Testing; Diagnosis of HIV