FFinalistSouthampton · 2027
Sexual health
AKT · Sexual health/HIV & prevention

Human immunodeficiency virus (HIV)

HIV-1 / HIV-2 — retrovirus (CD4 T-cell tropic)

Overview

Retroviral infection causing progressive CD4 depletion and immunodeficiency. Seroconversion → asymptomatic latency → AIDS-defining illness if untreated. Treatable to undetectable (U=U).

Recognise

  • Seroconversion: glandular-fever-like illness — fever, rash, lymphadenopathy, pharyngitis, mouth ulcers, weeks after exposure
  • Latent phase often asymptomatic for years
  • Advanced (low CD4): PCP, oesophageal candida, Kaposi sarcoma, CMV, cerebral toxoplasmosis, cryptococcal meningitis, TB

Red flags

  • AIDS-defining illness, very low CD4, seroconversion illness, needle-stick/exposure (PEP within 72h)

Differentials & how to tell them apart

Infectious mononucleosis (EBV/CMV)seroconversion mimics glandular fever — always offer an HIV test in a mono-like illness
Secondary syphilisrash + systemic; co-infection common — test both
Acute viral hepatitisderanged LFTs

Investigations

4th-generation combined HIV antibody/p24 antigen test (window ~45 days) — offer to all. Confirmatory testing; CD4 count and viral load to stage and monitor; resistance testing before ART.

Management

Start ART in everyone: 2 NRTIs + integrase inhibitor (e.g. tenofovir/emtricitabine + dolutegravir)

  1. 1Start ART in ALL people with HIV regardless of CD4 — usually 2 NRTIs + an integrase strand-transfer inhibitor. Aim: undetectable viral load.
  2. 2Opportunistic infection prophylaxis by CD4: co-trimoxazole for PCP when CD4 <200.
  3. 3Prevention — PrEP (tenofovir/emtricitabine) for HIV-negative at risk; PEP within 72h of exposure (28-day course).Gate: PEP is only effective if started within 72 hours of exposure — sooner is better
Antiretroviral therapy (ART) — start in ALL regardless of CD4; typically 2 NRTIs + integrase inhibitor (e.g. tenofovir/emtricitabine + dolutegravir)
PrEP (tenofovir/emtricitabine) — pre-exposure prophylaxis for HIV-negative at risk
PEP (Truvada + raltegravir/dolutegravir) — post-exposure, start <72h, 28 days
Co-trimoxazole — PCP prophylaxis when CD4 <200

Key points

Offer an HIV test in any glandular-fever-like illness and in all the off-map "indicator" conditions. Seroconversion is the high-yield trap. Antenatal screening + ART prevents vertical transmission.

Monitor & prognosis

Viral load (target undetectable) and CD4; ART adherence and toxicity; annual STI screen.

Near-normal life expectancy with early ART and adherence.

Source: BHIVA guidelines; NICE CKS HIV