Seroconversion

Seroconversion usually occurs between 1 and 10 weeks after the onset of the acute primary exposure to HIV. If a patient is potentially seroconverting, i.e. has had a recent high-risk exposure (Table 4) and has indicative symptoms (Table 5) then a full physical examination and appropriate serological testing should be undertaken; the patient should be handed over to the most senior doctor on duty, depending on the local clinic protocol. This acute primary seroconversion illness is self-limiting, and clinical recovery virtually always occurs.

Approximately 50-80 per cent of patients contracting HIV infection have an acute seroconversion illness - however, most go undiagnosed. Treatment starting at the seroconversion stage (with antiretroviral drugs) may be very beneficial in the longer term in preventing damage to the immune system, as seroconversion illness is known to be associated with more rapid HIV disease progression (Tyrer et al., 2003). It is important to distinguish between sero-conversion illnesses, and symptomatic HIV infection. Individuals have their own host responses to HIV, which may or may not lead to symptomatic disease. HIV can remain asymptomatic, potentially for many years. During the early asymptomatic phase, the CD4 lymphocyte count recovers from its initial depression during the primary illness, and may remain at close to normal levels for a number of years before there is a progressive decline associated with the clinical manifestations of HIV disease.

Table 4 Estimated exposure risks

Type of exposure

Risk

Percutaneous exposure

1

:333

Mucous membrane exposure

1

: 1000

Skin exposure

<1:1000

Insertive anal intercourse

1

:333

Receptive anal intercourse

1

: 30-1: 125

Receptive vaginal intercourse

1

: 600-1:2000

Insertive vaginal intercourse

1

: 1000-1: 5000

Intravenous needle/works sharing

1

:150

It is vital to remember that some of the symptoms of anxiety may also be attributed to seroconversion (see the section on HIV anxiety below). If you are in any doubt refer the patient to a Clinical Health Psychology department or discuss with an appropriate clinician, Health Practitioner or Health Adviser before undertaking the HIV test.

The patient may be at increased risk of HIV transmission if the contact has a high viral load (i.e. is seroconverting or is in the later stages of the disease). The symptoms of HIV seroconversion are listed in Table 5 below:

Table 5 Symptoms of seroconversion

Symptoms found in >50%

% of patients seroconverting

patients who are seroconverting

who experience these symptoms

Fever >38°C

77%

Fatigue

66%

Erythematous maculopapular rash

56%

Myalgia

55%

Headache

51%

Symptoms found in 20% to 50% of

% of patients serocoverting

patients who are seroconverting

who experience these symptoms

Axillary lymphadenopathy

24%

Weight loss

24%

Nausea

24%

Diarrhoea

23%

Night sweats

22%

Cough

22%

Anorexia

21%

Inguinal lymphadenopathy

20%

Symptoms found in 5% to 20% of

% of patients seroconverting

patients who are seroconverting

who experience these symptoms

Abdominal pain

19%

Oral candidiasis

17%

Vomiting

12%

Photophobia

12%

Sore eyes

12%

Genital ulcer

7%

Tonsillitis

7%

Depression

6%

Dizziness

6%

HIV PRE- AND POST-TEST DISCUSSION HIV/AIDS ANXIETY

Some patients who attend a GUM clinic may voice their fears about their possible exposure to HIV infection.These fears can often reveal a misunderstanding of the routes of transmission and the level of risk involved in various sexual and non-sexual situations.

Most commonly anxieties within this group relate to non-sexual modes of spread, such as sharing toothbrushes, cooking and eating utensils, towels and linen, and bathrooms, and non-sexual touching and kissing.

Patients who are worried about such contact usually respond positively to clear, rational discussion about the known routes of transmission and the absence of risk associated with such activities. If their anxiety persists, consideration should be given regarding referral to other services. These patients are often termed the 'worried well'.

THE WORRIED WELL

In using this term it is important to distinguish between a patient who is mildly or justifiably anxious because of reasonable risks as opposed to the patient who is unreasonably worried about exposure to HIV. Only after physical illness has been excluded can the patient be defined as 'worried' and 'well'.

This group of patients can be difficult to manage. Patients in this group can present with multiple physical complaints, which they have interpreted as evidence of their HIV infection. This may occur despite repeated assurances that, on the basis of their history, they could not, (or would be extremely unlikely to), have come into contact with HIV.

Occasionally fears of the infection reach obsessive proportions, and frank obsessive states are often seen in these patients. HIV seems to act as a vehicle for the expression of their psychological vulnerability and sexual guilt.

It is vital to establish the nature and background of their concerns, so that a decision can be made on what the most appropriate intervention would be.

With this group of patients it is important not to propagate their anxiety. It may often be an idea to involve other professionals from disciplines, such as clinical psychology. HIV testing would not be advisable in these cases, pending further psychological assessment. Common characteristics of the 'worried well' include:

• Low-risk sexual activity

• Repeated negative HIV tests

• Multiple symptoms that are misinterpreted, such an features usually associated with undiagnosed viral or postviral (although NOT HIV) infection, or anxiety or depression

• High levels of anxiety, depression and obsessional disturbance

• Psychiatric history or a high level of consultations with GPs or other physicians

Social isolation

• Dependence in close relationships

• Increased potential for suicidal tendencies

• Poor post-adolescent sexual adjustment.

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