We recommend all individuals with suspected or diagnosed PHI are reviewed promptly by an HIV specialist and offered immediate ART
Primary HIV infection (PHI) is defined as HIV infection within a maximum of 6 months from the estimated time of HIV transmission. It can be diagnosed based on laboratory test results in the setting of a clinical sexual history . In the setting of the recent results from the START, TEMPRANO and HPTN052 trials, there is now no longer equipoise when counselling all individuals diagnosed with HIV; these studies showed clinical benefit to starting immediate ART over deferral .
In the context of PHI there are additional considerations to take into account when considering best management. PHI is a distinctive situation where often-significant symptoms consistent with seroconversion occur at a time of the stress of coming to terms with a new HIV diagnosis. Individuals diagnosed with PHI with low initial CD4 T cell counts , high plasma HIV viral loads (>100,000 copies/mL) and short test intervals (diagnosis within 12 weeks of a previous negative test) have a more rapid rate of disease progression than others without these features at PHI, and hence early ART initiation should be prioritised.
ART should be started only when the individual feels ready to do so. However, there are certain clinical presentations of PHI where expedited ART initiation should be recommended. We recommend starting ART as soon as possible for patients presenting with PHI meeting any one of the following criteria known to be associated with morbidity or very rapid disease progression:
- Neurological involvement
- Any AIDS-defining illness
- CD4 cell count <350 cells/µL
- PHI diagnosed within 12 weeks of a previous negative test
- Plasma viral load >100,000 copies/mL
The pros and cons of early ART initiation with a view to long-term therapy should be clearly and sensitively presented to any individual diagnosed with PHI. ART once started, should be considered as potentially lifelong due to the increased all-cause mortality observed from treatment interruption in the SMART study. This was observed irrespective of nadir CD4 count.