Introduction

Infection with HIV causes a spectrum of clinical problems beginning at the time of
seroconversion (primary HIV) and terminating with AIDS and death. It is now
recognised that it may take 10 years or more for AIDS to develop after
seroconversion. The Centers for Disease Control (CDC) in the USA developed the
most widely used classification for HIV disease based on the presence of clinical
symptoms and signs, the presence of certain conditions and investigative findings,
the availability ofHIV screening and the degree of immunosuppression as measured
by the CD4 lymphocyte count. The infection is divided into four groups (Box 4.1):
Group I Primary HIV infection Group II Asymptomatic phase Group III Persistent
generalised lymphadenopathy Group IV Symptomatic infection
Group IV is subdivided into several subgroups and some of these (groups IVA, B, C1
and D) are AIDS-defining conditions (Box 4.1). In 1993 the CDC included all HIVinfected persons with CD4 lymphocyte counts of <200 cells/mm3 as fulfilling an
AIDS defining diagnosis. However, this additional classification is not widely used
outside the USA. A second classification also combines clinical and CD4 count
information. Symptoms and clinical findings are graded in severity from A to C0 and
CD4 counts as they fall from 1 to 3 (Table 4.1).
Group I Primary HIV infection
Primary HIV infection (PHI) is also called the seroconversion illness or acute HIV
infection. It represents the stage of infection after the acquisition of the virus when
antibodies are developing as shown in Figure 4.1. Between 25% and 65% of people
have been found to present with symptoms at the time of seroconversion. These
can range from a mild, glandular fever- like illness to an encephalopathy. Common
symptoms and signs are shown in Box 4.2. The severe symptoms are rare. The
differential diagnosis of the mild seroconversion illness is protean and, without a
high index of suspicion and a history indicating relevant risk behaviours or factors,
the diagnosis may be missed. Investigations that may be useful in reaching a
diagnosis are set out in Table 4.2. The appropriate diagnostic tests for PHI,which
should be carried out on serial blood samples, include tests for HIV antibodies and
antigen. If these are negative and PHI is suspected, the definitive test is an HIV RNA
PCR, which is the most sensitive test for the detection and quantification of the
virus. Some of these assays are not routine and the interpretation of investigation
results during PHI is difficult, therefore close consultation with colleagues in virology
is strongly advised. At the time of PHI there is sometimes a high rate of viral
replication,leading to a transient rise in HIV viral load and concomitant
immunosuppression due to a short-lived fall in the CD4 count. This may result in
manifestations of HIV disease