History and exam
Your Organisational Guidance
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Richtlijn zorg voor patiënten met hiv in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2023GPC sur la prise en charge des patients vivant avec le VIHPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2023Key diagnostic factors
common
increased risk of maternal HIV acquisition
Needle-sharing with injection drug use and percutaneous needle-prick injury carry risks of HIV acquisition rates of 63 to 240/10,000 exposures and 30/10,000 exposures to a person with HIV, respectively.[44][48][78]
Unprotected receptive anal intercourse leads to an infection rate of 1/70 exposures to a person with HIV with ejaculation and 1/154 without.[47] Unprotected, receptive penile-vaginal intercourse without barrier contraception carries a risk of 1 infection/333 exposures in low-income countries and 1 infection/1250 exposures in high-income countries.[46]
Recent sexually transmitted infection (STI) and vaginitis, particularly HSV-2, bacterial vaginosis, and gonorrhoea, are associated with an increased risk of HIV acquisition.[49][50][51][52]
increased risk of perinatal HIV transmission
High maternal viral load is associated with an increased risk of perinatal HIV transmission. Elevated HIV RNA at delivery is independently associated with risk of transmission.[22] The absence of antenatal antiretroviral therapy (ART) is associated with an increased risk of perinatal HIV transmission. Maternal antenatal ART is independently associated with reduced risk of transmission.[22]
Without a suppressed viral load on ART, breast milk contains high levels of the HIV virus and transmission can occur at any point during lactation.[1][35][36][37][38] High maternal viral load (in plasma and in breast milk), breast milk immunological factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples, abscesses), and low maternal CD4 count are associated with increased risk of transmission through breastfeeding. Infant gastrointestinal pathology, such as candidiasis, may disrupt mucosal integrity and aid viral transmission.[39][40][41][42][43]
Other diagnostic factors
uncommon
oral candidiasis
Suggestive of advanced HIV.
increasing dyspnoea
Suggestive of advanced HIV.
weight loss
Suggestive of advanced HIV.
fever
Occurs in the acute seroconversion phase of the virus.
malaise
Occurs in the acute seroconversion phase of the virus.
lymphadenopathy
Occurs in the acute seroconversion phase of the virus.
maculopapular blanching rash
Occurs in the acute seroconversion phase of the virus.
Risk factors
strong
people who inject drugs
unprotected penile-vaginal intercourse
Unprotected receptive penile-vaginal intercourse causes 1 infection/333 exposures to a person with HIV in low-income countries and 1 infection/1250 exposures to a person with HIV in high-income countries.[46]
The rate of HIV is lower among people who have unprotected insertive penile-vaginal intercourse.[47]
unprotected anal intercourse
percutaneous needle prick injury
Causes 30 infections/10,000 exposures to a person with HIV.[48]
coinfection with other sexually transmitted infections (STIs) or bacterial vaginosis
There is evidence that STIs increase the risk of HIV transmission.[49][50] Multiple studies have demonstrated the association between recent acquisition of an STI and transmission of HIV. After controlling for demographic and behavioural risk factors, the population attributable risk was 50.4% for sero-prevalent HSV-2, 5.3% for gonorrhoea, and 17.2% for bacterial vaginosis.[50][51][52]
high maternal viral load (perinatal transmission)
High maternal viral load is associated with an increased risk of perinatal HIV transmission. Elevated HIV RNA at delivery is independently associated with risk of transmission.[22]
The risk of perinatal transmission with a maternal viral load of <50 copies/mL is ≤0.2% overall, with zero transmissions seen among those on antiretroviral therapy (ART) before pregnancy and a maternal viral load of <50 copies/mL near birth.[8]
absence of antenatal maternal antiretroviral therapy (perinatal transmission)
The lack of antenatal maternal antiretroviral therapy (ART) is independently associated with risk of transmission.[22]
breastfeeding in mothers without viral suppression (perinatal transmission)
Without a suppressed viral load on antiretroviral therapy (ART), breast milk contains high levels of the HIV virus and transmission can occur at any point during lactation.[1][35][36][37][38] High maternal viral load (in plasma and in breast milk), breast milk immunological factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples, abscesses), and low maternal CD4 count are associated with increased risk of transmission through breastfeeding. Infant gastrointestinal pathology, such as candidiasis, may disrupt mucosal integrity and aid viral transmission.[39][40][41][42][43]
violence against women and girls
Women who are victims of intimate partner violence have been shown to be at greater risk of HIV/STI infection compared with women with no history of intimate partner violence.[53][54][55] A history of sexual or physical abuse during childhood or adulthood is also associated with an increased risk of HIV.
weak
multiple sexual partners
low maternal CD4 count (perinatal transmission)
May accompany advanced maternal HIV and therefore a high plasma viral load.
cosmetic injection procedures
Transmission of HIV via non-sterile cosmetic injection services via blood is theoretically possible, but no known cases have been previously documented. However, a cluster of HIV cases among people with no known HIV risk factors who received platelet-rich plasma microneedling facials at an unlicensed spa in New Mexico has been reported. The source of contamination remains unknown.[60]
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