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Ten tips on when to test for HIV

Too many early HIV infections are being missed in primary care, according to recent studies. Dr William Ford-Young gives his hints

Too many early HIV infections are being missed in primary care, according to recent studies. Dr William Ford-Young gives his hints

1 Primary HIV infection – or seroconversion – is commonly missed by both healthcare professionals and infected individuals. This is a lost opportunity to diagnose HIV before a period, often of many years, during which infection is asymptomatic. Between 70% and 90% of infected individuals develop symptoms between 10 days and six weeks after infection. These are usually self-limiting after two to three weeks.

2 Clinical features of primary HIV infection can be vague or non-specific. These include flu- or glandular fever-like illness, malaise and/or lymphadenopathy, and are often missed because they resolve and the GP says ‘come back if you're not better after a couple of weeks'. But the possibility of HIV should be raised even with a vague presentation and a simple risk assessment may suggest HIV testing.

3 A triad of symptoms – fever, rash and pharyngitis – should always suggest possible primary HIV infection. The rash is likely to be a maculopapular non-specific toxic exanthem, predominantly on the trunk. Other symptoms may include oral ulcers, arthralgia/myalgia, anorexia and weight loss. There may be acute immunosuppression, so severe as to lead to oro-pharyngeal candidiasis, shingles, recurrence of herpes simplex or other conditions associated with immunodeficiency.

4 Early diagnosis of HIV hugely improves the prognosis. A third of people who are diagnosed with HIV in the UK are diagnosed late – when their immune system is already significantly compromised – and their prognosis is poorer than if they were diagnosed early. In September 2007, the CMO wrote to all doctors advising of the need to be more aware of HIV and to encourage people to test.

5 Don't be put off testing for HIV by thinking the patient needs more than a brief pre-test discussion and informed consent. In-depth or lengthy pre-test counselling is no longer advised. Worries about confidentiality and the impact on insurance should be resolved by good in-house practices and policies. Remember that lifestyle and negative test results should not be disclosed in insurance reports (Medical Information and Insurance, BMA and ABI, July 2008). New testing guidance from the British HIV Association will be published next month.

6 Patient care pathways must be established for patients who test positive. This will usually be a referral to your local GUM clinic and health adviser, or to your local infectious disease unit. Ensure you know how to make the referral and facilitate a safe, confidential pathway for the patient. Don't wait to get a positive test, ask your local health adviser now what to do if a patient tests positive – and ensure your colleagues in the practice also know.

7 The ‘three-month window' is no longer a reason for delaying testing. Newer tests now mean that HIV can be diagnosed early in the infection. Most laboratories should be able to diagnose HIV viral antigens and an antibody response as early as 12 days following infection. Phone your local laboratory to find out what tests they use or discuss it with your local GUM clinic.

8 Don't forget post-exposure prophylaxis. PEP can be prescribed to those who have been exposed to HIV – whether by sexual or injecting means or occupationally – and may prevent infection after exposure. GPs are not expected to provide this but must be aware of their local GUM clinic's arrangements for urgent immediate referral as therapy needs to be started within 72 hours of exposure. PEP is available in some A&E departments.

9 Spotting a primary HIV infection is important but be alert to the possibility of HIV-related conditions in later-stage chronic infection. Ensure you have read the CMO's letter and that you carry out a risk assessment on patients presenting with minor conditions associated with a declining immune system:

• oro-pharyngeal candidiasis

• recurrent or severe shingles or herpes simplex

• recurrent or severe dermatophytoses

• unexplained diarrhoea or weight loss

• persistent lymphadenopathy.

And of course bear in mind the conditions that present as AIDS-defining diagnoses such as pneumocystis pneumonia, many lymphomas and tuberculosis.

10 There are excellent HIV resources for primary care. An ideal one for GPs is the excellent HIV in Primary Care available from Medfash and downloadable free from Also see the National AIDS Trust, Primary HIV Infection Report, July 2008

Other useful sources of information include:

• Aidsmap

• British Association for Sexual Health and HIV

• RCGP Sex, Drugs and HIV Task Group

Dr William Ford-Young is a GP in Cheshire and has an interest in the GP's role in HIV diagnosis and shared management. He sits on the Independent Advisory Group for Sexual Health and HIV, and is lead for HIV on the RCGP Sex, Drugs and HIV Task Group.

Competing interests None declared

Latest HIV tests mean HIV can be detected as early as 12 days post infection Latest HIV tests mean HIV can be detected as early as 12 days post infection

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