Symptoms of primary HIV infection often mistaken for malaria, representing missed opportunity for testing and prevention

Almost two-thirds of a cohort of Kenyans newly infected with HIV had sought treatment for fever, and 40% of these received presumptive treatment for malaria, but only 12% were tested for HIV, highlighting important missed opportunities for diagnosis and prevention of onward transmission, Eduard J Sanders and colleagues report in a prospective cohort study published in the advance online edition of AIDS.

Half of those treated were tested for malaria parasites; all were negative. Only six percent were suspected of having acute HIV infection; in spite of 25% having had a symptomatic sexually transmitted disease in the three months before an HIV diagnosis.

Many people within the first few weeks of HIV-infection (also known as acute HIV-1 infection or AHI) will experience a sudden onset of illness including: fevers, joint pains, headache, tiredness and rash. Many will seek care.

Identification of people with AHI presents an important public health opportunity.

Newly infected people are highly infectious and may account for a large number of new infections. Early diagnosis presents an opportunity for improved treatment and care as well as potential behaviour change.

It is common in resource-rich settings to seek urgent healthcare for these symptoms. However, the authors note that little is known about health care seeking behaviours in sub-Saharan Africa around the time of AHI.

Given the interest in using point-of-care tests for early diagnosis of AHI, the authors chose to look at healthcare seeking in patients diagnosed with AHI in Kenya.

In July 2005 a prospective open cohort of men and women at risk for HIV began in two research clinics in Kilifi district in Kenya. Men and women aged 18-49 years of age who reported transactional sex work or men having sex with men (MSM) were enrolled voluntarily. Volunteers were given either three-monthly or monthly (when receptive anal intercourse was reported) appointments.

Records covering clinical, counselling, treatment and laboratory work of all previously HIV-negative at-risk individuals who had seroconverted between July 2005 and October 2010 and had agreed to be a part of the AHI cohort were reviewed.

The cohort comprised a total of 72 volunteers (60 men and 12 women); 60% of whom had either p24-positive or RNA-positive or HIV-I discordant rapid test before seroconversion.

Median age at seroconversion was 25 (IQR: 22-28) for men and 24 (IQR: 23-27) for women. Over half had secondary or higher education. 93% of men were bisexual or homosexual; 77% (55) of men and 17% (2) of women reported receptive anal intercourse.

Before diagnosis 75% (54) reported fever. 69% (50) sought urgent care for symptomatic illness; 84% of whom had symptoms within a month of the estimated date of HIV infection. 32% first sought care in a non-research facility.

Over a quarter sought urgent care more than once before HIV diagnosis.

Only one in four patients with fever was tested for malaria parasites, yet in spite of negative results was treated for malaria.

Malaria treatment was strongly associated with fever (aOR: 46, 95% CI: 3-725) and a non-research setting (aOR: 5, 95% CI: 3-64).

However the World Health Organization’s (WHO) revised malaria treatment guidelines state that treatment be given upon a confirmed diagnosis. Treatment based on clinical symptoms can be considered only when “parasitological diagnosis is not accessible.”

The authors stress the urgent need for continued education for front line health care workers as well as for researchers working in a research setting.

The identification of people with acute HIV infection at point-of-care services will facilitate treatment and care as well as HIV prevention interventions.

The authors propose that, together with improved clinician training, a risk score algorithm is developed to evaluate acute HIV infection in resource-poor settings where previously malaria was the most common cause of fever.

The authors note that among research staff there was low recognition of AHI in spite of patients presenting with known predictors of HIV infection: symptomatic sexually transmitted infections and discordant rapid HIV test results before seroconversion.

While HIV is only one of many causes of fever in sub-Saharan Africa, the authors note they couldn’t determine whether testing for HIV was done at non research facilities but suspect it was not.

Limitations include the selection of a high-risk group; bias in recall; and differences in follow-up may have influenced estimated differences in illnesses in men compared to women.

The authors conclude the majority of adults with AHI in malaria-endemic areas seek urgent health care and most are treated presumptively for malaria. Improved recognition of AHI presents a public health opportunity for early diagnosis, treatment and care as well as improving HIV prevention strategies.

Sanders EJ et al. Most adults seek urgent healthcare when acquiring HIV-1 and are frequently treated for malaria in coastal Kenya.  Advance online edition AIDS, 2011 doi: 10.1097/QAD.0b013e3283474ed5