Survey reveals gay men with symptoms of primary HIV infection unlikely to seek an HIV test

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Most HIV-negative gay and bisexual men are aware of the symptoms of primary infection with HIV, but few men experiencing these symptoms seek care or a test for HIV infection, according to the results of a small survey carried out in Seattle. These findings were published in the May edition of The Journal of Acquired Immune Deficiency Syndromes.

The study’s investigators call for better education on the symptoms of early HIV infection in regions where nucleic acid testing for HIV is available. However, they point out that healthcare workers must also look out for symptoms of primary HIV infection and direct patients towards centres where primary infection can be diagnosed.

Up to 90% of people who become infected with HIV develop symptoms within two to four weeks. These are generally non-specific, including fever, chills, night sweats, tiredness, feeling unwell, rash, swollen glands, nausea, vomiting and other symptoms. This stage of disease is often referred to as 'seroconversion illness'.


primary infection

In HIV, usually defined as the first six months of infection.

ribonucleic acid (RNA)

The chemical structure that carries genetic instructions for protein synthesis. Although DNA is the primary genetic material of cells, RNA is the genetic material for some viruses like HIV.



A rash is an area of irritated or swollen skin, affecting its colour, appearance, or texture. It may be localised in one part of the body or affect all the skin. Rashes are usually caused by inflammation of the skin, which can have many causes, including an allergic reaction to a medicine.


The transition period from infection with HIV to the detectable presence of HIV antibodies in the blood. When seroconversion occurs (usually within a few weeks of infection), the result of an HIV antibody test changes from HIV negative to HIV positive. Seroconversion may be accompanied with flu-like symptoms.


acute infection

The very first few weeks of infection, until the body has created antibodies against the infection. During acute HIV infection, HIV is highly infectious because the virus is multiplying at a very rapid rate. The symptoms of acute HIV infection can include fever, rash, chills, headache, fatigue, nausea, diarrhoea, sore throat, night sweats, appetite loss, mouth ulcers, swollen lymph nodes, muscle and joint aches – all of them symptoms of an acute inflammation (immune reaction).

Although traditional HIV tests look for antibodies produced by the body in response to the virus, newer tests that look for HIV’s genetic material have been introduced to some clinics. These 'nucleic acid' tests, which are similar to viral load tests, can be used to identify ‘primary’ HIV infection, before antibodies are found in the blood.

While the benefits of treating HIV at this stage of disease have not yet been determined, early diagnosis can reduce HIV transmissions by influencing the behaviour of infected patients. However, diagnoses can only be made if patients attend an HIV clinic and ask to be tested.

The introduction of testing for primary infection in Washington, North Carolina and California in the United States has only had a small impact on the number of diagnoses. Accordingly, investigators from Seattle, Washington set out to assess the level of knowledge about the symptoms of primary infection and readiness to seek testing in a group of 150 gay and bisexual men from a sexually transmitted infection clinic in the city.

Ninety-six (64%) of the men could name at least one specific symptom of primary HIV infection, although this was increased to 106 (70%) if ‘flu-like symptoms’ were included. There was no difference in the rate of symptom knowledge according to the men’s age, race, level of education, sexual activity, degree of worry about HIV infection, or illness.

However, of the 46 men who knew that flu-like symptoms could be a symptom of primary HIV infection, only 18 (39%) said that they would seek care. This was despite 28% of the sample reporting unprotected anal sex with a partner who was HIV-positive or of unknown HIV status in the year before the survey, and 9% having a regular HIV-positive partner.

Twenty-three (15%) of the men had fever and rash lasting over five days in the year before the survey. However, only 15 (65%) of these sought care, and only seven (30%) were tested for HIV. As the questionnaire was anonymous, the investigators could not link the men’s responses to the outcomes of their HIV tests.

“In a high-risk population of men who have sex with men, we found that 15% had experienced an illness that may have represented HIV seroconversion in the preceding year and that 65% had sought medical attention for the illness”, the investigators write. “Inconsistent symptom recognition and health care-seeking behaviour by patients, coupled with lack of provider recognition and routine testing for HIV ribonucleic acid (RNA), are barriers to the goal of diagnosing HIV during acute infection and suggest potential targets for public health interventions.

“Reliance solely on routine HIV RNA screening of individuals seeking HIV testing is likely to fail to identify even greater numbers of individuals with primary HIV infection unless large numbers of individuals are tested with high frequency,” they add. “Future efforts should evaluate public health programmes to educate at-risk individuals about signs of primary HIV infection, increased health care-seeking behaviour, and direct them towards clinics where HIV RNA testing is routinely performed.”

Nucleic acid testing to diagnose primary HIV infection is not yet routinely available in the United Kingdom.


Stekler J et al. Primary HIV infection education. Knowledge and attitudes of HIV-negative men who have sex with men attending a public health sexually transmitted disease clinic. J Acquir Immune Defic Syndr 42: 123-126, 2006.