Patients may see doctor three times before primary HIV infection spotted

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A review of 30 patients recruited to a US cohort study during primary infection has found that doctors are routinely failing to diagnose primary HIV infection on a first clinic visit.

The findings echo previous British research that found many patients with advanced HIV infection had gone for long periods without an HIV diagnosis because their doctors or accident and emergency departments did not connect their symptoms with HIV.

The 30 patients were recruited by two US universities (Duke, North Carolina, and Emory, Georgia) from local primary care clinics, accident and emergency units and hospitals. All were symptomatic.


primary infection

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


Antibiotics, also known as antibacterials, are medications that destroy or slow down the growth of bacteria. They are used to treat diseases caused by bacteria.


Having symptoms.



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).

More than half of the patients were seen at least three times before primary HIV infection was diagnosed, and only five were diagnosed with primary HIV infection during their first visit to a health care provider. In four of these five cases, a diagnosis of primary HIV infection occurred after admission to hospital via emergency room for evaluation of febrile illness, and the mean time from admission to diagnosis was 11 days.

Only four patients were diagnosed with HIV infection within a week of presenting with symptoms, and the median time to diagnosis was 14 days.

“Clearly, health care providers caring for acutely ill outpatients do not consider primary HIV infection as part of the initial work up,” say the authors of the study.

The authors also note that even when primary HIV infection was suspected and an antibody test was ordered, the wrong test was carried out. Routine antibody testing may produce an indeterminate result in the earliest stages of infection, since antibodies to the full range of HIV proteins incorporated in the ELISA test do not emerge until after any seroconversion illness has cleared up.

The long duration between first visit and diagnosis also raises concerns about onward HIV transmission, particularly through sharing of injecting equipment, say the authors. Greater education about the symptoms of primary HIV infection for staff in acute health care settings might permit the early detection of many more HIV infections, the authors suggest, and avoid the inappropriate use of antibiotics (half of the patients in this study were prescribed antibiotics).

Further information on this website

Symptoms of primary HIV infection - factsheet.

HIV testing during primary infection

Fever and rash strongest signs of primary HIV infection - news story, May 9 2002.

GPs missing signs of primary HIV infection in South London - news story, March 10 2003.


Weintrob AC et al. Infrequent diagnosis of primary human immunodeficency virus infection. Missed opportunities in primary care settings. Archives of Internal Medicine 163: 2097-2100, 2003.