title: Challenges of diagnosing acute HIV-1 subtype C infection in African women: performance of a clinical algorithm and the need for point-of-care nucleic-acid based testing.
abstract: BACKGROUND
  Prompt diagnosis of acute HIV infection (AHI) benefits the individual and provides opportunities for public health intervention. The aim of this study was to describe most common signs and symptoms of AHI, correlate these with early disease progression and develop a clinical algorithm to identify acute HIV cases in resource limited setting.
  
  
  METHODS
  245 South African women at high-risk of HIV-1 were assessed for AHI and received monthly HIV-1 antibody and RNA testing. Signs and symptoms at first HIV-positive visit were compared to HIV-negative visits. Logistic regression identified clinical predictors of AHI. A model-based score was assigned to each predictor to create a risk score for every woman.
  
  
  RESULTS
  Twenty-eight women seroconverted after a total of 390 person-years of follow-up with an HIV incidence of 7.2/100 person-years (95%CI 4.5-9.8). Fifty-seven percent reported ≥1 sign or symptom at the AHI visit. Factors predictive of AHI included age <25 years (OR = 3.2; 1.4-7.1), rash (OR = 6.1; 2.4-15.4), sore throat (OR = 2.7; 1.0-7.6), weight loss (OR = 4.4; 1.5-13.4), genital ulcers (OR = 8.0; 1.6-39.5) and vaginal discharge (OR = 5.4; 1.6-18.4). A risk score of 2 correctly predicted AHI in 50.0% of cases. The number of signs and symptoms correlated with higher HIV-1 RNA at diagnosis (r = 0.63; p<0.001).
  
  
  CONCLUSIONS
  Accurate recognition of signs and symptoms of AHI is critical for early diagnosis of HIV infection. Our algorithm may assist in risk-stratifying individuals for AHI, especially in resource-limited settings where there is no routine testing for AHI. Independent validation of the algorithm on another cohort is needed to assess its utility further. Point-of-care antigen or viral load technology is required, however, to detect asymptomatic, antibody negative cases enabling early interventions and prevention of transmission.
authors: Centre for the AIDS Programme of Research in South Africa-CAPRISA, University of KwaZulu-Natal, Durban, South Africa. mlisanak@ukzn.ac.za
authors: Koleka
authors: K
authors: Mlisana
authors: Magdalena
authors: M
authors: Sobieszczyk
authors: Lise
authors: L
authors: Werner
authors: Addi
authors: A
authors: Feinstein
authors: Francois
authors: F
authors: van Loggerenberg
authors: Nivashnee
authors: N
authors: Naicker
authors: Carolyn
authors: C
authors: Williamson
authors: Nigel
authors: N
authors: Garrett
mesh_terms: D000328:Adult; D000465:Algorithms; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000517:prevention & control; D015497:HIV-1 / Q000235:genetics* / Q000276:immunology; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D025202:Molecular Diagnostic Techniques; D019095:Point-of-Care Systems; D015203:Reproducibility of Results; D012306:Risk; D013019:South Africa; D055815:Young Adult
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