HIV 2: prevention, symptoms, diagnosis and contact tracing

Introduction

Despite the major advances in treatment that have been made over recent decades, the human immunodeficiency virus (HIV) remains a significant and complex global health challenge. In the field of HIV nursing, it has never been more important to appreciate the lived experience of those with HIV and facilitate improved health outcomes through collaboration, negotiation and trust. This article discusses ways to prevent the spread of HIV, the signs and symptoms of the virus, and how it is diagnosed.

Prevention

There is no ‘one-size-fits-all’ way to prevent the onward transmission of HIV. Prevention requires a holistic and multi-faceted approach involving biomedical, behavioural and structural interventions. The reasons for the continued transmission of HIV are complex, with a host of behavioural, psychosocial, cultural, religious and economic determinants acting as barriers to prevention.

Table 1 outlines some primary prevention methods, along with potential barriers to their effectiveness.

Signs and symptoms

Since HIV therapy was introduced in 1995, HIV has shifted from being a fatal disease to a chronic one so there is now a focus on keeping patients healthy and minimising any symptoms or side-effects from medications. Some people living with HIV experience a diverse range of short- and long-term symptoms, often attributed to the status of their immune system and CD4 count (Table 2 – CD4 cells are a type of lymphocyte, discussed in more detail in the first article in this series). However, medications, comorbidities, stigma and social factors also contribute significantly to people’s health at every phase of infection.

Not everyone experiences signs and symptoms, and each person’s lived experience of HIV is different. Nurses should always conduct a comprehensive, holistic assessment, including clear and thorough history taking. They should also perform ongoing, longitudinal assessments of patients’ health status, as different factors may influence outcomes. A therapeutic relationship built on understanding and trust may also elicit deeper information sharing over time.

Acute phase

Upon initial infection with HIV – usually in the first 2-6 weeks – people can often experience a diverse and non-specific set of symptoms that tend to resolve after 1-2 weeks when the body starts to produce antibodies. These symptoms are often described as flu-like and include fever, myalgia, malaise, gastrointestinal disturbances and headaches.

People in this phase may visit their GP or access healthcare but appear to have short-lived, generalised symptoms of a seasonal virus or transient stomach upset that do not trigger further investigation.

Chronic latent phase

Following the development of antibodies, the number of virus particles in the blood reduces and HIV replication reduces. People generally have no symptoms, although some have persistently swollen lymph glands. As the CD4 count diminishes in the absence of treatment, minor symptoms may start to appear such as skin rashes, oral sores and fatigue. People may notice they get seasonal illnesses more often and take longer to recover.

Advanced HIV infection

Advanced HIV infection (previously called AIDS) is diagnosed when a particular type of infection or cancer arises as a result of a severely reduced immune system. These are usually opportunistic infections, viruses, fungi or parasites that would not usually cause illness in people who are not immunocompromised. These infections can affect any body system, creating a multitude of symptoms.

There is an agreed set of infections and conditions that are indicators of advanced HIV infection; these are referred to as AIDS-defining conditions. British HIV Association (BHIVA) guidelines by Nelson et al (2011) provide further information about these conditions and their treatment and Table 3 lists some examples.

Diagnosis

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set an ambitious global target for nations to achieve “90-90-90” by 2020. This meant:

• 90% of all people with HIV would know their HIV status;
• 90% of people living with HIV would receive anti-retroviral therapy;
• 90% of people receiving anti-retroviral therapy would have viral suppression (UNAIDS, 2014).

The UK achieved this target two years early, although 43% of people diagnosed with HIV are still being diagnosed at a late stage (BHIVA, 2020). This is important because being diagnosed late increases the risk of developing complications and the risk of onward transmission.

National guidelines for HIV testing were published in 2008 by BHIVA, the British Association of Sexual Health and HIV, and the British Infection Society. The guidelines are currently being updated but, at present, they recommend HIV testing for:

• Groups at increased risk of HIV, such as men who have sex with men, people who inject drugs, transsexual women and people from countries with a high prevalence of HIV;
• People attending health services associated with an increased risk of HIV, such as tuberculosis clinics and substance-misuse services;
• People presenting with symptoms or signs consistent with an HIV-indicator condition, such as lymphoma;
• People accessing healthcare in areas of high HIV prevalence (BHIVA et al, 2008).

There are many barriers to HIV testing, which need to be addressed to improve the rate of early diagnosis. These barriers include psychosocial, physical, structural and economic determinants, such as the following:

• Fear of judgement, for example among transsexual women, sex workers or drug users;
• Fear of impact on immigration status;
• Lack of knowledge, training or staff in NHS settings;
• Lack of funding or reimbursement for HIV testing across primary and secondary care settings;
• Lack of awareness or low perception of individual risk-taking behaviour;
• Lack of clinician skill to communicate or risk assess;
• Lack of access or proximity to a testing provider;
• Fears around a positive result, including stigma, confidentiality, rejection and discrimination;
• Fear of prosecution for reckless transmission.

There have been many interventions to try to improve HIV testing. These have often been locally determined, based on a health-needs assessment of the local population. A national strategy, however, has been to introduce opt-out testing. This has been adopted in antenatal screening in the UK for many years and uptake is near universal. As a result of this, vertical transmission of HIV from mother to child has nearly been eliminated in the UK, dropping from 2% in 2000-01 to 0.3% in 2012-14 (Carter, 2018).

Opt-out testing is also now used in sexual health clinics and other settings in which patients have a higher risk of HIV, such as tuberculosis and lymphoma clinics. Opt-out testing of patients attending medical services such as emergency departments and medical assessment units in areas of high prevalence is also a strategy, which is showing acceptability from patients and clinicians (BHIVA et al, 2008). Despite this recommendation featuring in the National Institute for Health and Care Excellence (2016) guidance for HIV testing, it can often be hindered by financial and structural barriers.

Another successful strategy is the introduction of home testing through self-sampling kits. These can reduce a host of barriers to testing, including fears around confidentiality and accessibility of services. These tests are available from pharmacies and must be CE-marked in the UK to be lawfully sold or advertised.

Window period

The HIV testing process involves a window period, which is the time between infection and a test being able to detect the infection. During this period, a person can be highly infectious but a test still gives a negative result. This is because tests detect antibodies or specific viral particles that are not always present in the early stages of infection.

Different generations of testing apparatus exist so advice should always be sought from the clinician or manufacturer about the window period, including, if necessary, when a retest should be performed.

Contact tracing

Contact tracing (also called partner notification) is the process of contacting sexual partners and advising them that they have been exposed to an infection. The intention is to notify as many partners at risk of an undiagnosed HIV infection as possible, and encourage them to attend for counselling, prevention, testing and treatment to stop further transmission.

Partner notification is a highly successful public health strategy, but is often viewed with apprehension by patients and must be handled with great care by an experienced sexual health or HIV professional – usually a sexual health adviser or clinical nurse specialist. Patients are often very anxious about violations of their privacy and confidentiality and, in some cases of HIV status disclosure, may be at risk of violence, discrimination or criminalisation. The specialist nurse or sexual health adviser should have a good understanding of the patient’s social and sexual networks, and any risks associated with partner notification, such as domestic violence.

The World Health Organization (2016) has developed specific standards for partner notification. Partner notification should always be voluntary: mandatory or coercive tactics should never be employed. Partner notification is a collaboration between specialist and patient, based on negotiation, empathy and trust, and a good rapport with patients is associated with successful outcomes.

Patients should be offered multiple options for methods of notification and given counselling around the risks and benefits. After this has been done, an approach should be selected that meets the patient’s preferences. There are a number of types of partner notification:

• Passive notification – a trained professional encourages the patient to share their diagnosis with their partner(s) themselves, and is given support and counselling to achieve this;
• Assisted notification – a trained provider, such as a health adviser or specialist nurse, confidentially contacts the patient’s sexual contacts to offer them counselling, prevention advice and testing.

The WHO (2016) guidelines also provide information about a variety of other methods, including contact slips, contact notification and where a healthcare professional accompanies HIV-positive clients when they disclose their status and the potential exposure to HIV infection to their partner.

Partner notification can be highly beneficial to patients: it is associated with increased adherence to medical care and better psychosocial health (Hosseinipour and Rosenberg, 2013). Broad conversations between the specialist and patient also allow other pertinent issues to be explored, such as attitudes to sex, understanding of viral-load testing and transmission (which is discussed in more detail in the first article in this series), shame and body image. It can be a longitudinal process. The health adviser should always know when to stop and re-evaluate, particularly if resistance occurs; for example, terms such as ‘must’, ‘should’ and ‘need’ can cause resistance. Motivational interviewing techniques are often an effective strategy.