Symptoms of HIV infection

INTRODUCTION — Recognizing symptoms of HIV is important since starting treatment quickly may improve the immune system's response to HIV. This topic review discusses the early signs and symptoms of HIV and the groups that are at risk for becoming infected with HIV. A separate topic is available that discusses testing for HIV. (See "Patient information: Testing for HIV").

AT-RISK GROUPS — HIV infection is usually acquired through sexual intercourse, exposure to contaminated blood or body fluids, or transmission from an affected woman to her baby during pregnancy, birth, or breast-feeding. In other words, HIV infection is not spread by casual contact but rather through direct exposure to contaminated body fluids. (See "Patient information: Blood and body fluid exposure").

Certain individuals may have an increased risk of HIV infection, including the following: Persons with a history of a sexually transmitted disease Sexual partners of persons who are infected with HIV Victims of sexual assault Men and women who have unprotected sex with multiple partners. Men and women who exchange sex for money or drugs or have sex partners who do Men who have sex with men who are infected with HIV Injection drug users who share needles or "works" Health care workers with needlestick exposure.

SYMPTOMS — Human immunodeficiency virus (HIV) infection is infection with a virus that gradually destroys cells in the immune system. Symptoms of HIV infection develop in 50 to 90 percent of infected patients. A few days or weeks after being exposed to HIV, many individuals develop a characteristic, flu-like illness that lasts approximately two weeks. This is referred to as primary (or acute) HIV infection.

HIV infection is highly contagious at this stage because there are large amounts of the virus in the blood and other bodily fluids. As an example, a man could potentially infect 7 to 24 percent of susceptible female partners during the first two months of HIV infection [1]. Recognizing symptoms early, being tested for HIV, and starting treatment as soon as possible could help to decrease the risk of transmitting HIV to another person.

The initial signs and symptoms of HIV include problems like fever, muscle and joint pain, and swollen lymph nodes. Because these signs and symptoms may be caused by other common illnesses like the flu, most people do not initially realize that they have HIV.

In most patients, symptoms of HIV begin about two to four weeks after exposure. However, there have been instances in which up to 10 months have passed between exposure and the first signs and symptoms of HIV infection.

The symptoms typically have an abrupt onset, beginning with a fever between 100.4ºF (38ºC) to 104ºF (40ºC). Most patients tend to develop the "full-blown" syndrome within one to two days. During the second week of the illness, most patients also have painless swelling of certain lymph nodes, including those under the arms and in the neck. Although the lymph nodes decrease in size after the first few weeks, some moderate swelling remains. Some patients develop mild enlargement of the spleen (known as splenomegaly). The spleen is an abdominal organ, located to the left of the stomach.

On average, these symptoms last for about two weeks. However, some patients experience lingering fatigue, listlessness, or depression that lasts for weeks to months.

Skin, mouth, genital symptoms — A characteristic feature of acute HIV infection is open sores or ulcers involving the mucous membranes and skin in certain areas of the body. They may be located in the mouth; the esophagus (throat, which extends from the mouth to the stomach); the anus; or the penis. Ulceration involving the esophagus often causes pain during swallowing. The ulcers tend to be shallow, with sharply defined edges, and are typically swollen and painful.

Many patients also develop a rash or reddish inflammation of the skin about two to three days after the onset of fever. The rash usually affects the face, neck, and upper chest or may be more widespread, involving skin of the scalp, the arms and legs, and the palms and soles. The inflammation is usually pink to deep red spots and/or small, solid, slightly raised areas of the skin. Itching is rare and tends to be mild.

Digestive symptoms — Many patients with primary HIV infection develop nausea and vomiting, diarrhea, lack of appetite (known as anorexia), and associated weight loss. Rarely, more severe abnormalities of the digestive system develop, such as inflammation of the liver or the pancreas.

Respiratory symptoms — A dry cough is usually the only respiratory symptom associated with acute HIV infection. A few rare cases have been reported in which patients developed inflammation of the lungs, resulting in difficulty breathing, coughing, and insufficient supply of oxygen to tissues.

Neurologic symptoms — Headaches are common in persons with primary HIV infection. Patients often describe pain behind the eyes that worsens with eye movement. Rarely, more severe neurologic features have been reported, including: Inflammation of the protective membranes that cover the brain and spinal cord (meningitis), with associated fever, severe headache, skin rash, abnormal sensitivity to light, or other signs Inflammation of the brain (encephalitis), sometimes with meningitis. Symptoms can vary and may include fever, headache, confusion, personality disturbances, and episodes of uncontrolled electrical activity in the brain (seizures). Impairment of certain "peripheral nerves" or motor and sensory nerves outside the brain and spinal cord. For example, following acute HIV infection, some patients develop facial nerve paralysis; paralysis and muscle wasting (shrinking of muscle) of the arm; or Guillain-Barré syndrome.

Guillain-Barré syndrome causes weakness, tingling, and numbness that begins in the legs and progresses upward to the chest, arms, and facial area. Weakness is rapidly progressive and can sometimes lead to paralysis.

Opportunistic infections — After becoming infected with HIV, the immune system may not function as well to protect the body from organisms that do not usually cause disease. These organisms cause infections known as "opportunistic infections".

Opportunistic infections may include yeast infections in the mouth or esophagus. Yeast infections are caused by Candida, a yeast-like fungal organism that is normally found on the skin and in the mouth, intestinal tract, and vagina in healthy individuals. Candidiasis of the mouth, also known as thrush, causes cream-colored, slightly raised patches in the mouth, soreness, and easy bleeding (show picture 1). Candidiasis of the esophagus may cause difficulty swallowing. Candidiasis of the vagina is known as a yeast infection (show picture 2). Candidiasis does occur in people without HIV, although people with HIV are at a higher risk for this and other types of opportunistic infection. (See "Patient information: Vaginal yeast infection").

TESTING FOR HIV — Human immunodeficiency virus (HIV) testing is the only way to determine if a person is infected with HIV. Most individuals who are at the highest risk for HIV have not been tested, usually because they do not realize that they are at risk. Others avoid testing because they are worried about the possibility of a positive test result.

However, testing is encouraged because treatment for HIV is highly effective and early diagnosis can improve a person's chance of living longer and being healthier. Furthermore, knowledge of HIV status can greatly reduce the risk of transmission to others if appropriate precautions are taken. (See "Patient information: Testing for HIV").

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. Centers for Disease Control and Prevention (CDC)

Toll-free: (800) 311-3435
(www.cdc.gov)
CDC (Centers for Disease Control and Prevention) National AIDS Hotline

English: (800) 342-2437
Spanish: (800) 344-7432
CDC National Prevention Information Network (NPIN)

Toll-free: (800) 458-5231
National Institute of Allergy and Infectious Diseases (NIAID)

(www.niaid.nih.gov)
HIV/AIDS Treatment Information Service

Toll-free: (800) 448-0440
(www.aidsinfo.nih.gov)
AIDS Clinical Trials Information Service (ACTIS)

Toll-free: (800) 874-2572
(www.actis.org)


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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Pilcher, CD, Tien, HC, Eron, JJ Jr, et al. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004; 189:1785.
2. Walensky, RP, Goldie, SJ, Sax, PE, et al. Treatment for primary HIV infection: projecting outcomes of immediate, interrupted, or delayed therapy. J Acquir Immune Defic Syndr 2002; 31:27.
3. Quinn, TC. Acute primary HIV infection. JAMA 1997; 278:58.
4. Pao, D, Fisher, M, Hue, S, et al. Transmission of HIV-1 during primary infection: relationship to sexual risk and sexually transmitted infections. AIDS 2005; 19:85.
5. Schacker, T, Collier, AC, Hughes, J, et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257.