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REPLY
Diagnosing Primary HIV Infection
Eric S. Daar, MD, and
Susan Little, MD
19 March 2002 | Volume 136 Issue 6 | Pages 488-489
Our study was designed to distinguish between symptomatic patients who had primary HIV infection and those who did not. Since primary HIV infection can present with a broad range of clinical manifestations (1), all referred patients, regardless of symptom complex, were screened. Thus, on the basis of our analysis, which is consistent with that of others (2), we stand by our conclusions that screening should not be limited to patients with select symptoms.
We agree that our estimate of p24 antigen sensitivity could be misinterpreted. Nevertheless, our study demonstrates that this assay can be used to diagnose primary HIV infection in symptomatic, seronegative persons. Clinicians should be aware that sensitivity decreases over time and may vary according to the assay used. As noted in our article, regardless of the virologic test used, all at-risk persons should be counseled about the need for follow-up testing.
Pilcher and colleagues take issue with our focus on patients who were negative for HIV antibody, arguing that studies of primary HIV infection often include the weeks or months from seroconversion. The objective of our study was to define the utility of virologic tests in diagnosing primary HIV infection during the seronegative window. After all, this is the setting in which the diagnosis is missed if virologic testing is not performed (3, 4). Moreover, patients with positive results on enzyme immunosorbent assay do not need a virologic test to establish their HIV status. Thus, we clearly state in our article the importance of assessing the sensitivity of virologic tests in the context of the clinical setting and the serologic status of the patient. The absence of serologic results in the data provided by Pilcher and colleagues only strengthens this point. Their Figure suggests that they have screened very few patients within the first weeks of infection, when a virologic test is likely to be necessary. Furthermore, the few patients that they have tested during the first weeks appear to be positive on p24 antigen assay, consistent with our observations.
We agree that a formal analysis of cost-effectiveness needs to incorporate the impact of false-negative results. However, such an analysis must also include the significant adverse psychological and financial effects of false-positive results. By defining the characteristics of each assay, our study allows clinicians to make informed decisions about the optimal screening strategy for specific patients in select clinical settings.
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Author and Article Information
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Harbor-UCLA Medical Center
Torrance, CA 90502
University of California, San Diego
San Diego, CA 92103
1. Vanhems P, Allard R, Cooper DA, Perrin L, Vizzard J, Hirschel B, et al. Acute human immunodeficiency virus type 1 disease as a mononucleosis-like illness: is the diagnosis too restrictive? Clin Infect Dis. 1997;24:965-70. [PMID: 9142802].[Medline]
2. Bollinger RC, Brookmeyer RS, Mehendale SM, Paranjape RS, Shepherd ME, Gadkari DA, et al. Risk factors and clinical presentation of acute primary HIV infection in India JAMA. 1997;278:2085-9. [PMID: 9403423].[Abstract]
3. Flanigan T, Tashima KT. Diagnosis of acute HIV infection: it's time to get moving! [Editorial] Ann Intern Med. 2001;134:75-7. [PMID: 11187423].[Free Full Text]
4. Schacker T, Collier AC, Hughes J, Shea T, Corey L. Clinical and epidemiologic features of primary HIV infection Ann Intern Med. 1996;125:257-64. [PMID: 8678387].[Abstract/Free Full Text]
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- Annals 2001 134: 25-29.
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