Diagnosing acute and prevalent HIV-1 infection in young African adults seeking care for fever: a systematic review and audit of current practice

Abstract

Fever is a common complaint in HIV-1 infected adults and may be a presenting sign of acute HIV-1 infection (AHI). We investigated the extent to which HIV-1 infection was considered in the diagnostic evaluation of febrile adults in sub-Saharan Africa (SSA) through a systematic review of published literature and guidelines in the period 2003–2014. We also performed a detailed audit of current practice for the evaluation of febrile young adults in coastal Kenya. Our review identified 43 studies investigating the aetiology of fever in adult outpatients in SSA. While the guidelines identified recommend testing for HIV-1 infection, none mentioned AHI. In our audit of current practice at nine health facilities, only 189 out of 1173 (16.1%) patients, aged 18–29 years, were tested for HIV-1. In a detailed record review, only 2 out of 39 (5.1%) young adults seeking care for fever were tested for HIV-1, and the possibility of AHI was not mentioned. Available literature on adult outpatients presenting with fever is heavily focused on diagnosing malaria and guidelines are poorly defined in terms of evaluating aetiologies other than malaria. Current practice in coastal Kenya shows poor uptake of provider-initiated HIV-1 testing and AHI is not currently considered in the differential diagnosis.

How can we better identify early HIV infections?

“…These studies demonstrate that far from being a rare event, AHI is likely a common clinical syndrome in HIV endemic parts of sub-Saharan Africa. These results have yet to translate into clinical practice or guidance recommending widespread AHI testing in general medical settings in sub-Saharan Africa [30•,31•]. However, this may change with improved, cheaper AHI diagnostics that are now becoming available.…”

Dengue and Chikungunya Virus Infections among Young Febrile Adults Evaluated for Acute HIV-1 Infection in Coastal Kenya

“…In a systematic review of adults seeking outpatient care from clinics in sSA in the period 2003–2014, 34 (79%) of 43 studies identified focused on malaria only. The remaining studies investigated the following aetiologies: acute HIV-1 infection (AHI) and malaria (2 studies), human herpes virus-8 and hepatitis B virus (1 study), pneumococcal bacteraemia (1 study), flaviviruses (1 study), influenza viruses (1 study), Lassa virus (1 study), intestinal helminths (1 study) and schistosomiasis (1 study) [4]. …”

Undiagnosed acute HIV infection identified through RNA testing of pooled serum samples obtained during a dengue outbreak in São Paulo, Brazil

“…This was also shown in a study in Singapore, where, among patients >15 years old suspected of dengue by emergency physicians, 8/294 (2.4%) acute phase HIV patients were identified; of these, 7 satisfied World Health Organization (WHO) case classification criteria for probable dengue 11 . Strategies to identify acute HIV infection have been proposed 12 and should be used concurrently to improve the incorporation of these patients into care.…”