Shortly after infection with HIV, the viruses multiply extremely rapidly. There is then a particularly high risk of transmission during unprotected sex. A significant proportion of HIV transmissions occur precisely in this "acute" phase of the infection - when most of those affected do not even realise that they are infected. However, there are a few indications that point to a recent HIV infection may indicate that Philip Eicker spoke to Axel Adam (48), general practitioner and HIV specialist at the Infection Medicine Centre Hamburg (ICH).
Axel, are there any unmistakable symptoms that indicate an acute HIV infection?
No. An acute HIV infection doesn't always trigger symptoms that bring a man to the doctor. For example, if I get a fever and aching limbs in winter, I easily classify it as the flu. But it could also be symptoms of an HIV infection. If there is also a skin irritation, a blotchy redness on the skin that doesn't hurt, then that would be something to look into. Especially if it happens after a risky contact, usually two to four weeks later. But as I said, an acute HIV infection can also proceed without any symptoms at all.
Are there any other differences to the classic flu?
True influenza is more severe: it starts suddenly with a high fever. This can be the case with HIV, but is rather rare. And if a patient has a runny nose and a sore throat, I don't initially suspect an HIV infection. But if I get the impression during a conversation that it could be more than that, then I ask more detailed questions.
What exactly happens during an acute HIV infection?
When the virus finds its way into the body, it multiplies explosively and floods the body's cells. HIV uses them to multiply. The cells are destroyed in the process. In most cases, the intestinal mucosa is the entry point, where there is a large so-called lymphatic tissue with many helper cells. This is where HIV really rages, the lymph nodes are literally scarred.
How does this flood of HIV come about?
Initially, the immune system does not yet know how to deal with the infection. It has not yet formed any HIV antibodies. This is why the virus can multiply so freely. Once antibody production starts, the viral load drops and the immune system can initially control the infection quite well.
When does the immune system stabilise?
Usually after a few weeks. There is also a range of variation here. In some patients, it can take a quarter of a year for the body's own defence system to get going. Incidentally, the usual HIV test is not effective until the antibodies are produced, i.e. after six to twelve weeks.
If I'm worried that I've been infected, I might want to know immediately. Is that possible?
In this case, viral load measurement using the so-called PCR method can be the method of choice. We do not measure the intact virus, but only its genetic information, the RNA. But it reliably shows us whether and to what extent the virus has multiplied. However, this type of PCR measurement is only useful around one and a half weeks after the risk contact.
Is there any advantage at all if an HIV infection is detected immediately?
This does not have any immediate consequences. To date, there have been no clinical studies showing that antiretroviral treatment is beneficial in this early phase. We only treat an acute infection, also known as a primary infection, if the clinical symptoms are very pronounced: high fever, thick lymph nodes and pharyngitis. Apart from this, it is of course very sensible to go to the doctor immediately if you suspect you have HIV and seek advice. If recognised at an early stage, an HIV infection can now be kept very well under control.
When men come to you with a suspicion of HIV: What questions do they ask you?
The most common question is about the notorious residual risk of blow jobs. If there is no squirting into the mouth, the risk is extremely low. Nevertheless, men are still concerned. Or they specifically ask, for example, whether rimming harbours an HIV risk. I can allay many fears by answering the questions clearly and referring to studies.
These men are obviously not afraid to talk to their doctor about sex ...
Many gay men come to us specifically because we are an HIV-focussed practice. Over the years, we have all learnt that the topic of sexuality also belongs here in the practice - regardless of whether it's erectile dysfunction or penile discharge. Our patients are very open about this. I can only advise everyone to talk to their doctor about sexuality so that they are not left in the dark. There's no point in running to the HIV test every week. Instead, you should get a realistic picture of the possible risks together and then decide whether a test makes sense.
Are imaginary sick people a problem?
There are always patients who take great care to protect themselves but are still terrified and want to take an HIV test every fortnight - and almost always get a negative test result. Some time ago, I had a very young patient whose condom broke. This caused him so much anxiety that he now thinks he can't have sex at all. That's an overreaction. Not having sex at all is unhealthy.
Are you often asked for post-exposure prophylaxis (PEP), a four-week treatment with HIV medication immediately after a risk situation to prevent the infection from "settling in and starting"?
This applies to a maximum of five patients per year. Sometimes they come to the practice with the medication because they have been to the emergency clinic at the weekend and were given a prophylaxis there. In most cases, the hospital doctors are not so familiar with HIV and play it safe. They prescribe a PEP without first clarifying the exact risk.
So PEP is not developing into the "morning-after pill"?
No. But we should be careful not to relieve people of their responsibility. There are plenty of other examples besides HIV: pills for overweight people, pills for erectile dysfunction ... The rule for all problems today is: I take a pill and then things go back to normal! I don't want to encourage this behaviour. Everyone has to deal with risks responsibly, there isn't a morning-after pill that solves every problem. And the same still applies to HIV: It's better not to have it!
Interview: Philip Eicker
Further information: Brochure Have you been at risk of HIV? What to do?
