Synopsis
Confirm HIV sensitively and respectfully, recognise acute and advanced disease, complete the baseline resistance, coinfection and safety assessment and link rapidly to specialist treatment and prevention.
- Use a laboratory fourth-generation HIV-1/2 antigen–antibody assay as the standard screening test and follow the national confirmatory algorithm after a reactive result.
- During very early infection, antigen, antibody and rapid tests may be negative; request HIV RNA when acute HIV is strongly suspected.
- Communicate a new diagnosis privately, non-judgmentally and with a clear same-day linkage plan; assess immediate mental-health and safeguarding needs.
- Obtain baseline HIV viral load, CD4 count, resistance genotype, full blood count, renal, liver, bone and metabolic profile before or at ART initiation.
- Test hepatitis B and C, syphilis and exposure-site STIs; assess tuberculosis, toxoplasma and other infections according to history and CD4 count.
- Check HLA-B*57:01 before abacavir and never use abacavir in a positive patient.
- Start ART rapidly for nearly everyone, but coordinate timing with treatment of cryptococcal meningitis, TB meningitis and selected unstable opportunistic infections.
- Explain that sustained undetectable viral load on treatment prevents sexual transmission: undetectable equals untransmittable.
Key red flags
Breathlessness, dry cough and hypoxia with advanced HIV suggests Pneumocystis pneumonia and needs urgent blood gas and imaging.
Headache, confusion or meningism can represent cryptococcal, tuberculous or other CNS infection and requires urgent lumbar-puncture planning.
Visual floaters, field loss or reduced acuity in severe immune suppression requires same-day retinal examination for CMV.
Acute fever, rash, pharyngitis and lymphadenopathy after recent exposure may be primary HIV despite an initially negative antibody test.
Severe weight loss, chronic diarrhoea, oral or oesophageal candidiasis and recurrent infections suggest advanced immune deficiency.
A reactive antenatal or blood-donor screen needs urgent confirmatory testing and supportive specialist communication, not delayed or casual disclosure.
Fever, rash, sore throat, lymphadenopathy, myalgia, diarrhoea, headache or aseptic meningitis occurs weeks after some acquisitions.
Wasting, oesophageal candidiasis, chronic diarrhoea, dyspnoea, neurological disease and unusual skin lesions suggest low CD4 count.
Acute distress, self-harm thoughts, coercion, insecure housing, immigration concern or partner violence requires immediate supportive assessment.
Investigation priorities
Screen for established and many early HIV-1 or HIV-2 infections using venous laboratory testing.
Management branches
An HIV screen is reactive or acute infection remains likely despite negative screening.
- Send the national confirmatory differentiation and nucleic-acid tests and urgently request HIV RNA when acute infection is suspected.
- Explain that a screening result needs confirmation, maintain privacy and assess immediate emotional safety and support preferences.
- Take a focused exposure, previous test, PrEP or PEP, ART, pregnancy and symptom history without assigning blame.
- Link directly to an HIV specialist team and ensure the patient knows exactly when, where and how follow-up will occur.